am argumentative this morning i think i can be of more use to the court back and i'm going to start where i think this case is going to end for at least the issue on wh will turn having read all the briefs and thought this time through i believe it comes down to this is there a special rule for epidural anesthesia that trumps the general rule in sapporo as we're concerned about submitting claims to medicaid now the general rule is patients now that is the general rule now to help us get started you have probably run across you what's that would you base that young exhibit twelve become plane which is the most recent handbook for practitioners rendering medical services i fear look at the record that's seven fifty six and then on seven fifty seven is the general rule and then on seven fifty care and this very important and a sleazy anesthesia services are to be submitted only for the time period spent in the operating room beginning with the are absolutely now that that is not a rule that applies across the board because if we go if we go on in the same in the same handbook for instance if you anesthesia and it's followed by a general anesthesia which sometimes happens you have to bill for those separately but again separately and minutes and regulations it depends for instance you're going to hear about the acronym the c p t which is the common protocol terminology which has a general application across the united states every a  says some form or the other and some of those have different requirements this is they may let you build an order of an hour some of them like the state of indiana for instance just heels by the procedure there but the answer to that is no one has to participate in the medicaid program and that was going to be the next thing i was going to tell you enter it under exhibit fifteen it shows what a claim is how you fill it out with instructions and i think it's exhibit three tells you you have to have a written agreement with the state of illinois in exhibit four shows you what you're agreeing to and you agreed to do this i mean it's not like this is a surprise you have to do it this way it's a state sponsored program murphy does but mark where you're at so you can get back to the i want to back away from the specifics here and first ask you what kind of action is this this is a claim under the only false claims act ok what are the elements of a claim under the also claims act well first of all you have to submit a climb to the state of illinois to the state of illinois which is  can't blame it on your secretary i mean you know when we submitted a claim that's the first that's the first thing and when you do it and you do it the claim is false and what we set out here in very very particular that doctors are saying that they spent this time in minutes with their patients and in many times it's exaggerated by as much as seven or eight hundred percent o what the trial or on the missing two things i think first we we used up a lot of trees arguing over what the custom and practice is and i don't know if you had a chance to pull that out of the briefs but the c p t manual itself i think now in the fourth edition talks about that you see you submit your time in accordance with the custom and practice terminology as is actually happy name a name but an elnora there is only one way you have to submit it in minutes that's that would be  on if you if you look at it i think that is exhibit fifteen to the second amended complaint and it's the field is twenty four f and you but the day and you put the number of minutes will counsel i really feel that you hit the nail on the head when you started out by indicating the issue is whether or not there's a special rule for after all procedures why doesn't that answer our question and why doesn't that trump the general rule that you're talking ok if you could go to page seven fifty eight of the record and i don't know if you have that immediately in front anesthesia and now this is after the general rule that you have to be with your patience well i mean we're looking at bacon i think and i recalling correctly they can handle up to four patients that's a whole different issue  you can you can i think it's supervised up to over but then per each patient supervise it's at a reduced right if my memory doesn't pay only i think it's at about thirty five but that is not in this case ok so let's get back epidural anesthesia services during a single operative session using the appropriate c p t co these you know here the appropriate physical status modifier and the total anesthesia administration time do not submit the major surgical procedure co other words when you're doing this we're not concerned whether you're getting on an appendectomy or whatever it is you've just got your total time here and you only say you only get the submit four for the total for the total time now the argument for the deficiency is well this if you don't you don't you don't even have to be there you can you can start you can start induction and you can just leave but here's the bank is they say and i think this really tells you what what they're doing here under two twenty one two point four well the girl anesthesia is started during labor but discontinued and then a general anesthetic administered to charges should be submitted the push charge should be for the appropriate epidural anesthesia and the epidural time in minutes and the second code should be the appropriate general anesthesia c charged you just you don't get to charge if you're not there to me we've got a case here of the doctors come in they send thirty minutes with the patients they go home i mean this isn't the pleats i'd like to go back  federal cases so there's no intent of it all but the real reason is yellowstone eleanor attorney general is broke they can hardly staff their trials they are bleeding lawyers because because of it they were the only attorney general rare in this day and age will get in a false claims act case the fact of the matter is the a g is not staffed and is not funded to do the job that exchange that's our analysis of the six fifteen motion over what was put in the complying well yes and that's why i said the case ends where we're stuck if you believe if you believe that the section that specifically references  the general rule that if it exempts the doctor from the physical presence then they win if you don't we win that but there's no conflict in what we've alleged and what and what is here what they're saying deek manual which this is all based on which by the way isn't operating it is incorporated by rule a cody this is that's it and the judge the judge thought west said this before very good judge perry gives a listen he thought that this custom and practice in the first instance had something to do with how you bill in other words but this is the general rule down here in springfield you know that's that's a good enough well course there would be no end to the run on the public fis if that is that if that is the rule no ended all the end of all syria now the question m p was involved in the billing practices of a us during the period of two thousand and two to two thousand and eight where the allegations of the complaint looking at the handbook for the aperiodic time there's specific language that controls how the billing of epidural should be conducted by the hands these out as practice groups in their billing services in section eighty two eighty three point delivery submit one total charge then moves the total it ministration time and then it goes on it says enter the total of ministration time in field twenty four if the total number of minutes of service and is just this they are mind pointed out it further continues to say that if you go over fourteen hundred forty minutes which is twenty four hours you then have to submit an anesthesia record to support th mistreatment this is important because one the attorney general has not entered this case and i can't speak to whether or not their finances are the reason why but another thing that could have occurred because this they did not provide the who what where and when whose custom for what period of time that period of time is important because we have a billing service provider that's in place from two thousand to two thousand and eight if you look at the pleadings they they talk about over the time that in fact it was with the patients for thirty minutes in the bill was for the total time which could be of three hundred minutes all of those allegations relate to periods of time after two thousand and eight they don't specifically allege any facts that there was billing above the amount of time that the physician dancy's alice was with the patient during the period my client was there the fact that they can't tell us we believe that the specific provisions of the handbook which should control over the c p t general provision when you look at the second sentence it talks about the time which begins when the patient may be safely placed under post operative supervision the trial court found that the omission of any facts that the patient was placed safely under post operative supervision was dispositive of the issue and was a second reason for finding a deficiency and a two six fifteen basis to dismiss the case this is a false claims and claim it's a fraud like all the fend and submit th occasions that the c p code is just a general application it comes back to as we've stated her briefs as we've argued here today that the special rule that rule that applies to how epidural should be bil state c p t codes are a set of medical coding numbers utilized by health care providers to report to insurance companies and other medical payers for specific medical surgical or guy who with that they give a number to that's what the whole c p t system is and everybody uses these numbers because they don't want to have to have a description of whatever procedure it is they use the numbers and in in front of each of the sections within the c p t code is a little bit of a general overview and then this is the end of speeches section there's a little bit of general overview and in there there is a paragraph customary in the local area now if that sentence is to be given any meaning then you have to look about how other providers are billing this and that's why i think that the statement that the counsel made at the end of the hearing in front of judge but don't worry any admitted that virtually everybody is now billing this way is absolutely relevant to this very issue and the core of the t regulations are sufficient i don't think even look at this but if you're going to look at this you've got to look at in the context of what it really is this is some sort of treatise on exactly how him as he just the bill no it's just general sort of things this paragraph deals with the specific situation when you're in an operating room and that's all it's meant it's not meant to cover every single situation nationwide for everything and then it's clear here that we've got him put out by the state of illinois they have special provisions for epidurals that's what's governing that's the specific who controls the with the general very general totally misplaced thank  generally it's it's because the plaintiff either did not has not stated because the back should against the defendants and even further than that it's the defendant cannot state a cause o or and in this case the relator cannot state a cause of action that these defendants committed submitted balls claims to illinois medicaid i went through it is not earlier mister murphy said that what happened to four surgeries going on one time really didn't mean anything because the medical direction or medical supervision there's two different charges what is important because when this case began in federal court the argument was that the labor after girl added a fifth operational procedure which then man that the anesthesiologist was not medically directing but instead a lower level of lower charge supervised and the u s district court said no that's it's it's not treated that way so that is another indication of the carve out and if you look at the services may be provided by an anesthesiologist and should be reported according to the anesthesia guidelines in the c p p and they will be based on intra operative time so yes this is a manual of general application but the state of illinois has saw fit to pull it into their medicaid plan that's true doesn't make it any less in force but we have more we have the regulations that are also in exhibit twelve that are attached that make specific walk is required in this case and they track the c p t code almost perfect the same language that you just heard two things and i just want you to think about this everyone knows that a physician can't stay with a patient per quarter for hours agree accordingly he can't build for twenty four hours if the patient requires anesthesia anesthesiology during that time somebody is going to have to come and relieve the doctor it's on top and then their back doctor can bill for that it's still you can't build more than the actual time but you can't bail for when you're not there so that that should not lead us astray now the third point i don't think this is a problem but the federal court case is really not before this case we did not state a claim in the federal district court for a violation of the federal false claims act case under medicare different scheme different requirements for what it's worth the federal district judge said there very well may be a false claim under the state statute but that judge was happy to exercise that order that every federal judge you just heard an argument about that is when the state medicaid is going to make an adjustment for what medicare is paid for and how they're going to make those adjustments has absolutely nothing to do with this  with this with this case so this case and i don't back down from this case will him when you carefully read the regulation and by the way i've been back through it i believe the other hand books are attached for all relevant periods of time ok the language is almost identical all the way through so there won't be a difference between the two away to a six and then the current other questions that i