United States of America v. Northwestern Memorial Healthcare

CourtDistrict Court, N.D. Illinois
DecidedSeptember 29, 2023
Docket1:19-cv-00593
StatusUnknown

This text of United States of America v. Northwestern Memorial Healthcare (United States of America v. Northwestern Memorial Healthcare) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United States of America v. Northwestern Memorial Healthcare, (N.D. Ill. 2023).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

UNITED STATES OF AMERICA and THE STATE OF ILLINOIS, ex rel. PCTLS, LLC, No. 19-cv-00593

Plaintiffs, Judge John F. Kness v.

NORTHWESTERN MEMORIAL HEALTHCARE d/b/a NORTHWESTERN MEDICINE; and CONNANCE, INC.

Defendants.

MEMORANDUM OPINION AND ORDER Plaintiff-Relator PCTLS, LLC sued Defendants Northwestern Memorial Healthcare and Connance, Inc. on behalf of the United States of America and the State of Illinois in a qui tam action alleging a multi-million-dollar fraud on U.S. taxpayers in violation of the False Claims Act, Anti-Kickback Statute, and Illinois Insurance Claims Fraud Prevention Act. (Dkt. 1.) Plaintiff asserts that Northwestern engaged in five principal fraudulent schemes beginning in 2006, generally resulting in privately insured patients receiving discounts on services. (Id. ¶ 2.) Plaintiff also asserts that Connance provided information to Northwestern that Northwestern then used in the alleged fraudulent schemes. (Id. ¶ 15.) Plaintiff seeks treble damages, civil penalties, and attorneys’ fees and costs. (Id. ¶ 6.) Presently before the Court are Defendants’ motions to dismiss under Rule 12 of the Federal Rules of Civil Procedure. (Dkt. 29; Dkt. 32.) Because Plaintiff, as explained below, fails to state a claim for which relief could be granted under the heightened requirements for pleading claims involving fraud, the Motions to Dismiss are granted without prejudice and with leave to replead.

I. BACKGROUND Plaintiff PCTLS, LLC is a limited liability company acting on behalf of the United States of America and State of Illinois. (Dkt. 1 at ¶¶ 12–13.) Defendant Northwestern Memorial Healthcare is the sole corporate member of Central DuPage Hospital Association, which operates the medical testing facility HealthLab.1 (Dkt. 1 ¶¶ 14, 35; Dkt. 33 at 4.) Defendant Connance, Inc. is a technology company that purportedly uses a proprietary algorithm and publicly available information to

estimate patients’ ability to pay medical bills. (Dkt. 1 ¶ 15.) Plaintiff alleges that Northwestern’s practice of waiving or discounting patient co-payments is an unlawful kickback scheme. (Id. ¶ 16.) Plaintiff alleges that one of the “principal purposes behind co-payment and deductible requirements is to make patients conscious of the expense of their medical services, and thereby discourage the ordering and performance of unnecessary medical services.” (Id. ¶ 25.) Plaintiff

further alleges that Northwestern discounts or waives insurance co-payments or

1 Northwestern contends that it is an improper defendant, and that Plaintiff’s failure to allege a basis for its liability for Central DuPage Hospital Association’s conduct is reason enough to dismiss the Complaint. (Dkt. 33 at 8.) Another judge in this District previously granted a motion to dismiss when a plaintiff attempted to sue a parent corporation for its subsidiary’s FCA/IFCA violations. United States v. Am. at Home Healthcare and Nursing Servs., Ltd., 2018 WL 319319, at *3 (N.D. Ill. Jan. 8, 2018). Failure to plead facts such that the “court may properly pierce the parent’s corporate veil” may lead to dismissal. Id. But because the Court grants the motion to dismiss on other grounds, it will assume for present purposes that Northwestern is a proper defendant in this case. deductibles as part of a scheme to make their medical offices more appealing. (Id. ¶ 26.) Plaintiff asserts that such patient-friendly practices induce physicians to order additional and unnecessary tests. (Id. ¶ 27.)

Plaintiff also alleges that Northwestern’s fraudulent activity is perpetrated through its subsidiary, HealthLab. HealthLab is an outpatient reference laboratory that serves physicians and physician groups throughout Illinois. (Id. ¶ 35.) HealthLab performs clinical laboratory services including analyses of human body specimens (such as blood). (Id.) HealthLab performs those clinical laboratory services for physicians, clinics, and hospitals on behalf of patients insured by federal Medicare, state Medicaid, and private insurance companies. (Id.) Plaintiff alleges that

Healthlab is operated as, and thus bills at the higher rates of, a hospital laboratory. (Id. ¶¶ 37–39.) But although HealthLab bills out at high rates, Plaintiff alleges HealthLab deeply discounts charges to privately insured individuals that otherwise would use a different lab. (Id. ¶¶ 40–43.) In its Complaint, Plaintiff alleges that five HealthLab practices are or were fraudulent. First, Northwestern routinely waived patient co-payments and

deductibles from 2006 to 2013. (Id. ¶¶ 45–49.) Second, from 2014–2016, Northwestern allegedly capped privately insured patients’ co-payments at $25 to $45 based on the patients’ presumed household income as calculated by Connance. (Id. ¶¶ 50–55.) Northwestern called this its “presumptive charity” program. (Id. ¶ 51.) Third, from 2016 through the present, Northwestern modified its payment pricing process to extend deductible discounts of up to 96.5%. (Id. ¶¶ 56–59.) Fourth, HealthLab provided physician clients with rates on laboratory tests far below what the physician receives from payers. (Id. ¶¶ 63–65.) And fifth, some number of tests billed by HealthLab occurred in downtown Chicago rather than at Central Dupage

Hospital. (Id. ¶¶ 66–68.) Plaintiff alleges that these schemes violate the False Claims Act (FCA) (Counts I to IV)2 and the Illinois Insurance Fraud and Prevention Act (Count V). II. LEGAL STANDARD A motion to dismiss under Rule 12(b)(6) of the Federal Rules of Civil Procedure “challenges the sufficiency of the complaint to state a claim upon which relief may be granted.” Hallinan v. Fraternal Order of Police of Chicago Lodge No. 7, 570 F.3d 811,

820 (7th Cir. 2009). Under Rule 8(a)(2) of the Federal Rules of Civil Procedure, a complaint must include “a short and plain statement of the claim showing that the pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2). A plaintiff “must give enough details about the subject-matter of the case to present a story that holds together.” McCauley v. City of Chicago, 671 F.3d 611, 616 (7th Cir. 2011) (quoting Swanson v. Citibank, N.A., 614 F.3d 400, 404 (7th Cir. 2010)). The required level of “factual

specificity rises with the complexity of the claim.” Id. at 616–17. Allegations brought under the FCA are subject to the heightened pleading standard set forth in Rule 9(b) of the Federal Rules of Civil Procedure. See United States ex rel. Nedza v. Am. Imaging Mgmt., Inc., 2019 WL 1426013, at *5 (N.D. Ill. Mar. 29, 2019) (citing Thulin v. Shopko Stores Operating Co., 771 F.3d 994, 1000 (7th

2 Plaintiff’s separate claims for relief, called “Counts” in this opinion, are referred to as “Causes of Action” in the Complaint. Cir. 2014)).

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United States of America v. Northwestern Memorial Healthcare, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-of-america-v-northwestern-memorial-healthcare-ilnd-2023.