UNITED STATES OF AMERICA v. UPMC

CourtDistrict Court, W.D. Pennsylvania
DecidedJune 29, 2022
Docket2:12-cv-00145
StatusUnknown

This text of UNITED STATES OF AMERICA v. UPMC (UNITED STATES OF AMERICA v. UPMC) is published on Counsel Stack Legal Research, covering District Court, W.D. Pennsylvania 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. UPMC, (W.D. Pa. 2022).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA

UNITED STATES OF AMERICA, ) et al., ) ) Plaintiffs, ) Civil Action No. 12-145 ) v. ) Judge Cathy Bissoon ) UPMC, et al., ) ) Defendants. )

MEMORANDUM AND ORDER

I. MEMORANDUM Defendants’ Motion for summary judgment (see Doc. 206) will be denied.1 The parties’ cross-Motions to strike each other’s expert opinions regarding fair market value (see Docs. 198, 209 & 219) – the only expert opinions implicated by the Court’s summary judgment analyses – also will be denied. Opinions regarding fair market value (“FMV”) aside, the parties’ cross Motions to strike each other’s experts (see Docs. 193, 194, 196, 198, 200, 209, 213 & 219) will be denied, without prejudice. Finally, Plaintiffs’ Motion (Doc. 266) to continue the seal will be granted, and Defendants’ Motions to continue the seal (Docs. 265 & 268) will be denied, with instructions. In moving for summary judgment, Defendants take issue, early and often, with Plaintiffs’ decision to make little (or no) effort to adduce evidence regarding how, specifically, the Physicians are alleged to have inflated their wRVUs. See, e.g., Doc. 206-1 at pg. 6 of 32

1 Plaintiffs have withdrawn their Motion (Doc. 203) for partial summary judgment, and that will be denied as moot. In light of the rulings herein, moreover, Plaintiffs’ Motion (Doc. 223) to strike Defendants’ statement of facts likewise will be denied as moot. (“Despite fifteen fact depositions, two third party data subpoenas, nearly 100 document requests, hundreds of requests for admission, and more than two-dozen interrogatories, all yielding hundreds of thousands of pages of produced documents and a decade of claims data, Relators have unearthed no evidence of fraud.”).2 While, admittedly, this Court likewise took issue with Plaintiffs’ failure to plead such facts, the Court of Appeals for the Third Circuit’s Opinion

teaches that such evidence is not required. Rather, the Circuit Court indicated that such a showing was only one of five different ways Plaintiffs might establish that the Physicians’ compensation “varie[d] with, or [took] into account, the volume or value of referrals.” See generally Doc. 116-1 at pgs. 6 and 17 of 33. [Plaintiffs] allege five sets of facts that suggest that the [Physicians’] pay far exceeded [FMV]: pay exceeding collections, pay above the 90th percentile, extreme Work Units, bonuses above the Medicare reimbursement rate, and [“]the settlement[,” which the Circuit Court used as shorthand for Plaintiffs’ then-stated theories of fraudulent wRVU inflation].

Id. at pg. 24 of 33. The undersigned does not read the Opinion as stating or implying that, through discovery, Plaintiffs were required to identify specific instances of fraudulent wRVU inflation. To the contrary, there is zero indication that Plaintiff cannot proceed through summary judgment, and ultimately at trial, on the other four indicia referenced by the Circuit Court. Thus, the questions on summary judgment are, do triable issues of fact remain regarding: (a) FMV; and (b) whether payment in excess of FMV would allow a reasonable inference that Defendants “kn[ew], recklessly disregard[ed], or deliberately ignore[d]” that compensation “varie[d] with, or [took] into account, the volume or value of referrals.” Id. at pg. 17 of 33.

2 For the sake of consistency, all record citations are made by reference to the ECF banner numbers, irrespective of the documents’ internal pagination. Given the theories permitted, and in all candor, it is unsurprising that Plaintiffs survive summary judgment. Plaintiffs have elicited enough testimony and documentation in support of the “common sense,” “obvious”3 conclusion: “Compensation for personal services above [FMV] can suggest that the compensation is really for referrals.” Id. at pg. 18 of 33. The evidence summarized in Plaintiffs’ opposition brief, read in a light most favorable to

them, is sufficient to present a jury issue regarding scienter. See Doc. 236 at pgs. 14-17 of 34 (citing and quoting record evidence). Plaintiff also has retained an expert, Kathy McNamara, who opines regarding FMV. So too have Defendants, and the Court rejects the parties’ mutual attacks on their competing expert’s methodologies. These points are for a jury to decide. See Sun Pharma Global Fze v. Lupin Ltd., 2021 WL 856886, *7 (D. N.J. Mar. 8, 2021) (citing and quoting numerous legal principles applicable under these circumstances); see also generally Lansford-Coaldale Joint Water Auth. v. Tonolli Corp., 4 F.3d 1209, 1216 (3d Cir. 1993) (“in a battle of the experts, the factfinder decide[s] the victor”) (alteration in original, citation to quoted source omitted).

To be sure, Defendants and their counsel have fought the good fight, and the Court has considered their varied, numerous arguments as to why no jury issues present. As for where the case stands, after discovery, it seems fair to say that not much has been done to “move the ball down the field.” But, in light of the Circuit Court’s teachings, the undersigned cannot say it is not enough. Although Defendants have tried to insulate, or explain away, Plaintiffs’ strands of evidence regarding scienter, the collective weight of the “full wins” necessary for Defendants to prevail on summary judgment proves too much. And, while Defendants argue that “no court has

3 See generally id. at pgs. 5, 18, 19 and 32 of 33. allowed a relator to rely exclusively on the opinion of an expert witness” regarding FMV,4 the implications of the Circuit Court’s Opinion run opposite (i.e., an issue of material fact regarding obvious, common sense inferences of scienter, plus competent expert testimony regarding FMV, is enough). Summary judgment must be denied. These things being said, the Court notes that Defendants have not moved for partial

summary judgment, regarding certain of the Physicians, or certain of the Physician work-years, for which compensation is not opined to have exceeded FMV. See Doc. 242-1 at pg. 6 of 50 (McNamara report, asserting that compensation exceeded FMV for Drs. Abla, Bejjani, Horowitz, Kassam, Spiro, El-Kadi and Maroon, most of which for less than all years during the relevant timeframe). Defendants’ briefing highlights that Plaintiffs’ Stark Act proofs must extend to “each named neurosurgeon, for each year of their employment during the relevant time period.” See Doc. 206-1 at pg. 18 of 32. Although the point does not establish that summary judgment, on the whole, is warranted − it is not incorrect, and it may well inform the universe of putative

recovery. Defendants, understandably, have not sought to so-parse Plaintiffs’ claims on summary judgment. To be clear, though, the Court has not passed on the issue.5 The only other resolution presently required is the parties’ requests to extend the seal regarding summary judgment papers. Plaintiffs’ requests present an easy case, because their

4 See Doc. 206-1 at pg. 23 of 32.

5 In the Circuit Court’s decision, discussions regarding FMV appear in rarified air. Although the matter presently is not before the Court, whether McNamara’s opinions warrant or allow extrapolation of putative liability beyond her select FMV determinations appears an open question. At the very least, Defendants can be expected to argue to the jury that liability, if any, is appropriately limited. See Doc. 206-1 at pg. 23 of 32 (emphasizing McNamara’s opinion that “the aggregate compensation paid to [only] seven of the thirteen neurosurgeons exceeded [FMV] in some (but not all) years”). redactions are narrowly tailored to shield the disclosure of protected health or personal identifying information of patients. The former implicate HIPAA, and the latter are covered under Local Rule 5.2.D.

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UNITED STATES OF AMERICA v. UPMC, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-of-america-v-upmc-pawd-2022.