United States Ex Rel. Health Outcomes Technologies v. Hallmark Health System, Inc.

409 F. Supp. 2d 43, 2006 U.S. Dist. LEXIS 1593, 2006 WL 137308
CourtDistrict Court, D. Massachusetts
DecidedJanuary 6, 2006
DocketCIV.A.01-11375-NMG
StatusPublished
Cited by1 cases

This text of 409 F. Supp. 2d 43 (United States Ex Rel. Health Outcomes Technologies v. Hallmark Health System, Inc.) is published on Counsel Stack Legal Research, covering District Court, D. Massachusetts 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. Health Outcomes Technologies v. Hallmark Health System, Inc., 409 F. Supp. 2d 43, 2006 U.S. Dist. LEXIS 1593, 2006 WL 137308 (D. Mass. 2006).

Opinion

MEMORANDUM & ORDER

GORTON, District Judge.

In the instant qui tam action, the government alleges that the defendants committed fraud involving Medicare by “knowingly submitting to Medicare, between 1992 and 1997, false claims for the treatment of patients that did not have the primary diagnoses the hospitals claimed”. Suit was originally brought by Health Outcomes Technologies (“Health Outcomes”), a Pennsylvania corporation with its principal place of business in Doylestown, Penn *45 sylvania, and, after an extremely lengthy delay, the government chose to intervene. The defendants move to dismiss the case or, in the alternative, to stay the proceedings.

I. Background

A. Facts

The government alleges that during the early 1990s Whidden Memorial Hospital in Everett, Massachusetts (“Whidden”), Malden Hospital (“Malden”) and Lawrence Memorial Hospital of Medford (“Lawrence”) (collectively “the Hospital Defendants”) each decided to increase its Medicare reimbursement by increasing its “case mix index” (“CMI”). 1 The CMI is the hospital’s average “weight” of codes assigned to its Medicare claims. The higher the CMI, the higher the reimbursement.

The government alleges that the Hospital Defendants accomplished the increases by mis-coding Medicare claims with respect to pneumonia. There are 24 different Medicare codes for pneumonia based upon the different potential causes and the codes generate reimbursements at different rates.

Specifically, if a physician diagnoses “bacterial pneumonia” but does not specify the organism that caused it, the proper code is allegedly 482.9, “bacterial pneumonia unspecified”. In contrast, if the physician diagnoses “bacterial pneumonia” and also concludes that it arose from a specific bacteria of a kind that does not have a specific code associated with it, the proper code is 482.89, “pneumonia due to other specified bacteria”. In the latter scenario, it is apparently necessary to specify the kind of bacteria in the file. Code 489.89 is a higher paying code than 482.9. The government’s allegation is simple: the Hospital Defendants repeatedly used 482.89 when they should have used 482.9 and thereby received a higher reimbursement than warranted.

B. Procedural History

On February 27, 1996, Health Outcomes filed, against 100 hospitals, an action on behalf of the United States under seal in the Eastern District of Pennsylvania pursuant to the qui tam provisions of the False Claims Act, 31 U.S.C. §§ 3729-3733. The suit was based upon statistical evidence and alleged misconduct to defraud Medicare with respect to the use by the hospitals of certain diagnosis codes. 2 The complaint seeks treble damages and civil penalties under the False Claims Act. Several hospitals in Massachusetts, including the three Hospital Defendants in this action, were among the 100 original hospital-defendants.

More than five years later, in August, 2001, the United States District Court for the Eastern District of Pennsylvania severed claims against the Massachusetts hospitals and transferred them to this Court. The case was assigned to United States District Judge Tauro until July 13, 2004, when it was re-assigned to this session.

While- the case was assigned to Judge Tauro, the government repeatedly sought and obtained extensions of the time to consider whether to intervene. The government finally filed a Notice of Intervention on December 31, 2003. Its complaint, entitled the “First Amended Complaint” *46 (replacing Health Outcomes’s complaint), was filed on July 1, 2004. It alleged claims for violations of the False Claims Act, 31 U.S.C. §§ 3729 et seg., unjust enrichment, “payment by mistake” and recoupment.

On January 13, 2005, the government filed a “Second Amended Complaint” which added additional factual allegations to the claims. The government did not seek leave of Court before filing the amendment, claiming it was unnecessary pursuant to Fed.R.Civ.P. 15 (which permits one amendment without leave before a responsive pleading is filed) because “no responsive pleading ha[d] been served” by the defendants.

The defendants deny all allegations of wrongdoing and allege that the coding practices they used were legitimate. Two motions to dismiss and a motion to strike had been filed at the time of the scheduling conference on March 30, 2005. At that conference, the Court, after hearing oral argument, 1) denied defendants’ Motion to Strike the Second Amended Complaint, 2) denied defendants’ Motion to Dismiss pursuant to Fed.R.Civ.P. 12(b)(6) as moot, 3) denied defendants’s Motion to Dismiss pursuant to Fed.R.Civ.P. 9(b) as moot and 4) gave defendants leave to re-file their motions to dismiss with respect to the second amended complaint. Since that conference, defendants have filed four motions: 1) Motion to Stay Pursuant to the Primary Jurisdiction Doctrine, 2) Motion to Dismiss the Second Amended Complaint for Failure to Comply with the Particularity Requirements of Fed.R.Civ.P. 9(b), 3) Motion to Dismiss the Second Amended Complaint Based on Statute of Limitations and 4) Motion to Dismiss the Entire Second Amended Complaint for Failure to State a Claim and, with Regard to the Common Law Claims Asserted Therein, for Lack of Jurisdiction. The government opposes all of those motions and the Court now resolves them as follows.

II. Legal Analysis

A. Standard of Review

A court may not dismiss a complaint for failure to state a claim under Fed.R.Civ.P. 12(b)(6) “unless it appears, beyond doubt, that the [pjlaintiff can prove no set of facts in support of his claim which would entitle him to relief.” Judge v. City of Lowell, 160 F.3d 67, 72 (1st Cir.1998)(quoting Conley v. Gibson, 355 U.S. 41, 45-46, 78 S.Ct. 99, 2 L.Ed.2d 80 (1957)). In considering the merits of a motion to dismiss, the court may look only to the facts alleged in the pleadings, documents attached as exhibits or incorporated by reference in the complaint and matters of which judicial notice can be taken. Nollet v. Justices of the Trial Court of Mass., 83 F.Supp.2d 204, 208 (D.Mass.2000) aff'd, 248 F.3d 1127 (1st Cir.2000).

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Bluebook (online)
409 F. Supp. 2d 43, 2006 U.S. Dist. LEXIS 1593, 2006 WL 137308, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-ex-rel-health-outcomes-technologies-v-hallmark-health-mad-2006.