United States Ex Rel. Estate of Cunningham v. Millennium Laboratories of California, Inc.

713 F.3d 662, 2013 WL 1490435, 2013 U.S. App. LEXIS 7398
CourtCourt of Appeals for the First Circuit
DecidedApril 12, 2013
Docket12-1258
StatusPublished
Cited by25 cases

This text of 713 F.3d 662 (United States Ex Rel. Estate of Cunningham v. Millennium Laboratories of California, Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the First Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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United States Ex Rel. Estate of Cunningham v. Millennium Laboratories of California, Inc., 713 F.3d 662, 2013 WL 1490435, 2013 U.S. App. LEXIS 7398 (1st Cir. 2013).

Opinion

TORRUELLA, Circuit Judge.

This is an appeal from a dismissal of a federal False Claims Act (“FCA”) complaint on grounds that it was jurisdictionally barred by the FCA’s public disclosure provision. The Appellant, the Estate of Robert Cunningham (“Relator”), 1 brought an FCA suit against Millennium Laboratories of California (“Millennium”) and John Doe physicians (collectively, “Appellees”), alleging that Millennium encouraged physicians to bill the government multiple times for single drug tests and to perform excessive, medically unnecessary original and confirmation tests.

Prior to the filing of said complaint, Millennium had filed a suit against Relator’s employer, Calloway Laboratories (“Calloway”), in California state court (“California suit”), attaching e-mails from Calloway employees to third parties suggesting fraudulent activity in Millennium’s billing practices. The district court found this prior disclosure to constitute a jurisdictional bar to Relator’s suit, dismissing his complaint. This appeal followed.

Since we find error in the district court’s dismissal of all of Relator’s claims when only some of them had been disclosed by way of being substantially similar to the information contained in Millennium’s pri- or California suit, we affirm in part and vacate in part the district court’s dismissal, remanding for the district court’s consideration of whether Relator’s remaining FCA claim was sufficiently pled under Fed. R.Civ.P. 12(b)(6) and 9(b).

I. Background

A. Factual Background

Jurisdiction is determined based on whether it existed at the time the plaintiff filed the original complaint, Sallen v. Corinthians Licenciamentos LTDA, 273 F.3d 14, 23 (1st Cir.2001), so we provide the factual background as alleged in Relator’s original complaint. Since we ultimately find that said facts were integrated in Relator’s amended complaint, we only distinguish between the two complaints when there are noted differences as to the language and count number of their respective allegations. 2

*665 As relevant here, Millennium developed a urine drug-testing program for physicians to monitor the medications of chronic pain patients and to assess patients’ compliance with prescribed medication regimes. The testing method begins as point-of-eare testing in a doctor’s office and uses various chemically-treated test strips (“units”) inserted into a single cup filled with the patient’s urine (“specimen”) (collectively, the “test kit”).

Robert Cunningham, now deceased, worked as a compliance officer for Callo-way, a competitor of Millennium’s, in 2007 and 2008. It was during his employment at Calloway that Cunningham learned of the allegedly improper billing practices at issue in his qui tarn complaint against Millennium and the unnamed physicians. Cunningham labeled Millennium’s alleged fraudulent practices, collectively, as “Millennium’s Physician Billing Model” in his original complaint. The overall scheme is alleged to involve different components, but as a general matter, is

designed to 1) encourage physicians to perform and order medically excessive and unnecessary testing, thereby significantly increasing the revenues of the John Doe [physician] defendants at the expense of the government and private health insurance programs, and 2) by increasing the John Doe [physician] defendants’ revenues, significantly increase Millennium’s revenues and market share, enabling Millennium to profit from the billing for reflex screenings and confirmations.

The complaint states that, unlike other laboratories “which profit from the tests ordered by a physician with no payment to the physician,” Millennium’s model allows a physician “to substantially increase his or her revenue based upon the laboratory tests ordered.” The complaint then proceeds to break down the various aspects of the larger scheme, which involves alleged fraudulent activity related to multiple billing for single test kits, excessive testing without medical necessity, and improper confirmation testing.

First, Millennium is alleged to have billed multiple times for the testing of a single test kit. Specifically, the original complaint alleges that Millennium encouraged doctors “to use a multi-class qualitative drug screen which uses a single specimen, and to bill the government and private insurance programs multiple units for the single testing event devices” (“Aspect 1”). Millennium then encouraged doctors “to improperly bill the government under CPT codes 80101, 80101QW, and/or other pathology and laboratory codes,” resulting in federal monies lost as a result of “laboratory services which were not performed as claimed or were inflated.” Millennium did this by informing physicians that, rather than bill one unit of 80101QW for each test kit, the physician should bill, “as many units as there are panels in the test kit.” (emphasis added). Further, Millennium gave physicians a document, entitled “Gross Revenue by Insurance Category for Mul-ti-Clin 11 Panel Test Kit,” which suggest *666 ed that “each physician can bill at least 9 units per kit,” despite the fact that all nine units are tested “in a single testing event.” Relator alleges fraud in that payment because use of CPT code 80101QW “would only be proper if it was billed in one unit.... Rather, at Millennium’s encouragement and in conspiracy with Millennium, the John Doe [physician] defendants ... have billed Federal programs and other health insurance programs multiple units of 80101QW per patient per day.”

Second, Relator claims that Millennium directed and encouraged physicians to.test excessively, more than was reasonable or medically necessary (“Aspect 2”). Specifically, the original complaint alleges that Millennium

represents to the physician that by simply ordering one (1) test per day and billing Medicare at the rate of $19.24 per panel for nine (9) units, the physician can earn $173.18 per day.... Millennium also informs the physician that if she or he were to order twenty (20) tests per day and bill Medicare at the rate of $16.67 per panel for nine (9) units, the earnings would be $3,463.20 per day....

Thus, as distinct from the first set of allegations, the second set of allegations does not involve billing more than one time for a single unit, but rather involves the unnecessary frequency with which physicians were encouraged to use and bill entire test kits. These allegations also include charges that Millennium informed physicians that, if they were to order twenty tests per day, they could earn $8,640.00 per day based on “the standard indemnity, auto insurance, and [w]orkmen’s compensation policies at the reasonable and customary rate of $80.00 per panel for nine (9) units.” These amounts are also reflected in the “Gross Revenue by Insurance Category for Multi-Clin 11 Panel Test Kit” document, which also breaks down the potential revenues a physician can earn by ordering between one and twenty tests per day.

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713 F.3d 662, 2013 WL 1490435, 2013 U.S. App. LEXIS 7398, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-ex-rel-estate-of-cunningham-v-millennium-laboratories-of-ca1-2013.