United States Ex Rel. Willard v. Humana Health Plan of Texas Inc.

336 F.3d 375, 56 Fed. R. Serv. 3d 458, 2003 U.S. App. LEXIS 12933, 2003 WL 21467963
CourtCourt of Appeals for the Fifth Circuit
DecidedJune 26, 2003
Docket02-40285
StatusPublished
Cited by505 cases

This text of 336 F.3d 375 (United States Ex Rel. Willard v. Humana Health Plan of Texas Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth 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. Willard v. Humana Health Plan of Texas Inc., 336 F.3d 375, 56 Fed. R. Serv. 3d 458, 2003 U.S. App. LEXIS 12933, 2003 WL 21467963 (5th Cir. 2003).

Opinion

GARWOOD, Circuit Judge:

In this qui tam action, the United States of America, through its relator Irvin Willard (Willard), appeals from the judgment of the district court, pursuant to Fed. R.Civ.P. 12(b)(6) and 9(b), dismissing the second amended complaint filed against Humana Health Plan of Texas, Inc. and Humana, Inc. (Humana) alleging Humana violated the False Claims Act, 31 U.S.C. § 3729, et seq. (FCA). We affirm.

Facts and Proceedings Below

Humana, Inc., through its subsidiary Humana Health Plan of Texas, Inc., operates health maintenance organizations in various counties in Texas. Humana entered into contracts with the Health Care Financing Administration (HCFA) of the United States Department of Health and Human Services to provide health care services to Medicare beneficiaries. Huma-na is paid a fixed rate for each enrollee, determined annually, based on the average anticipated Medicare expenses of all Medicare-eligible individuals in a given geographic area, generally on a county-by-county basis. These rates are referred to as capitation rates.

Willard worked as a sales representative for Humana from 1995 through 1998, selling Humana’s Medicare HMO products. During this time, Humana operated an HMO for Medicare beneficiaries in a Houston service area comprised of Harris, Austin, Colorado, Fayette, and Waller counties. Harris County encompasses the metropolitan Houston area, while the other counties are comprised of more rural areas.

An HMO under contract with the HCFA may not discriminate in enrollment on the basis of health, or on any other basis used as a proxy for health. See 42 U.S.C. § 1395mm(i)(6)(a)(iv); 42 C.F.R. § 417.428(b)(1). Willard contends that, fairly read, its Second Amended Complaint alleges that Humana engaged in a “cher-rypicking” scheme “whereby less healthy potential program participants and those living in counties outside Humana’s favored geographic area were methodically discouraged from joining Humana’s HMO.” Willard alleged in his complaint that Humana adopted a variety of techniques to prevent eligible participants from learning they can join Humana’s HMOs. Willard further alleged that he was “told that Humana only wanted to insure healthy people, and would lose money if it enrolled sick people or people who lived *379 too far from Humana’s established providers.” Willard asserts that when he persisted in sohciting and enrolling people from the outlying counties, he was warned not to do so, and was ultimately fired.

Willard contends that in order for Hu-mana to gain entry into the lucrative Houston market, HCFA required that Hu-mana serve the outlying counties. In his complaint, Willard alleged that “[w]ithout reveahng its intentions to either relators or HCFA, Humana Texas entered [into] contracts to serve those counties with no intention of actually enrolling Medicare participants there.”

In May 1999 Willard filed a qui tam complaint under the FCA against Humana and other HMOs. The Government elected not to intervene. Thereafter, in May 2000 Willard filed his First Amended Complaint and Humana filed a motion to dismiss Willard’s First Amended Complaint pursuant to Federal Rules of Civil Procedure 12(b)(6) and 9(b), and challenged the constitutionahty of the FCA’s qui tam provision. On August 10, 2000, Judge Kent stayed the ease pending this court’s en banc decision in Riley v. St. Luke’s Episcopal Hospital, 252 F.3d 749 (5th Cir.2001) (en banc), in which this court, upheld the constitutionahty of the FCA’s qui tam provision. At a July 2001 status conference following the Riley decision, Humana reasserted its request for Willard to plead fraud with specificity. Judge Kent granted Willard leave to amend his complaint and allowed Humana to reassert its non-constitutional grounds for dismissal. Willard filed his Second Amended Complaint later in July 2001.

On July 30, 2001, the case was transferred to Judge Lake. Humana filed a renewed motion to dismiss Willard’s Second Amended Complaint pursuant to Fed. R.Civ.P. 12(b)(6) and 9(b) and Willard moved for partial summary judgment. Judge Lake granted the motion to dismiss and denied the motion for summary judgment as moot. Willard appeals the district court’s grant of the motion to dismiss, as well as the district court’s denial of leave to amend his complaint.

DISCUSSION

I. Standard of Review

We review a Rule 12(b)(6) motion de novo and accept all well-plead factual allegations as true. Abrams v. Baker Hughes, Inc., 292 F.3d 424, 430 (5th Cir.2002). “[T]he central issue is whether, in the light most favorable to the plaintiff, the complaint states a vahd claim for relief.” Copeland v. Wasserstein, Perella & Co., Inc., 278 F.3d 472, 477 (5th Cir.2002). “Under Rule 12(b)(6), a claim maybe dismissed when a plaintiff fails to allege any set of facts in support of. his claim which would entitle him.to relief’ and “the court accepts as true the well-pled factual allegations in the complaint, and construes them in the light most favorable to the plaintiff.” Taylor v. Books A Million, Inc., 296 F.3d 376, 378 (5th Cir.2002). However, “eonclusory allegations ... will -not suffice to prevent a motion to dismiss,” id., and neither will “unwarranted deductions of fact.” Guidry v. Bank of LaPlace, 954 F.2d 278, 281 (5th Cir.1992). In deciding a motion to dismiss the court may consider documents attached to or incorporated in the complaint and matters of which judicial notice may be taken. Lovelace v. Software Spectrum Inc., 78 F.3d 1015, 1017-18 (5th Cir.1996).

We review the district court’s denial of leave to amend the complaint for abuse of discretion. Hypes v. First Commerce Corp., 134 F.3d 721, 727-28 (5th Cir.1998).

*380 II. Dismissal of Willard’s Claims

Willard’s Second’ Amended Complaint alleges that Humana violated 31 U.S.C. § 3729(a)(1) and (a)(2). Section 3729 states in relevant part: ■

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336 F.3d 375, 56 Fed. R. Serv. 3d 458, 2003 U.S. App. LEXIS 12933, 2003 WL 21467963, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-ex-rel-willard-v-humana-health-plan-of-texas-inc-ca5-2003.