United States Ex Rel. Foust v. Group Hospitalization & Medical Services, Inc.

26 F. Supp. 2d 60, 1998 U.S. Dist. LEXIS 19033
CourtDistrict Court, District of Columbia
DecidedSeptember 8, 1998
DocketCivil Action 93-2285(NHJ)
StatusPublished
Cited by4 cases

This text of 26 F. Supp. 2d 60 (United States Ex Rel. Foust v. Group Hospitalization & Medical Services, Inc.) is published on Counsel Stack Legal Research, covering District Court, District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United States Ex Rel. Foust v. Group Hospitalization & Medical Services, Inc., 26 F. Supp. 2d 60, 1998 U.S. Dist. LEXIS 19033 (D.D.C. 1998).

Opinion

MEMORANDUM OPINION

NORMA HOLLOWAY JOHNSON, Chief Judge.

Former federal government auditors Steven M. Foust and Richard A. Gedrich bring this action under the qui tam provisions of the False Claims Act. This is an action for statutory civil penalties and damages arising out of alleged violations of 31 U.S.C. § 3729. All defendants have moved to dismiss Foust and Gedrich’s second amended complaint and the United States has moved to dismiss Foust and Gedrich from this action.

The False Claims Act allows a private plaintiff to make a claim on behalf of himself *63 and the United States for violation of the Act. 31 U.S.C. § 3730(a). Such plaintiffs, including Foust and Gedrich, are called “rela-tors.” Qui tam relators are entitled to receive part of any government recovery when suit is brought. The government investigates the complaint to determine whether to intervene in the action; if it declines to do so, the private plaintiff, or relator, may proceed with the action alone. 31 U.S.C. § 3730(b)(4). In this case, after a lengthy investigation, the government elected to intervene in only part of the relators’ case.

In order for qui tam relators to proceed without the government’s intervention, they must meet the jurisdictional requirements laid out in 31 U.S.C. § 3730(e). Here, the government has elected not to intervene in the claims that now constitute relators’ second amended complaint. The Court finds that it lacks subject matter jurisdiction to hear relators’ allegations and will grant defendants’ motions to dismiss relators’ complaint and the United States’ motion to dismiss relators from this action. The portion of the case in which the government chose to intervene will remain before the Court.

I. Background

Relators originally filed their claims under seal on November 4, 1993, and their complaint remained under seal pursuant to 31 U.S.C. § 3730(b) while the government determined whether to intervene. On October 31, 1996, the government notified the Court that it was intervening in part and declining to intervene in part and the case was unsealed at that time.

A. The Defendants

Defendants in this case are Blue Cross Blue Shield of the National Capital Area (“BCBSNCA”), also known as Group Hospitalization and Medical Services, Inc., and several individual Blue Cross Blue Shield organizations. 1 The individual organizations are known as “participating plans” and BCBSNCA is known as the “control plan.” The participating plans provide health insurance benefits to local individuals who subscribe to the plans. They also maintain national accounts for employers whose employees are located within the service areas of other individual Blue Cross Blue Shield plans. All participating plans’ national accounts are administered by a control plan, BCBSNCA. BCBSNCA reimburses the participating plans for health benefits they pay out and other costs they incur in administering national accounts.

Defendants BCBSNCA and the participating plans negotiate agreements with the institutional health care providers that serve the insured individuals who subscribe to defendants’ insurance plans. Under these negotiated agreements, the participating plans reimburse the health care providers—primarily hospitals, nursing homes, and home health care agencies—for the medical services they render to the subscribers. The health care providers also agree to give the participating plans discounts, refunds, or rebates on those medical services. The participating plans receive these discounts, refunds, or rebates from the health care providers at or after the time the participating plans pay the health care providers for their services. Moreover, participating plans periodically receive other refunds and rebates from these health care providers when incorrect payments are cor *64 rected and when similar adjustments take place.

B. The Relators’ Allegations 2

In brief, relators allege that the participating plans failed to credit the government with the money they received from the health care providers and that BCBSNCA failed to collect this money from the participating plans for credit to the government. These allegations appear in two counts: one relating to the Federal Employees Health Benefits Program (“FEHBP”) and the second relating to contracting government agencies, namely the Board of Governors of the Federal Reserve Board and the Smithsonian Institution.

1. Count One: FEHBP

BCBSNCA contracts with certain employee organization plans (“EOPs”) under the FEHBP. EOPs are one type of health plan available to federal employees who are members of those groups and the participating plans provide health care benefits to members of the EOPs. BCBSNCA acts as the control plan, or the administrator, when health benefits are provided to EOP subscribers who live within the service area of the respective participating plans.

The five EOPs at issue in this case are the National Treasury Employees Union, the National Alliance of Postal and Federal Employees, the Beneficial Association of Capital Employees, the National Association of Postmasters of the United States, and the United States Secret Service Employee Health Association. At the time relevant to relators’ claims, these EOPs were administered by BCBSNCA, which underwrites and administers claims submitted by these EOPs to participating local plans nationwide.

Under the statute and regulations governing the FEHBP, BCBSNCA and the participating plans may charge the government only for the actual costs they incur in providing health benefits. “Actual costs” are defined as the costs of health benefits provided less applicable refunds, rebates, allowances, and credits. 48 C.F.R. § 1652.216-71(b)(2)(i). Relators contend that the participating plans failed to credit or refund to FEHBP the provider discounts, refunds, and rebates they received for services rendered to members of the five EOPs at issue. Rela-tors further claim that the participating plans breached their duty to pass on to BCBSNCA, for credit to the FEHBP, the discounts, refunds, and rebates the plans secured, thereby fraudulently overcharging the government. Therefore, relators aver, defendant participating plans have made false claims to the government within the meaning of 31 U.S.C. § 3729.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Little v. Shell Exploration & Production Co.
690 F.3d 282 (Fifth Circuit, 2012)
United States Ex Rel. Maxwell v. Kerr-McGee Oil & Gas Corp.
486 F. Supp. 2d 1217 (D. Colorado, 2007)
US Ex Rel. Schwedt v. Planning Research Corp.
39 F. Supp. 2d 28 (District of Columbia, 1999)

Cite This Page — Counsel Stack

Bluebook (online)
26 F. Supp. 2d 60, 1998 U.S. Dist. LEXIS 19033, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-ex-rel-foust-v-group-hospitalization-medical-services-dcd-1998.