United States v. CMC II, LLC et al 8:11 CV 1303 SDM-TBM (M.D. Florida)
This is one of our qui tam cases which has been unsealed and is being litigated in Florida. The Middle District of Florida is part of the 11th Circuit which sets a very high bar on False Claims Act cases when challenged with a motion to dismiss under “rule 9(b).” This rule requires that any False Claims Act case alleging fraud against the defendant should describe the “who, what, where and when” of the fraud. The Court ruled that the whistleblower had provided enough detail and that the complaint is sufficient to meet the exacting standard of the 11th Circuit.
This relator alleges the wholesale upcoding of reimbursement claims to Medicare and Florida Medicaid. The whistleblower, a nurse who worked at the defendants’ medical facilities, alleges that they provided substandard care and inflated billing codes submitted to government health care programs. Discovery will now proceed on the relator’s allegations that:
• Defendants falsified paperwork (MDS Assessments) for residents covered by Medicare and TRICARE by overstating residents’ medical needs and the amount of care provided to them.
• Defendants fraudulently inflated the Resource Utilization Group (“RUG”) levels reported in MDS Assessments in order to increase their Medicare and TRICARE reimbursement rates.
• Defendants routinely falsified MDS Assessments to report that they had completed care plans for their Medicaid residents, when in fact no such care plans even existed.
• To avoid detection of this fraudulent scheme, Defendants would routinely create generic, boilerplate care plans for residents many months after their admission, but shortly before scheduled audit periods.
• Defendants routinely falsified the identities of the persons submitting MDS Assessments to facilitate their fraudulent scheme.