the relator here and if i could begin i'd like to highlight a group of allegations in our complaint that standing alone all by themselves even without all of the understood that they were expected by the defendant's medical director to sign anesthesia records as if they were present in the operating room and fifteen minute intervals even when they were not we al ninety three make the general allegation that in fact the practice of the defendants anesthesiologists was to falsely signing in your records indicating their presence in the operating room when they weren't there relating that he never goes into the operating rooms and that his practice was to always sign the anesthesia records beforehand as if he were present in the operating room at fifteen minute intervals even when he was not told him those allegations all by themselves are enough to plead that the defense that all of the defendants bills for doctor with child services were false claims submitted to the united states government now we think all by itself that is enough to cause this complaint to live under rule nine be not the complete of course is far more detailed and belief but in fact we don't our complaint throughout is based on the relator personal knowledge in depth at every element of this fraud with regard to every particular practice that was required of the anesthesiologist in order to bill for medical direction with regard to every one of those items the relator please based on his own personal knowledge of not only the broad failures of the defendant fancy the ologies to comply with the rules for billing but also very specifically laying out again when the district court asked us for specific examples laying out ten examples of that happening and by the way those ten examples including all of the defendants various anesthesiologists which were not a big group this correct but i don't think that that really ultimately is going to bear on the decision here you know your honor for example in our various in the very near not a bad thing in your complain at least i don't see anywhere in this i'm wrong please identify where that these services could not have lawfully built been tilled under the code for medical supervision your complaint seems to be to be focused on medically directed our complaint is focused on medically direct we allege that this is that these defendants made it their policy to bill for medical directions they gave instructions for how it was going to be that they were going to bill for medical direction and we believe we are entitled to be in for it's that at least in a lot of cases in the ports we believe that all of the cases that at least in a lot of the cases they actually did bill in accordance with their policy in accordance with the the overall guidance that they were giving to their doctors i said why no hands on your power from your allegations why is the necessary inference that the defendants bill for the claims as medically directed versus medically supervised well st the answer is in two  well we begin with at the very beginning at the very inception of the defendants taking over the n s c is the anesthesia services at this hospital that they declared to the doctors we are going to be a firm that bills for medical direction they then gave instructions to their doctors this is how we are going to do it we plead what it is that the doctors understanding of those instructions were fixed but i just reached for the wrong document but in the same paragraph where we allege that dr pease the medical director gave her instruction we also allege well your honor because we planned it we have a very high confidence that those ten examples were all billed as medical directions if that in fact were the instructions that would be an instruction that we would take back to the district with great confidence we don't actually believe the bet's the requirement but assuming that were the instruction and if in fact some number of those ten were actually built or of the seven and you're on a raid were actually built for medical direction then we are free to go forward your honor we don't actually believe that that's a bad result because if we have the courage of our convictions and remember dump doctrine on a lack of part of the small team the really didn't understand what was going on here  then we'd be right and those instances will in fact prove out to be medical direction billing and fraudulent medical direction billing i you know i mean answering on one foot so to speak but i do believe i can say w confidence we'd be all right i think it's also you know you know we get down into the specifics of all of these but i do think that it's important for us to back up for us to elevate ourselves in take the broader perspective on how with in the case law of the th circuit and if we take the lost the case and we look and see you know how do the facts of our case how the allegations of our case compare with other cases that have come down in the th circuit we discovery and public obloquy i think we have anything other than vague and unsubstantiated allegations we have a firm that has said they intend to bill every thing in medical direction and we have them never complying with the rules of medical direction laski goes through a probability analysis to say that the plaintiff is entitle to an intern based on this that they did submit some false bills we are entitled to that same inference and by that same probability analysis we come through we come through with flying colors thank you thank you thank your honor may it please the court after five years and three complaints the district court below dismissed a related key t m suit because he did not plead a single representative example that alleged with particularity all the critical aspects of it fraud theory his complaint suffers from two independent defects st related has not played falsity he has not played with particularity that the defendants falsely coded anesthesia care under medicare is a medical direction rubric instead of one of the lawful alternatives he concedes existed such as medical supervision or even direct c r in a care nd and in any event or later has not played presentment that would necessarily lead to the conclusion that a false bill was presented to medicare falsity under relator theory is a two part question consisting of care and coding care to a medicare patient that did not satisfy the requirements of medical direction coding but excuse me but the procedure was coded under the medical direction model anyway the key problem with her latest complaint is probably the closest he gets to particularities the hearsay statement of the c r a who purportedly told him that the case that issue was hurted under the medical direction model the problem with that allegation your honor is that he doesn't plead a pleadings your honor there's nothing categorically wrong with the hearsay allegation but as this court pointed out perelli if you're going to rely upon somebody else's knowledge you need to lay a foundation for that knowledge in fact the honor i think i think that raises another critical failing of his complaint which is that he has not laid any kind of basis for a care provider to know anything about the coding process that that's not an well your honor i don't think there's really anything to infer from this complaint because the relator hasn't told us anything about that process his only in a high what would you say to a limited release for discovery on those  entire case is that these these examples were in fact coded under the medical direction model instead of one of the other rubric and on that key allegation all d he offers  so your honor if you've got a point to himself it's the basis of that for that particular fact he needs to plead particularize facts showing that he's actually in possession of knowledge related to that key element he needs to tell us what he reviewed applies to rule nine b he's required as this court said in perelli and as it is repeated several times after that a relator is required to plead it's required to plead facts around his allegations that inject precision  substantiation into his claims the key paragraph he relies upon for his own personal knowledge is paragraph one of two of his complaint this is a paragraph that he cites throughout and he asserts it's the main paragraph that the district court missed all that paragraph says is that each of the patients in his examples each of his examples involved patients who were insured by government payers and whose procedures were known to be billed to the allegation is there but what's missing here on air is anything to back that bear allegation up he cannot satisfy his burden under rule ninety merely by baldly claiming to know or baldly claiming to be an no i'm not advocating for the p s l are a standard and specifically i think the key difference between those two standards is that under the p s l are a you have to please the sight center of the day of the defendant with particularity whereas under rule nine b it can be more general i'm not saying that or but i am saying that in so far as he's trying to lay out the key elements of falsity by pointing to his personal knowledge by claiming to be an insider he needs to put some meat on that  he has not done that well but only make an allegation that the relator complained to management about fraudulent billing practices and they ignored his complaints no your honor i don't think it does that's for two reasons number one those allegations are pretty high level he doesn't he doesn't i'm struggling to think of a paragraph or specifics of a conversation that he had with management and how that would inform his purported knowledge when it comes to the coding issue and nd i think it's also so paragraph required for the medical director so your honor my understanding of the regulation is that they are required to pursue scribe the anesthesia plan there or not there's nothing per se wrong with a he just does not put any additional allegations around that where we could draw an inference that this was a command for doctors to go out and commit fraud and every single can't be that explicit  needs to be every case well your honor i point that out because he cites paragraph seventy two as it relates to the specific allegation again if we're using this for his personal knowledge i don't see anything here related to the coding requirement and therefore i don't that's i don't think it's a it's a helpful allegation for him on that front he's going to push back again for a little bit because on the specific examples for build in particular instances where we didn't comply with the requirements for medical correction commit here we have a fairly broad d instruction coming from the medical director the seems to follow right and my response to that your honor is that number one i'm not based upon the facts that are played here set aside set aside the color that is adding to this their conclusions i don't necessarily view this as a as an instruction to violate the regulations but on top of that i think this comes back to the broader this comes back to the broader distinction between care and coding if anything this relates to the care aspect of the equation not the coding aspect of the allegation of the equation and that's where his case is deficient that's why he fails falsity your honour's with my remaining time if there are no further questions on falsity i'd like to turn quickly to the issue of presentment because this is a separate basis upon which he is complete sales he's got two big problems here and i'd really like to focus on the nd the st he claims he's entitled to relax rule nine but for the reasons stated in our read brief he has not satisfied the preconditions for triggering that limited doctrine but nd even if you want to give him the benefit of the relaxed standard that does not mean that he can just baldly allege present he still has to satisfy the rule ninety standard and in order to do that he needs to plead facts that necessarily lead one to the conclusion that false claims were presented to the government on this front the main allegation he highlights of from his complaint is this high level statistic that fifty percent of team health patients were insured by government payers there's two problems with the st it's it's it's a it's a largely unhelpful statistic it's not specific to all things hospital it's not specific to medicare and it's not specific to anesthesia nd he doesn't do anything to take the statistic and plug it back into his transactional level allegations in order to create that necessary an actual false claim was presented to the government what he's given you instead is a non random sampling of ten cases out of what he purports are potentially hundreds of thousands and he tacks on to that a conclusory statement that medicare patients right in those instances so there's two problems there in those instances your honor he simply says that they're medicare patients but even if you want even if you want to credit that he doesn't actually he plead to nothing that would lead to a necessary conclusion that a bill was actually tendered to medicare following these cases let alone feel like a reasonable inference flow the for profit company treating medicare patients will bill d medicare for them or not so i think there's there's two things there your honor it's not necessarily the case these big companies will write off  case is not properly documented don't write off cases all the time and number two this dovetails back into his failures when it comes to pleading the falsity element in that he has not given us any indication as to how the bill was actually was it a bill for medical direction we don't know all he does is give the broad allegation that time has expired if you want to have thought if there's no further questions i asked the court to affirm for not coming up with specifics on every single element but the case law is an especially the case law in this particular circuit is that when you have related or you are always going to entitled to these insurance and look if you have a policy of medical director of billing for medical direction if you have and i think i'd like to focus for one moment here on paragraph one hundred and three paragraph one hundred and three we have one doctor calling the relator saying hey we've got a problem here because dr levy is not in the hospital and if i take his case and i start signing for him that's five concurrent cases for me i can't do that members of the court there is only one reason why they wouldn't be able to do that and that's because it exceeds the four concurrent case limit of medical direction so when they say that and under those circumstances where we have doctors conferring with one another saying we have a problem here because we can't do that which is necessary to bill for medical direction i think we  can then we have the direct allegation that dr lee came back signed them anyway despite not being there i think we are certainly entitled to be inference that they billed for a medical direction in that case because there's no other reason why they would do anything else members of the court this is this is a case that stands apart from the cases if you just kind of look in see how we fit into the cases where the complaints were allowed to go forward and the cases where the complaints words a lot of the go forward you really kind of need to shoehorn in the scene to the cases where they weren't allowed us to be allowed to go forward and we fit really quite smoothly and with for example occasion let's be where they were allowed to go forward you have they cited to the perelli case i noted you know perelli was a case where the relator was actually or where the where the th was actually relying on allegations that he read in another case in a complaint in another case we have in the insider part of a small group of people whose behaviors and actions were the absolute essential to this company making money in accordance with what i practice is supposed to be we think we have to we were told that we had a good complaint provided we pled representative examples we came back we gave ten good representative examples members of this court this claim ought to be allowed to go forward thank you so much