Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca11-14-14281/USCOURTS-ca11-14-14281-0/pdf.json

Nature of Suit Code: 840
Nature of Suit: Trademark
Cause of Action: 

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[PUBLISH]

IN THE UNITED STATES COURT OF APPEALS

FOR THE ELEVENTH CIRCUIT

________________________

No. 14-14281

________________________

D.C. Docket No. 8:11-cv-00775-SCB-TBM

AMERITOX, LTD., 

a Texas limited partnership,

 Plaintiff - Counter

 Defendant - Appellee,

versus

MILLENNIUM LABORATORIES, INC.,

a California corporation,

 Defendant - Counter

 Claimant - Appellant.

________________________

Appeal from the United States District Court

for the Middle District of Florida

________________________

(September 3, 2015)

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Before TJOFLAT, COX and SENTELLE,

∗ Circuit Judges.

TJOFLAT, Circuit Judge: 

In this three-year high-stakes litigation—a case that “[t]he [medical] industry is 

watching,” Ameritox assured the jury—the parties tried various state statutory and 

common law unfair competition claims predicated upon the alleged violation of two 

federal statutes that provide no private right of action. The parties, however, did not 

realize that it was an open question whether or not any of the nine states involved 

would permit the commandeering of state law to create a right of action where none 

existed. A district court sitting in diversity and faced with such a situation would have 

had no choice but to use whatever tools it had available to correctly divine and apply 

state law. See, e.g., Moreno v. Nationwide Ins. Co., 114 F.3d 168, 169 (11th Cir. 

1997) (answering a question of first impression under Alabama law only after 

certifying that question to the Alabama Supreme Court and having that court decline 

to answer the question). The court below, however, did not sit in diversity—or under 

any other circumstance that would have required it to answer the state-law questions. 

See, e.g., Price v. Time, Inc., 416 F.3d 1327, 1335 (11th Cir. 2005) (answering a 

potentially dispositive state-law question before reaching a federal constitutional 

question). Rather, the District Court took supplemental jurisdiction over the state-law 

claims, see 28 U.S.C. § 1367(a), and accordingly could have dismissed those claims 

 ∗

The Honorable David B. Sentelle, Senior United States Circuit Judge for the District of 

Columbia Circuit, sitting by designation.

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once their novel nature became apparent, see id. § 1367(c)(1). We hold that the 

District Court’s decision to retain jurisdiction over novel and complex state-law 

claims hailing from nine different states—claims that the parties either did know or 

should have known were novel and complex—constituted an abuse of discretion.

I.

This litigation was extraordinarily complex. We recount only those facts 

relevant to our disposition.

A.

Ameritox and Millennium are competitors in the drug-testing industry. Both 

sell physicians a variety of products and services that enable timely and accurate 

analysis of a patient’s drug use. One such product is the point-of-care testing 

(“POCT”) cup. Appellant’s Br. 2; Appellee’s Br. 8. POCT cups perform the same 

primary function as standard urine specimen cups: enabling the safe and sanitary 

collection, storage, and transport of urine samples. Appellant’s Br. 2–3; Appellee’s 

Br. 8. POCT cups, however, provide an additional advantage. POCT cups contain 

chemically activated strips that indicate the presence of certain drugs in a patient’s 

urine. Appellant’s Br. 3; Appellee’s Br. 8. Physicians can therefore use POCT cups 

to perform in-office (or “point-of-care”) “qualitative testing” to learn about their 

patient’s drug use (or misuse). Appellant’s Br. 3; Appellee’s Br. 8. Though the 

POCT cups provide only limited information—they cannot, for example, reveal the 

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exact quantity of a drug in a patient’s system—some clinical information is better than 

no clinical information.

To verify the qualitative testing results and acquire more detailed patient 

information, physicians send patients’ POCT cups to clinical laboratories for 

“confirmatory testing.” Appellant’s Br. 3–4. Ameritox and Millennium compete for 

confirmatory-testing business. And, despite the need for this additional confirmatory 

testing, the timely information qualitative testing yields is sufficiently valuable that 

physicians have widely replaced standard specimen cups with pricier POCT cups. See

Appellant’s Br. 3; Appellee’s Br. 8. It also does not hurt that physicians can bill 

Medicare and other insurers for conducting qualitative testing, such as for using a 

POCT cup instead of a specimen cup.

Millennium, a relative upstart in the drug-testing industry, saw in POCT cups 

an opportunity. In 2009, Millennium pioneered a program under which it would 

provide free POCT cups to physicians in exchange for a promise to send used cups to 

Millennium for confirmatory testing. Appellant’s Br. 4; see Appellee’s Br. 9.

Interested physicians entered into a Free Cup Agreement (“FCA”) that memorialized 

this transaction and additionally barred physicians from billing the federal government 

for in-office, qualitative testing. Appellant’s Br. 4; Appellee’s Br. 9–10. In 

Millennium’s view, this prohibition was essential to avoid violating two federal laws: 

the Stark Law (“Stark”), 42 U.S.C. § 1395nn(a), and the federal Anti-Kickback 

Statute (“AKS”), 42 U.S.C. § 1320a-7b(b). See Appellant’s Br. 4; Appellee’s Br. 9.

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Both statutes forbid entities like Millennium from offering any “remuneration” to a 

physician in exchange for referrals if payment for the referred services can be made 

under a federal healthcare program.

1

 Stark defines “remuneration” as “any 

remuneration, directly or indirectly, overtly or covertly, in cash or in kind.” See id.

§ 1395nn(h)(1)(B). The AKS definition is materially indistinguishable and includes 

“any remuneration (including any kickback, bribe, or rebate) directly or indirectly, 

overtly or covertly, in cash or in kind.” See id. § 1320a-7b(b). Millennium reasoned 

that the provision of free POCT cups in exchange for confirmatory-testing referrals 

did not constitute prohibited remuneration so long as doctors could not bill for the inoffice qualitative testing.

2 Appellant’s Br. 4. If doctors could bill for qualitative 

testing, then the provision of free POCT cups would effectively be the provision of a 

paycheck; doctors could simply have a patient use the free POCT cup, qualitatively 

 1 Specifically, Stark prohibits physicians from making referrals “for the furnishing of 

designated health services for which payment otherwise may be made” under Medicare to entities 

with which the physician has a “financial relationship.” 42 U.S.C. § 1395nn(a)(1)(A). A “financial 

relationship” includes “a compensation arrangement . . . between the physician . . . and the entity.” 

Id. § 1395nn(a)(2)(B). In turn, a “compensation arrangement” is “any arrangement involving any 

remuneration between a physician . . . and an entity.” Id. § 1395nn(h)(1)(A).

By contrast, AKS makes it a felony to:

knowingly and willfully offer[] or pay[] any remuneration (including any kickback, bribe, or 

rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce 

such person . . . to refer an individual to a person for the furnishing or arranging for the 

furnishing of any item or service for which payment may be made in whole or in part under a 

Federal health care program.

Id. § 1320a-7b(b).

2 Millennium had additional arguments regarding the legality of its FCAs even if the 

provision of POCT cups constituted remuneration. Those arguments, along with substantive Stark 

and AKS law, are not relevant to our disposition.

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test the sample (by inspecting the cup’s embedded chemically-activated strips), bill 

the government for the qualitative testing, and then ship the sample to Millennium for 

confirmatory testing.3

Although neither Stark nor AKS provide private rights of action, see, e.g., U.S. 

ex rel. Drakeford v. Tuomey Healthcare Sys., Inc., 675 F.3d 394, 395 (4th Cir. 2012) 

(“[T]he Stark Law does not create its own right of action . . . .”); U.S. ex rel. Barnett 

v. Columbia/HCA Healthcare Corp., 251 F. Supp. 2d 28, 37 (D.D.C. 2003) (“There is 

no private right of action under the Anti-Kickback Act.”), the threat of civil and 

criminal sanctions compelled Millennium to seek expert counsel on the FCAs’ 

legality. Appellant’s Br. 4–5. Millennium thus presented its FCAs to a “nationallyrecognized legal expert on clinical laboratory regulatory issues” and a law firm with 

“one of the nation’s leading health care practices” for their blessing. Appellant’s Br. 

4. And, having received that blessing—that the provision of free POCT cups was 

legal so long as physicians entered into FCAs—Millennium rolled out its plan. While 

the majority of Millennium’s customers continued to purchase POCT cups (and 

presumably continued to bill for qualitative testing), approximately ten percent 

entered into FCAs. Appellant’s Br. 5.

B.

1.

 3 Millennium, of course, would then bill the government (or another insurer) for the 

confirmatory testing. 

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This ten percent was too much for Ameritox. While Millennium grew, 

Ameritox shrank or stalled. Prior to Millennium’s FCAs, Ameritox alleged that it 

“experienced record sales year after year.” Appellee’s Br. 11. With the advent of the

FCAs, Ameritox began experiencing losses in the POCT segment of its business. 

Appellee’s Br. 11. Ameritox, however, did not experience corresponding losses in its

non-POCT business. Appellee’s Br. 11. Accordingly, Ameritox determined that the

FCAs were responsible for its POCT segment losses.

Believing that the FCAs were illegal—and that its refusal to violate Stark or 

AKS simply to compete on a level-field with Millennium was costing it current and 

future customers—Ameritox filed a complaint (the “Florida complaint”) against 

Millennium in the District Court for the Middle District of Florida (the “District 

Court”) on April 8, 2011. Ameritox alleged that Millennium had “formed a business 

plan to increase its market share, revenue, and profits” by providing financial 

inducements and other kickbacks, in violation of both federal and state law. Ameritox 

argued that Millennium’s FCAs, two other schemes not relevant here,4 and various 

“false or misleading statements in commercial advertisements for its services” 

violated the Lanham Act, 15 U.S.C. § 1125, et seq.; violated Florida’s Deceptive and 

 4 Ameritox also argued that two other practices violated Florida and federal law: (1) 

Millennium’s statements to patients and healthcare providers that Millennium would not attempt to 

collect deductibles or copayments for laboratory services rendered; and (2) Millennium’s provision 

of in-office chemical analyzers (besides the POCTs governed by FCAs) for free or below fair-market 

value, free laboratory certification required before healthcare providers can bill for in-office chemical 

analyzer tests, and free consulting services.

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Unfair Trade Practices Act (“FDUTPA”), Fla. Stat. § 501.201, et seq.; and constituted 

unfair competition under Florida common law. The District Court exercised federalquestion jurisdiction over the Lanham Act claim, see 28 U.S.C. § 1331, and 

supplemental jurisdiction over the remaining Florida claims, 28 U.S.C. § 1367(a).5

Ameritox’s complaint was short-lived. Following Millennium’s motion to 

dismiss, Ameritox filed its First Amended Florida Complaint. And, during an 

additional year of wrangling between the parties, Ameritox filed a substantially 

similar complaint against Millennium in the District Court for the Southern District of 

California (the “California court”), amended that California complaint once, and filed 

the Second Amended Florida Complaint. Like it had done with the First Amended 

Florida Complaint, Ameritox then attempted to amend the California complaint for a 

second time. Its aim was “to clarify the scope of its claims,” thereby ensuring “that 

such claims are congruent with the claims set forth in the . . . Second Amended 

[Florida] Complaint.” Additionally, Ameritox sought to add “new claims” to the First 

Amended California Complaint based upon law in New Hampshire, Texas, and 

Tennessee. The California court, however, did not allow the amendment and instead 

transferred the case to the Middle District of Florida. That court then consolidated it 

with the Second Amended Florida Complaint. Likely exasperated with Ameriox’s 

 5 Because the Lanham Act claim relates to unfair competition rather than trademarks, the 

District Court did not possess original jurisdiction over the state-law unfair competition claims. See 

28 U.S.C. § 1338(b) (“The district courts shall have original jurisdiction of any civil action asserting 

a claim of unfair competition when joined with a substantial and related claim under the . . . 

trademark laws.”).

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inability to draft a comprehensible complaint, the District Court directed Ameritox “to 

file one[,] final amended complaint” by April 9, 2012, “which includes all counts and 

allegations it intends to raise in this matter,” concluding with the admonition that 

“[t]he Court will not permit further amendments without good cause.” 

Ameritox obliged and, on the deadline, filed its Third Amended Florida 

Complaint. That document bore only a superficial resemblance to either its Florida or 

California predecessors. Now, Ameritox sought to recover based on Millennium’s 

violations of the Lanham Act, 15 U.S.C. § 112, the FDUTPA, Fla. Stat. § 501.201, et 

seq.6

, the California Business and Professions Code, Cal. Bus. & Prof. Code § 17200,

and the New Hampshire Consumer Protection Act, N.H. Rev. Stat. Ann. § 358-a, et 

seq. Ameritox also alleged that Millennium had committed the common-law torts of 

unfair competition7 and interference with business relationships in Arizona, 

 6 Ameritox asserted two claims under the Florida Deceptive and Unfair Trade Practices Act, 

seeking injunctive relief in one and damages in the other.

7 In reality, Ameritox’s unfair competition count alleged a “violation of Federal common 

law”. Plaintiff Ameritox Ltd.’s Third Amended Complaint for Injunctive Relief, Declaratory Relief 

and Damages at 46, ECF No. 92. Nowhere did its claim allude to six distinct state-law causes of 

action. Millennium moved to dismiss this non-existent claim. See Water Techs. Corp. v. Calco, Ltd., 

850 F.2d 660, 670 (Fed. Cir. 1988) (stating that “there is no federal common law of unfair 

competition”). Ameritox responded to Millennium’s motion by stating that Millennium “argues form 

over substance and seeks to dismiss the claim because of Ameritox’s scrivener’s error.” Ameritox 

also asserted that it “properly pleads Ameritox’s claim for unfair competition by virtue of 

Millennium’s unconscionable, deceptive or unfair acts or practices in the conduct of commerce,” and 

finishes with the conclusory statement that “Paragraphs 198 through 209 of the T[hird] A[mended]

C[omplaint] lay out in plain, concise and direct language a claim for unfair competition in each of the 

six states identified.” That is, Ameritox did not deny—for it could not deny—that the unfair 

competition count was directed toward a non-existent federal common law claim, disparaged 

Millennium for highlighting Ameritox’s embarrassing error, and then stated that whatever it had 

written actually was good enough.

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California, Florida, New Hampshire, Texas, and Tennessee. Allegedly false 

advertising, the provision of free POCT cups, and other irrelevant schemes8 provided 

the foundation for these claims.

Notably, Ameritox’s Third Amended Florida Complaint referenced the Stark 

Law only once9 and the Anti-Kickback statute twice.10 The only thing tying either 

federal statute to any of the state-law claims was a conclusory paragraph, virtually 

copied-and-pasted into the state-law counts:

As set forth in more detail above, Millennium engages in a pattern and 

practice of offering and providing inducements, kickbacks and other 

improper financial inducements to Health Care Providers and health care 

 

The District Court agreed. It proclaimed that, despite the fact that Ameritox still could not 

get its complaint correct on the sixth try, it nonetheless “clearly intended to advance claims for unfair 

competition under the state laws of Arizona, Florida, California, New Hampshire, Tennessee, and 

Texas.” Having created six new claims for Ameritox, the District Court then dismissed the 

California and Tennessee claims for unfair competition because “the tort of unfair competition is 

limited to those instances in which a party passes off its goods or services as those of another.”

8 Ameritox presented a litany of bad deeds supporting its claims. The jury eventually 

considered the legality of three schemes: the provision of free POCT cups pursuant to FCAs in 

exchange for confirmatory testing referrals, the facilitation of “below fair market prices on analyzers 

and supplies from third-parties” in exchange for confirmatory testing referrals, and the provision of 

“non-public billing, coding, or reimbursement advice at no charge in exchange for referrals.” The 

latter two schemes are irrelevant to our disposition. 

9 “The federal regulations implementing the Stark Law and Anti-Kickback statute specifically 

prohibit the use of a ‘per click’ arrangement and prohibit costs from being determined by volume or 

value of referrals.” Plaintiff Ameritox Ltd.’s Third Amended Complaint for Injunctive Relief, 

Declaratory Relief and Damages at 16, ECF No. 92.

10 See supra note 9; see also Plaintiff Ameritox Ltd.’s Third Amended Complaint for 

Injunctive Relief, Declaratory Relief and Damages at 9, ECF No. 92 (“Millennium’s illegal 

inducements also violate the federal Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b), and a number 

of state anti-kickback statutes, including those of Arizona, Florida, California, New Hampshire and 

Texas.”).

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consumers in exchange for the referral of business, in violation of 

Federal and [state] law.

See, e.g., Plaintiff Ameritox Ltd.’s Third Amended Complaint for Injunctive Relief, 

Declaratory Relief and Damages at 35, ECF No. 92. Ameritox did not allege that the 

existence of a Stark or AKS violation proved that Millennium had violated state 

law. 11 But cf. Doe v. Fulton-DeKalb Hosp. Auth., 628 F.3d 1325, 1339 (11th Cir. 

2010) (noting that, under the doctrine of negligence per se, establishing the violation 

of a statute or regulation can establish that the defendant breached a duty as a matter 

of law, leaving the plaintiff to prove only causation and damages to make his claim). 

Rather, Ameritox appeared to allege that Millennium’s conduct directly violated both 

state law, see, e.g., Plaintiff Ameritox Ltd.’s Third Amended Complaint for Injunctive 

Relief, Declaratory Relief and Damages at 44, ECF No. 92 (“Millennium implements 

these practices in New Hampshire. . . . Through these practices, Millennium engages 

in unconscionable, deceptive or unfair acts or practices in the conduct of commerce.” 

(emphasis added)), and federal law.

Shortly thereafter, Millennium answered Ameritox’s Third Amended Florida 

Complaint and asserted various affirmative defenses and counterclaims. 

Millennium’s counterclaims contained counts based upon: (I) the FDUTPA, Fla. Stat. 

 11 Put another way: to prevail on its state-law claims, Ameritox had to allege tortious conduct. 

That conduct could be Millennium’s direct actions—the provision of free POCT cups pursuant to 

FCAs. Alternatively, the conduct could be the existence of a Stark or AKS violation itself. This 

latter situation obtains only if state courts have recognized that actions giving rise to Stark or AKS 

violations constitutes tortious conduct as a matter of law, e.g., that a Stark or AKS violation 

necessarily involves actions the state has deemed tortious. 

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§ 501.201, et seq., (II) Cal. Bus. & Prof. Code § 17200, et seq., (III) Cal. Bus. & Prof. 

Code § 17000, et seq., (IV) the Texas Deceptive Trade Practices-Consumer Protection 

Act, Tex. Code Ann. Bus. & Com. Code § 17.41, et seq., (V) the New York 

Consumer Protection from Deceptive Acts and Practices Law, N.Y. Gen. Bus. Law 

§ 349, (VI) common law unfair competition in Florida, Texas, and Washington, and 

(VII) common law tortious interference with business relationships in Florida, 

California, Texas, Tennessee, New York, Washington, and Oregon. Ameritox moved 

to dismiss counts II, III, and V. The Court granted Ameritox’s motion to dismiss 

Count III and partially granted and partially denied the motion with respect to Count 

V. Once the dust had settled, the parties were ready for discovery, and the District 

Court was prepared to adjudicate one federal claim and a bevy of what appeared to be 

state statutory and tort claims.

2.

After an additional year of discovery, Ameritox filed a motion for partial 

summary judgment. In it, Ameritox contended that Millennium “violated the Stark 

Law and the anti-kickback statute.”12 This was a curious claim, given that Ameritox 

did not assert any claims against Millennium predicated upon those laws. Indeed, it 

could not have done so had it wanted to, for neither law creates a private right of 

 12 Millennium also moved for summary judgment. However, it did not premise any of its 

counterclaims on Stark or AKS. Indeed, it did not even ask for summary judgment on its 

counterclaims. 

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action. See supra Part I.A.13 Ameritox explained its strategy: demonstrating that 

Millennium had violated Stark and AKS would prove, as a matter of law, “part of 

Claims I-VII of its Third Amended Complaint.” See Fed. R. Civ. P. 56(a) (“A party 

may move for summary judgment, identifying each claim or defense—or the part of 

each claim or defense—on which summary judgment is sought. . . . The court shall 

grant summary judgment if . . . the movant is entitled to judgment as a matter of law.” 

(emphasis added)). Which part? The part where “Ameritox must show that 

Millennium engaged in unfair, deceptive, or unconscionable business practices.” 

Ameritox had apparently changed course. One would have assumed from the 

operative complaint that Ameritox intended to prove its state-law claims with sole 

reference to Millennium’s conduct and state-law precedent. Now, it was clear that 

Ameritox hoped to prove its state-law claims by establishing violations of 

independent federal healthcare statutes. Supporting Ameritox’s novel theory—that 

proving a violation of either Stark or AKS was legally sufficient to prove the central 

element of fourteen different causes of action, three of which involved state statutes, 

and ten of which involved state common law torts14—was Millennium Labs., Inc. v. 

 13 Neither party argued that an implied right of action exists under either Stark or AKS.

14 Those fourteen causes of action involved: (1) the Lanham Act; (2) the Florida Deceptive 

and Unfair Trade Practices Act; (3) the California Business and Professions Code; (4) the New 

Hampshire Consumer Protection Act; (5) common law tortious interference in Arizona; (6) common 

law tortious interference in California; (7) common law tortious interference in Florida; (8) common 

law tortious interference in New Hampshire; (9) common law tortious interference in Tennessee; (10) 

common law tortious interference in Texas; (11) common law unfair competition in Arizona; (12) 

common law unfair competition in Florida; (13) common law unfair competition in New Hampshire; 

and (14) common law tortious interference in Texas.

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Universal Oral Fluid Labs., Inc., No. 8:11-cv-1757, at 6–7 (M.D. Fla. Apr. 25, 2012), 

ECF No. 72, an unpublished opinion from a district court in the Middle District of 

Florida. 

Rather than challenge Ameritox’s Stark/AKS state-law incorporation theory,

15

Millennium responded to Ameritox’s motion for partial summary judgment by 

disputing that any Stark or AKS violation had occurred.16 Like Millennium, the 

District Court accepted at face value Ameritox’s Stark/AKS incorporation theory. 

Indeed, the court merely flagged Ameritox’s theory as it proceeded to rule on the 

motion:

Ameritox contends that the provision of free POCT cups violates th[e] 

Anti-Kickback Statute (“AKS”) and/or the Stark Law. . . . If such 

conduct is found to violate the AKS or Stark Law, then Ameritox 

contends that such conduct provides the basis for liability under 

Ameritox’s Lanham Act and unfair competition claims in Counts I 

through VII.

 15 Millennium did argue that proving a Stark/AKS violation could not prove part of 

Ameritox’s Lanham Act claim, given that the Stark/AKS violation was based upon anti-competitive 

conduct, while the Lanham act claim was based upon alleged false advertising.

16 Millennium Labs., Inc. v. Universal Oral Fluid Labs., Inc., No. 8:11-cv-1757, at 6–7 (M.D. 

Fla. Apr. 25, 2012), ECF No. 72—the case Ameritox cited to support its Stark and AKS theory—

likely explains Millennium’s perplexing silence. In that unrelated case, Millennium sued Universal 

Oral Fluid Labs, alleging several state statutory and common law claims. Millennium proposed to 

prove these claims by demonstrating that Universal Oral Fluid Labs had violated Stark and AKS. Id. 

at 6–7. Millennium also sought a declaratory judgment to that effect. Id. at 7. That case settled prior 

to Ameritox’s filing of its motion for partial summary judgment. Regardless, Millennium used the 

same theories that Ameritox sought to use against it in the case sub judice. Millennium may not have 

contested those theories because it believed them to be legally sound—an unlikely scenario given the 

court’s response to Millennium’s efforts in Universal Oral Fluid Labs, see infra Part II.A.—or that 

Millennium believed that the court might estop efforts to contest the validity of Ameritox’s theories 

that Millennium itself once used.

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Indeed, the Court later explained that “Ameritox is using the alleged violation of the 

Stark Law and AKS as the basis for its Lanham Act and unfair competition claims.”

Regardless, the District Court obliged Ameritox in its efforts to get a ruling on 

the relevance of Stark and AKS. It concluded that “to the extent that the doctors 

could not bill for the [qualitative] testing done using a POCT cup for other reasons 

(such as, because they were using chemical analyzers to test the specimens), then 

Millennium’s provision of free POCT cups” constituted remuneration under Stark. 

When it came to doctors who did not bill for POCT cup qualitative testing because 

they had agreed not to do so pursuant to an FCA—the issue at the heart of case—the 

District Court stated the following:

To the extent that the doctors could bill for the [qualitative] testing done 

using a POCT cup but decline to do so solely because they agreed to 

Millennium’s requirement not to bill for the [qualitative] testing, the 

Court finds that a genuine issue of material fact exists regarding whether 

the provision of free POCT cups in this scenario constitutes 

remuneration. Instead, in such a situation, it appears that the doctors are 

giving up the ability to bill for [qualitative] testing, which is giving up 

the opportunity to net approximately $15 per specimen. Thus, whether 

the free POCT cups constitute remuneration in this scenario must be 

determined by the jury.

That is, the District Court proposed giving the factfinder an undisputed factual 

scenario—a physician accepts a free cup from Millennium in exchange for a promise 

not to bill for POCT testing and a promise to refer confirmatory testing to

Millennium—and allowing it to determine whether, as a matter of law, those facts 

constituted “remuneration.” With the entry of that order, the case proceeded on.

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3.

Beyond its bevy of state-law claims, Ameritox also asserted a Lanham Act 

claim against Millennium based upon allegedly false representations. Over the course 

of this litigation, Millennium slowly whittled away at this claim until it vanished 

entirely. After Millennium successfully moved for summary judgment on the 

damages portion of Ameritox’s claim, the District Court realized that “the viability of 

[Ameritox’s Lanham Act] claim is questionable.” The court therefore informed the 

parties that if diversity jurisdiction did not exist and the Lanham Act claim was 

resolved prior to trial, the court “could decline to exercise supplemental jurisdiction 

over the remaining claims in this case.” See 28 U.S.C. § 1367(c)(3) (permitting 

district courts to decline to exercise supplemental jurisdiction over state-law claims 

when “the district court has dismissed all claims over which it has original 

jurisdiction”).

Thus, the Court directed Ameritox—a limited partnership—to provide a list of 

all of its general partners to determine whether diversity jurisdiction existed and could 

provide jurisdiction for the state-law claims beyond 28 U.S.C. § 1367(a). In response, 

Ameritox conceded that diversity jurisdiction was lacking, but argued that the court 

should retain jurisdiction over the state-law claims even if the Lanham Act claim were 

dismissed. For its part, Millennium argued that the court should relinquish 

supplemental jurisdiction for two reasons. First, it continued to argue that the Lanham 

Act claim should be dismissed and that the state-law claims should go with it pursuant 

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to 28 U.S.C. § 1367(c)(3). Second, it argued that, without regard to the Lanham Act 

claim, the District Court should dismiss the state-law claims both because they were 

novel and complex, see id. § 1367(c)(1), and because they substantially predominated 

over the Lanham Act claim, see id. § 1367(c)(2). 

Shortly after briefing the question of supplemental jurisdiction, Millennium 

offered to enter into a consent decree enjoining it from representing that “offering 

chemical analyzers at below-market-value is legal.” Millennium hoped that the 

consent decree would moot Ameritox’s Lanham Act claim, thereby removing the only 

federal claim from the case. The District Court thereafter asked Ameritox to explain 

why a consent decree would be an insufficient remedy. In the same order—and 

without any explanation or analysis—the court proclaimed that it “will not decline to 

exercise supplemental jurisdiction if the Lanham Act claims are removed from trial.” 

With that order went the last clear chance to avert the spectacle of trial. Two days 

before trial, the court entered a consent decree, mooting Ameritox’s Lanham Act 

claim. Thus, the stage was set for a trial based entirely upon hypothetical legal 

theories.17

C.

 17 Millennium did note in the Joint Pretrial Statement that the District Court needed to 

address a particularly important question of law: “Whether violations of the Stark Law or AntiKickback Statute can form the basis for Ameritox’s state-law claims for statutory unfair competition, 

tortious interference, and common law unfair competition.” Unfortunately, this suggestion that 

Ameritox’s Stark/AKS incorporation theory was suspect arrived years too late.

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The trial began on June 2, 2014 and lasted for ten days. The jury considered 

Ameritox’s eleven remaining claims18 and Millennium’s ten counterclaims.19 Once 

both sides had rested, and prior to closing argument, the court instructed the jury on 

Stark and AKS:

Both parties have asserted claims that are based, in part, on the 

contention that the other party violated the Stark Law and the AntiKickback statute. If you determine that either party has violated the 

Stark Law or the Anti-Kickback Statute, such a violation may constitute 

unfair competition, an unfair trade practice, and/or tortious interference 

with business relationships under particular state laws. Accordingly, 

before the Court instructs you on the specific law underlying the parties’ 

claims, the Court will first instruct you on the Stark Law and the AntiKickback Statute. . . .

And, although the court did go into specifics on Stark and AKS—including the 

incorrect statement that whether Millennium’s provision of free POCT cups pursuant 

to FCAs constituted remuneration under Stark and AKS was somehow a question of 

fact for the jury20—the court provided no additional information linking Stark or AKS 

to the state-law claims.

 18 Ameritox tried claims for: (1) tortious interference in Arizona, (2) unfair competition in 

Arizona, (3) tortious interference in California, (4) a violation of the FDUTPA, (5) tortious 

interference in Florida, (6) unfair competition in Florida, (7) a violation of the New Hampshire 

Consumer Protection Act, (8) tortious interference in New Hampshire, (9) tortious interference in 

Tennessee, (10) tortious interference in Texas, and (11) unfair competition in Texas.

19 Millennium tried claims for: (1) tortious interference in California, (2) a violation of the 

FDUTPA, (3) tortious interference in Florida, (4) unfair competition in Florida, (5) tortious 

interference in New York, (6) tortious interference in Oregon, (7) tortious interference in Tennessee,

(8) tortious interference in Texas, (9) unfair competition in Texas, and (10) tortious interference in 

Washington.

20 Specifically, the court instructed the jury as follows:

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That link, however, did come. In its closing argument following the 

instructions, Ameritox explained that, to prevail on its unfair competition claims, it 

would need to demonstrate that (1) “Millennium is a competitor of Ameritox,” (2) 

“Millennium engaged in deceptive or fraudulent conduct contrary to honest practices 

in commercial matters,” (3) and that these actions caused damages. Stark and AKS 

related to the second element: “This is where the remuneration question comes in. If

you find that this is a Stark violation, the point-of-care test cups constituted prohibited 

remuneration, we’ve satisfied number two.” Regarding the tortious interference 

claims, Ameritox explained that it had to prove: (1) Ameritox had a preexisting 

business relationship with a doctor in a particular state, (2) Millennium knew about 

that relationship, (3) “Millennium has to intentionally and unjustifiably interfere with 

that relationship,” and (4) Millennium caused Ameritox damages. Again, Stark and 

AKS came to the rescue: “If we can establish that this is prohibited remuneration, 

we’ve satisfied element number three.”

Millennium made no objection and the District Court did not intervene; 

presumably both believed that Ameritox had accurately stated the law. Millennium 

responded in closing simply by contesting whether any Stark or AKS violations had 

 

You must decide whether Millennium’s provision of free point-of-care testing cups to 

doctors who could bill for point-of-care testing using a point-of-care testing cup, but 

agreed not to bill for such testing by signing a “cup agreement” with Millennium, 

constitutes remuneration under the anti-kickback statute.

It gave the jury materially identical instructions regarding the Stark law.

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occurred. It did not seriously press any of its ten counterclaims, beyond suggesting 

that Ameritox employees had repeatedly violated company policy. It did, however, 

state that “Ameritox behaves in ways that are expressly prohibited by Stark,” and that 

“[t]here won’t be any doubt about that.”

Given that the parties’ closing arguments revolved almost entirely upon 

whether the FCAs violated Stark and AKS, it was fitting that the verdict form

prefaced both Ameritox and Millennium’s state-law claims with “Special 

Interrogatories to the Jury” concerning Stark and AKS. Those interrogatories 

included nonsensical questions like “[d]o you find by a preponderance of the 

evidence” that Millennium’s provision of free POCT cups pursuant to FCAs “is 

remuneration” under Stark or AKS. Faced with such confusing instructions, the jury 

nonetheless persevered and completed its civic duty. It found that the FCAs violated 

both Stark and AKS,21 and that, in combination with Ameritox’s separate proof of 

damages and causation, Ameritox had proven: (1) tortious interference in Florida; (2) 

unfair competition in Florida; (3) tortious interference in Tennessee; (4) tortious 

interference in Texas; and (5) unfair competition in Texas.22 Conversely, the jury 

found that Ameritox had not violated Stark, AKS, or any other law. 

 21The jury additionally found that Millennium’s facilitation of “below fair market prices on 

analyzers and supplies from third-parties in exchange for referrals” and provision of “non-public 

billing, coding, or reimbursement advice at no charge” in exchange for referrals did not violate Stark 

or AKS.

22 Although the jury found that Millennium’s actions violated the New Hampshire Consumer 

Protection Act, it found that Ameritox failed to prove causation. The jury also found that 

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In all, the jury awarded Ameritox $14,755,000. After trial, Millennium 

renewed the motion for judgment as a matter of law it had made in earlier. It also 

moved for a new trial and to set aside or reduce the award of punitive damages. The 

District Court denied Millennium’s renewed motion for judgment as a matter of law

and granted in part and denied in part its motion for a new trial or reduction in the 

award of punitive damages; upon reconsideration, the District Court reduced the 

award of punitive damages. 

Millennium appealed, raising four primary arguments. First, it argued that the 

District Court abused its discretion when it decided to retain jurisdiction over the 

supplemental state-law claims. Second, it argued that the court misapplied Stark and 

AKS, an error which necessitated either judgment for Millennium or a new trial. 

Third, it argued that Ameritox had not sufficiently proven damages or causation for 

any of its claims. Finally, it argued that the District Court’s refusal to limit the 

exemplary damages awarded under Texas law was error. Because we hold that the 

District Court’s decision to retain supplemental jurisdiction over the state-law claims 

constituted an abuse of discretion, we do not reach Millennium’s final three 

arguments.

 

Millennium’s actions in Florida and Tennessee merited an award of punitive damages, while its 

actions in Texas merited an award of exemplary damages.

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II.

The doctrine of supplemental jurisdiction—sometimes referred to as “pendent 

jurisdiction”—permits “federal courts to decide certain state-law claims involved in 

cases raising federal questions” when doing so would promote judicial economy and 

procedural convenience. Carnegie-Mellon Univ. v. Cohill, 484 U.S. 343, 348–49, 108 

S. Ct. 614, 618, 98 L. Ed. 2d 720 (1988). Now codified at 28 U.S.C. § 1367, the 

modern doctrine of supplemental jurisdiction derives from United Mine Workers v. 

Gibbs, 383 U.S. 715, 86 S. Ct. 1130, 16 L. Ed. 2d 218 (1966), and Carnegie-Mellon 

University v. Cohill. See City of Chicago v. Int’l Coll. of Surgeons, 522 U.S. 156, 

173, 118 S. Ct. 523, 533, 139 L. Ed. 2d 525 (1997) (explaining that “[t]he 

supplemental jurisdiction statute codifies [the] principles” outlined in Gibbs and 

Cohill); Parker v. Scrap Metal Processors, Inc., 468 F.3d 733, 742 (11th Cir. 2006) 

(noting that 28 U.S.C. § 1367 codified Gibbs’s holding). Those cases continue to 

guide federal courts as they determine whether to retain or relinquish jurisdiction over 

supplemental state-law claims. See City of Chicago, 522 U.S. at 172–73, 118 S. Ct. at

533–34 (noting that § 1367 “reflects the understanding that, when deciding whether to 

exercise supplemental jurisdiction,” courts should look to the principles outlined in 

Gibbs and Cohill); Lucero v. Trosch, 121 F.3d 591, 598 (11th Cir. 1997) (noting that 

District Courts “weigh the competing interests set forth in § 1367(c) and Gibbs in 

deciding whether it is appropriate to exercise supplemental jurisdiction”). “As 

articulated by Gibbs, the doctrine of pendent jurisdiction . . . is a doctrine of 

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flexibility, designed to allow courts to deal with cases involving pendent claims in the 

manner that most sensibly accommodates a range of concerns and values.” Cohill, 

484 U.S. at 350, 108 S. Ct. at 619.

Gibbs itself concerned an inter-union dispute between the United Mine 

Workers and the Southern Labor Union. Gibbs, 383 U.S. at 718, 86 S. Ct. at 1135. 

Gibbs brought suit against United Mine Workers in the District Court for the Eastern 

District of Tennessee based upon alleged violations of § 303 of the Labor 

Management Relations Act of 1947 and a Tennessee common-law claim for tortious 

interference with two contracts; jurisdiction for the common-law claims was based 

upon pendent jurisdiction. Id. at 720, 86 S. Ct. at 1135–36. Although a jury found for 

Gibbs on both his federal and state claims, the court thereafter held that Gibbs’s Labor 

Management Relations Act claim—the claim that permitted the exercise of pendent 

jurisdiction over the state claims—was not cognizable. Id., 86 S. Ct. at 1136. The 

Sixth Circuit affirmed, and the Supreme Court granted certiorari. Id. at 721, 86 S. Ct. 

at 1136.

The Court began its analysis by examining the propriety of the District Court’s 

exercise of jurisdiction over the state-law claims. Id., 86 S. Ct. at 1136. The Court 

noted that a federal court’s power to hear pendent state-law claims exists wherever a 

distinct claim arises under federal law, and “the relationship between that [distinct] 

claim and the state claim permits the conclusion that the entire action before the court 

comprises but one constitutional ‘case.’” Id. at 725, 86 S. Ct. at 1138. The Court, 

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however, immediately cautioned courts against using this power “in every case in 

which it is found to exist.” Id. at 726, 86 S. Ct. at 1139. It explained that pendent 

jurisdiction is “a doctrine of discretion, not of plaintiff’s right,” and should be 

exercised only when doing so would promote “judicial economy, convenience and 

fairness to litigants.” Id., 86 S. Ct. at 1139. 

Indeed, it admonished courts that “[n]eedless decisions of state law should be 

avoided both as a matter of comity and to promote justice between the parties by 

procuring for them a surer-footed reading of applicable law.” Id., 86 S. Ct. at 1139. 

One such needless decision would occur when a court decides issues of state law after 

the federal claims are dismissed before trial; in that situation, “the state claims should 

be dismissed as well.” Id., 86 S. Ct. at 1139.23 Another occurs where it appears that 

the “state claim constitutes the real body of a case, to which the federal claim is only 

an appendage.” Id. at 727, 86 S. Ct. at 1140. The Court also explained that “the issue

whether pendent jurisdiction has been properly assumed is one which remains open 

throughout the litigation.” Id., 86 S. Ct. at 1139. Indeed, when a litigant is “well 

aware of the nature of his proofs and the relative importance of his claims,” and a 

court later discovers this, the court need not “tolerate a litigant’s effort to impose upon 

it what is in effect only a state law case.” Id. at 727, 86 S. Ct. at 1139–40.

 23 The Court subsequently clarified that dismissal of pendent state-law claims was not

mandatory whenever the federal claims are dismissed prior to trial. See Cohill, 484 U.S. at 350 n.7, 

108 S. Ct. at 619 n.7. Rather, Gibbs “simply recognizes that in the usual case in which all federallaw claims are eliminated before trial, the balance of factors to be considered under the pendent 

jurisdiction doctrine . . . will point toward declining to exercise supplemental jurisdiction over the 

remaining state-law claims.” Id.

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As previously noted, Congress codified Gibbs in 28 U.S.C. § 1367. Parker,

468 F.3d at 742. Like Gibbs and Cohill, § 1367 grants federal courts the power to 

exercise jurisdiction over claims “that are so related to claims in the action within 

such original jurisdiction that they form part of the same case or controversy under 

Article III of the United States Constitution.” 28 U.S.C. § 1367(a); Lucero, 121 F.3d 

at 597. Unlike those cases, however, § 1367 mandates that district courts—at least 

initially—exercise jurisdiction over those supplemental claims that satisfy the case or 

controversy requirement. See Parker, 468 F.3d at 743 (“Whenever a federal court has 

supplemental jurisdiction under section 1367(a), that jurisdiction should be exercised 

unless section 1367(b) or (c) applies.”). Additionally, the doctrine of supplemental 

jurisdiction under § 1367 is less flexible than it was under Gibbs or Cohill insofar as it 

permits dismissal of supplemental claims only under particular circumstances. 

District courts only possess the authority to dismiss claims brought under § 1367(a) if:

(1)the claim raises a novel or complex issue of State law,

(2)the claim substantially predominates over the claim or claims over 

which the district court has original jurisdiction,

(3)the district court has dismissed all claims over which it has original 

jurisdiction, or 

(4)in exceptional circumstances, there are other compelling reasons for 

declining jurisdiction.

28 U.S.C. § 1367(c); Parker, 468 F.3d at 743 (“Any one of the section 1367(c) factors 

is sufficient to give the district court discretion to dismiss a case’s supplemental state 

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law claims.”). Once any of these factors is satisfied, the district court possesses the 

discretion to dismiss supplemental claims and must “weigh . . . at every stage of the 

litigation,” whether to dismiss the supplemental claims. See City of Chicago, 522 

U.S. at 173, 118 S. Ct. at 534 (quotation marks omitted). Actually determining 

whether to dismiss the claims calls for the court to weigh the “host of factors” 

outlined in Gibbs and Cohill: “judicial economy, convenience, fairness, and comity.” 

Id., 118 S. Ct. at 534. 

Against this backdrop, we evaluate first whether the District Court possessed 

the discretion to dismiss the supplemental claims, and if it did, whether retaining 

jurisdiction was an abuse of discretion. See Lucero, 121 F.3d at 598. “A district court 

abuses its discretion if it applies an incorrect legal standard, follows improper 

procedures in making the determination, or makes findings of fact that are clearly 

erroneous.” Klay v. United Healthgroup, Inc., 376 F.3d 1092, 1096 (11th Cir. 2004) 

(quotation marks omitted); see also Estate of Amergi ex. rel. Amergi v. Palestinian 

Auth., 611 F.3d 1350, 1365 (11th Cir. 2010) (“A district court does not abuse its 

discretion when it has a range of choices and the court’s choice does not constitute a 

clear error of judgment.” (quotation marks omitted)). 

A.

Millennium’s abuse of discretion argument is a nonstarter unless one of the 

§ 1367(c) factors applies. Millennium principally argues that § 1367(c)(3) was 

animated following the District Court’s resolution of Ameritox’s Lanham Act claim. 

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Appellant’s Br. 19–20 (“Once Ameritox’s lone federal claim was definitely resolved 

before trial, the court should have dismissed the case.”). That provision allows a 

district court to dismiss supplemental claims after it “dismiss[es] all claims over 

which it has original jurisdiction.” 28 U.S.C. § 1367(c)(3). Ameritox counters that 

the District Court did not “dismiss” the Lanham Act claim. Appellee’s Br. 26–27. 

Rather, that claim was “resolved” in Ameritox’s favor following Millennium’s 

decision to enter into a consent decree prohibiting certain objectionable conduct. 

Appellee’s Br. 26. Accordingly, Ameritox argues, § 1367(c)(3) is inapposite.

We need not resolve this question of statutory interpretation because the 

District Court possessed discretion to decline to exercise jurisdiction over the 

supplemental claims on another basis. Ameritox’s state-law claims raise “a novel or 

complex issue of State law.” See 28 U.S.C. § 1367(c)(1).24 It may be true that, 

“[g]enerally, state tort claims are not considered novel or complex.” Appellee’s Br. 

33 (quotation marks omitted) (quoting Parker, 468 F.3d at 743). This, however, is an 

extraordinary case predicated upon extraordinary legal theories. When Ameritox filed 

its partial motion for summary judgment, it effectively amended (for a fourth time) its 

 24 Millennium raised this argument in the District Court and on appeal. Below, Millennium 

stated that “regardless of whether Ameritox’s Lanham Act claim should be out of the case, the Court 

should not retain jurisdiction over the complicated and varied state law claims that remain.” That 

assertion flows logically only if a factor other than § 1367(c)(3) granted the court authority to dismiss 

the supplemental claims. See 28 U.S.C. § 1367(c). Indeed, Millennium specifically noted the

existence of novel and complex issues of state law and that those issues predominated over 

Ameritox’s anemic Lanham Act claim. And, before this court, Millennium argued that retention of 

jurisdiction was error in part because deciding whether states had incorporated Stark/AKS presented 

“novel and complex issues of state law” best left for state courts to resolve. See Appellant’s Br. 30.

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complaint. There, Ameritox sought partial summary judgment that Millennium 

“violated the Stark Law and the anti-kickback statute.” This finding would

purportedly “show that Millennium engaged in unfair, deceptive, or unconscionable 

business practices,” thus satisfying the central element of all of Ameritox’s state-law 

claims. 

That is, rather than proving the sine qua non element of its claims by 

comparing Millennium’s conduct to conduct a state court had already declared to be 

tortious (or unlawful, in the case of the statutory claims), Ameritox sought to prove 

this element by demonstrating that Millennium had violated an independent federal 

statute. Ameritox necessarily travelled on the theory that the supreme courts of 

Arizona, California, Florida, New Hampshire, Tennessee, and Texas had incorporated 

(or obviously would incorporate) Stark and AKS into their respective unfair 

competition statutes and common-law torts. See LeFrere v. Quezada, 582 F.3d 1260, 

1263–64 (11th Cir. 2009) (“In addressing issues of state law, we are bound by the 

decisions of the state supreme court. Only where no state court has decided the point 

in issue may a federal court make an educated guess as to how that state’s supreme 

court would rule.” (citation omitted) (quotation marks omitted)).

Ameritox did not cite to any state-law precedent to support this point. One 

explanation for Ameritox’s total failure to support its Stark/AKS incorporation theory 

with binding citations is that no such support exists. No Arizona or New Hampshire 

cases mention either Stark or AKS. No reported Florida decisions consider whether a 

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Stark or AKS violation suffices to prove any element of Florida’s Deceptive and 

Unfair Trade Practices Act, Florida common law unfair competition, or Florida 

tortious interference with business relationships. And there are no California or 

Tennessee cases connecting either Stark or AKS to tortious interference with business 

relationships.

This brings us to Texas. In Texas, a case does exist connecting AKS to unfaircompetition torts. In Reliable Ambulance Service, Inc. v. Mercy Hospital of Laredo, 

No. 04-02-00188-CV, 2003 WL 21972724 (Tex. App. Aug. 20, 2003), Reliable 

alleged that Mercy committed the “generic tort of wrongful competition” based upon 

an alleged AKS violation. 2003 WL 21972724, at *6 n.1 (quotation marks omitted). 

After reasoning that “recognizing a common law cause of action by a competitor for 

damages and injunctive relief for violation of the anti-kickback statute would be 

inconsistent with the intent of Congress,” the court rejected Reliable’s efforts to coopt state common law into providing a private right of action where Congress saw fit 

to establish none.25 2003 WL 21972724, at *6. The only case anchoring Stark or 

 25 Although the Reliable court’s rationale sounds in preemption, the Texas Court of Appeals’ 

holding—that it would not “recognize a common law cause of action” based on an AKS violation—

and explicit admonition that it would not “address appellees’ arguments that the claim is preempted,” 

makes it clear the preemption played no part in the decision. Reliable Ambulance Serv., 2003 WL 

21972724, at *6. Other courts, however, have explicitly grappled with whether state anti-kickback 

laws might be preempted. See, e.g., State v. Harden, 938 So. 2d 480, 493 (Fla. 2006) (finding that 

AKS preempts “the Florida anti-kickback statute . . . because it presents an obstacle to the 

accomplishments of the purposes” of AKS); People v. Guiamelon, 140 Cal. Rptr. 3d 584, 604 (Cal. 

Ct. App. 2012) (finding that AKS does not “preempt state law regarding the payment of 

consideration for patient referrals”). Because neither party raised preemption arguments, we decline 

to rule on that question. Access Now, Inc. v. Sw. Airlines Co., 385 F.3d 1324, 1330 (11th Cir. 2004).

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AKS to state laws explicitly rejects using an AKS violation as the basis for a common 

law unfair competition tort.

To be fair, Ameritox attempted to provide some support for its theory that proof 

of a Stark Law or AKS violation was sufficient to prove that Millennium engaged in 

unconscionable, unfair, or deceptive acts or practices (for the statutory and common 

law unfair competition claims) or unjustifiable interference with Ameritox’s business 

relationships (for the tortious interference claims). Although it did not cite state-law 

decisions evidencing incorporation of Stark or AKS, Ameritox pointed to a solitary

unpublished case from the Middle District of Florida: Millennium Laboratories, Inc. 

v. Universal Oral Fluid Laboratories, LLC, No. 8:11-cv-1757 (M.D. Fla. Aug. 16, 

 

Indeed, we could not do so if we desired. Neither Stark nor AKS contain explicit preemption 

clauses. Accordingly, any preemption analysis would focus on implied preemption. Given that 

providing healthcare to Americans is partially a joint effort between the several states and the federal 

government, see Pharm. Research & Mfrs. of Am. v. Meadows, 304 F.3d 1197, 1206 (11th Cir. 

2002), field preemption seems unlikely, see Fresenius Med. Care Holdings, Inc. v. Tucker, 704 F.3d 

935, 939 (11th Cir. 2013) (“Field preemption exists where Congress determines that a certain field 

must be regulated exclusively by the federal government.”). But see Cong. of Cal. Seniors v. 

Catholic Healthcare W., 87 Cal. App. 4th 491, 508–09 (Cal. Ct. App. 2001) (holding that “[f]ederal 

law governing provider cost reporting and reimbursement so thoroughly occupies the field with its 

pervasive and complex regulatory system” that plaintiff’s efforts to bring a § 17200 claim predicated 

upon alleged violations of Medicare and Medicaid statutes and regulations were preempted). This 

leaves us with possible conflict preemption—the type of preemption featured in Harden and 

Guiamelon. “We use our judgment to determine when state law creates an unconstitutional obstacle 

to federal law, and this judgment is informed by examining the federal statute as a whole and 

identifying its purpose and intended effects.” Tucker, 704 F.3d at 939.

However, to even begin to analyze state law’s effect on a federal law, we must know the 

content of the state law. The entire problem in this case is that we have no idea whether or not any of 

the relevant states would recognize common law or statutory causes of action predicated upon Stark 

or AKS violations. This was not an issue in either Harden or Guiamelon. There, the state courts 

analyzed state statutes specifically crafted to address referrals and kickbacks in the medical industry. 

We will not engage in any speculative preemption analysis pitting hypothetical causes of action 

against Stark or AKS. 

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2013), ECF No. 136. This case crumples under the staggering burden Ameritox 

places upon it. In Universal Oral Fluid Laboratories, Millennium brought various 

unfair competition and tortious-interference claims against Universal Oral Fluid, 

arguing that “Universal engaged in deceptive and unfair trade practices because 

[contested business] agreements violate the federal Anti-Kickback Statute and the 

Stark Law.” Universal, at *6. 

Millennium raised precisely the same theories that Ameritox raises here. In 

response, Universal argued that Millennium’s claims failed because they relied upon 

“allegations that [Universal’s conduct] violate[d] the Anti-Kickback Statute and the 

Stark Law, and [Millennium] does not have a private right of action under those 

Statutes.” Id., at *6. Universal also argued that Millennium did not “allege[] any 

actionable conduct independent of the . . . allegations that their conduct violates the 

Anti-Kickback Statute and the Stark law.” Id., at *6.

The court rejected Universal’s arguments, explaining—as it had earlier in 

response to Universal’s motion to dismiss—that 

case law provides that conduct violating the Anti-kickback Statute and 

the Stark Law may provide the basis for liability under recognized 

common law causes of action and other state statutory laws provided all 

the elements of the causes of action are met.

Id., at *7. 

A district court’s unremarkable observation that a single course of conduct 

might give rise to multiple claims provides the entire support for Ameritox’s Stark 

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and AKS incorporation theory. As far as Ameritox and Millennium are concerned, 

this proposition boils down to the following tautology: to prove an unfair competition 

claim, you must prove every element of that claim as required by established state 

law. Stark and AKS are simply irrelevant. This much is evident from the court’s next 

statement that Millennium “is entitled to summary judgment in this case if it can 

establish that Universal’s conduct, although in violation of the Anti-Kickback Statute 

and the [s]tark law, also violates state statutory or common law.”

Indeed, the court was even clearer on this point when ruling on Universal’s 

earlier motion to dismiss. After surveying other decisions regarding the 

(in)applicability of Stark and AKS to state unfair competition claims, the court arrived 

at Synthes (U.S.A.) v. Globus Medical, Inc., No. Civ.A. 04-cv-1235, 2005 WL 

2233441 (E.D. Pa. Sept. 14, 2005). See Millennium Labs., Inc. v. Universal Oral 

Fluid Labs., LLC, No. 8:11-cv-1757, at 12 (M.D. Fla. Apr. 25, 2012), ECF No. 72. 

The court’s discussion went as follows:

[T]he Synthes Court, citing Reliable Ambulance, held that the fact the 

Anti-Kickback Statute prohibited the plaintiff’s conduct does not mean 

the same conduct could not provide a basis for civil liability under 

another state or federal statute. The critical question for the court in 

Synthes was whether the underlying conduct also violated state law. The 

court thus proceeded to analyze each of the defendant’s common law 

causes of action (tortious interference with prospective contractual 

relationships, unfair competition, civil conspiracy, and violations of the 

Lanham Act) under the applicable Pennsylvania State law. This Court 

agrees with the reasoning of Synthes as foreshadowed by Reliable 

Ambulance. Plaintiff may bring an action for unfair competition in this 

case provided all of the elements of common law unfair competition are 

present under the applicable state laws.

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Id. at 12–13. The message is clear: the court would allow Millennium’s claims to 

survive so long as, beneath their Stark and AKS packaging, the claims were valid with 

sole reference to the relevant state statutes and precedent. Of course, this does not 

mean that state-court decisions could not or did not accept proof of a Stark or AKS 

violation as a means of proving deception and interference for unfair competition and 

tortious interference claims, respectively.26 It just meant that the court would need 

proof of such an adoption, and in the absence of proof, the claims could still survive 

so long as the challenged conduct fell within some extant unfair competition or 

tortious interference cause of action. 

Simply put, whether or not Stark or AKS are relevant to any of the claims in 

this case is a novel question. It is also a complex question, laden with important 

 26 It may be that California courts would allow a Stark or AKS violation to constitute an 

“unlawful” business practice for the purpose of proving a violation of California Business & 

Professions Code § 17200. That section “defines unfair competition as ‘any unlawful, unfair or 

fraudulent business act or practice.” Saunders v. Super. Ct., 27 Cal. App. 4th 832, 838 (Cal. Ct. App. 

1994). A California Court of Appeal has held that “the ‘unlawful’ practices prohibited by section 

17200 are any practices forbidden by law, be it civil or criminal, federal, state, or municipal, 

statutory, regulatory, or court-made.” Id. at 838–39. That blanket statement, however, does not 

necessarily mean that Ameritox can bring a § 17200 claim on the basis of a Stark or AKS violation. 

See, e.g., Cong. of Cal. Seniors, 87 Cal. App. 4th at 508–09 (holding that “[f]ederal law governing 

provider cost reporting and reimbursement so thoroughly occupies the field with its pervasive and 

complex regulatory system” that plaintiff’s efforts to bring a § 17200 claim predicated upon alleged 

violations of Medicare and Medicaid statutes and regulations were preempted); cf. State Med. 

Oxygen & Supply, Inc. v. Am. Med. Oxygen Co., 750 P.2d 1085, 1087–88 (Mont. 1988) (holding that 

plaintiff could not bring a cause of action under § 27–1–202, MCA—a statute allowing parties to 

seek damages after suffering “detriment from the unlawful act or omission of another”—predicated 

upon an AKS violation). Most importantly (and ironically), the jury did not hear Ameritox’s § 17200 

claim.

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policy choices. 27 See generally Reliable Ambulance Serv., 2003 WL 21972724. Yes, 

Ameritox does claim that “[i]n reality, there were no highly complex issues of state 

law” and that “[t]hese were garden-variety state tort claims.” Appellee’s Br. 33. That 

may have been true before Ameritox’s decision to rely upon independent federal

statutes to prove its claims. Regardless, whether or not unfair competition and 

tortious interference claims are novel and complex in the abstract is irrelevant. The 

novel and complex question here is whether or not these states should hold that a 

Stark or AKS violation proves part of an unfair competition or tortious interference 

claim. Indeed, Ameritox’s own appellate brief effectively concedes the complexity 

point. When arguing that equitable factors supported the District Court’s decision to 

retain supplemental jurisdiction, Ameritox noted that dismissal would waste judicial 

resources because it would require state courts “to master not only the facts but also

predicate federal-law issues under the Stark Law and Anti-Kickback Statute.” 

Appellee’s Br. 31. However, deciding whether or not Stark or AKS violations are 

relevant to any state cause of action necessarily requires state courts first to “master”

those same federal issues, and second, to determine whether or not enforcing those 

laws via state statutes and common law would advance the state’s unique interests and 

policy goals.

 27 Additionally, § 1367(c)(1) grants district courts the discretion to decline to exercise 

supplemental jurisdiction if “the claim raises a novel or complex issue of State law.” 28 U.S.C. 

§ 1367(c)(1) (emphasis added). Thus, even if the claims were not complex—and they are complex—

the claims’ novelty would be sufficient to vest the District Court with discretion.

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In the end, the reality is likely that none of these states—besides Texas—

appears to have even considered whether or not a Stark or AKS violation could prove

that Millennium “engaged in unfair, deceptive, or unconscionable business practices.” 

We say with certainty that each one of Ameritox’s state-law claims presented the 

District Court with novel and complex issues of state law. Accordingly, from the 

moment Ameritox filed its motion for partial summary judgment, thereby making 

manifest its actual legal theories, the District Court possessed the discretion to dismiss 

Ameritox’s supplemental state-law claims.28

B.

Having determined that the District Court possessed the power to either retain 

or reject supplemental jurisdiction over Ameritox’s state-law claims, we must now 

determine whether the decision to retain jurisdiction was an abuse of discretion. The 

Supreme Court’s teachings in Gibbs, guide us in this endeavor. “Where § 1367(c) 

applies, considerations of judicial economy, convenience, fairness, and comity may 

influence the court’s discretion to exercise supplemental jurisdiction.” Baggett v. 

First Nat’l Bank of Gainesville, 117 F.3d 1342, 1353 (11th Cir. 1997); see Palmer v. 

Hosp. Auth., 22 F.3d 1559, 1569 (11th Cir. 1994) (holding that when “one or more 

[§ 1367(c)] factors is present, the additional Gibbs considerations may, by their 

 28 The District Court may have additionally possessed discretion to dismiss the state-law 

claims because they arguably “substantially predominate[] over the claim . . . over which the district 

court has original jurisdiction.” 28 U.S.C. § 1367(c)(2). However, having determined that the 

District Court possessed discretion to decline to exercise supplemental jurisdiction on another basis, 

we do not pass upon § 1367(c)(2)’s relevance here.

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presence or absence, influence the court in its decision concerning the exercise” of 

supplemental jurisdiction). Furthermore, once a district court possesses discretion to 

dismiss the supplemental claims, it must be continuously mindful regarding whether 

or not the factors favor dismissal. City of Chicago, 522 U.S. at 173, 118 S. Ct. at 534 

(holding that “a federal court should consider and weigh in each case, and at every 

stage of the litigation” the Gibbs and Cohill values to determine whether it is proper to 

retain jurisdiction over state claims (quotation marks omitted)). Ameritox argues that 

each of the Gibbs factors—judicial economy, convenience, fairness, and comity—

weigh in favor of retaining jurisdiction.

We first consider judicial economy. Two separate district courts have already 

been involved in this dispute, see supra Part I.B.1., and the Middle District alone 

invested over three years’ time resolving these issues. That court’s docket boasts 

nearly seven hundred entries, about three hundred of which were entered prior to 

Ameritox’s motion for partial summary judgment. Additionally, the litigation 

spawned a ten-day jury trial. Dismissal of the state-law claims at this point would 

render much of the efforts below a nullity. Accordingly, there can be no doubt 

whatsoever that Ameritox’s complaint ultimately required and received a tremendous 

amount of attention from the federal courts. Furthermore, dismissal at this stage 

would potentially continue to consume resources, as it would also require the parties 

to re-litigate in multiple state courts. For these reasons, Ameritox argues that factors 

of judicial economy weigh in favor of retaining jurisdiction. If we were to hold that 

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the District Court abused its discretion, the argument goes, we would effectively 

waste judicial resources.

This myopic view overlooks the fact that from at least January of 2014—five 

months prior to trial—the onus for this waste lies squarely with Ameritox. From that 

point on, Ameritox consumed scarce judicial resources so that it could try nonexistent claims. That the case did go to a jury means that Ameritox additionally 

wasted each of the jurors’ time. Furthermore, there is no telling how far in advance of 

filing its complaint Ameritox knew it was going to rely entirely upon Stark and AKS 

to prove all of its state-law claims. Ameritox filed its motion for partial summary 

judgment on the deadline for dispositive motions as set forth in the Second Amended 

Case Management and Scheduling Order; presumably it did not develop its legal 

theories that very day. 

Here, one of two things occurred. First, Ameritox’s attorneys did not know at 

the time they filed the Third Amended Florida Complaint that proof of its state-law 

claims would rely upon Stark or AKS. If that were true, it meant that these attorneys

bumbled along for up to a year and a half trying to figure out what claims they had

before finally settling upon non-existent legal theories. In other words, Ameritox’s 

attorneys wasted both judicial resources and Ameritox’s money. 

The second possibility is that, when they filed the Third Amended Florida 

Complaint, Ameritox’s attorneys did know that their case would rely entirely upon 

Stark and AKS. If Ameritox’s attorneys intentionally omitted its Stark and AKS 

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theory from the complaint so as to obscure their theories and prolong litigation, then 

we need not look beyond Gibbs for a reason to dismiss the supplemental claims.

Gibbs unequivocally condemns such opportunistic behavior when discussing the 

appropriate response to litigants who knowingly conceal the dominance of their statelaw claims as a means of ensuring that courts exercise supplemental jurisdiction over 

those claims:

The issue whether pendent jurisdiction has been properly assumed is one 

which remains open throughout the litigation. Pretrial procedures or 

even trial itself may reveal a substantial hegemony of state law claims, 

or likelihood of jury confusion, which could not have been anticipated at 

the pleading stage. Although it will of course be appropriate to take 

account in this circumstance of the already completed course of the 

litigation, dismissal of the state claim might even then be merited. For 

example, it may appear that the plaintiff was well aware of the nature of 

his proofs and the relative importance of his claims; recognition of a 

federal court’s wide latitude to decide ancillary questions of state law 

does not imply that it must tolerate a litigant’s effort to impose upon it 

what is in effect only a state law case.

383 U.S. at 727, 86 S. Ct. at 1139–40. The Court explicitly condoned dismissal of 

state-law claims after trial if it appeared that a party concealed or omitted facts that, if 

known, might have resulted in dismissal of the supplemental claims. The point is that, 

under either scenario—Ameritox knew it would use Stark and AKS versus Ameritox 

did not know it would use Stark and AKS—the onus for the waste of judicial 

resources lies with Ameritox. And, if Ameritox purposefully concealed the novel and 

complex nature of its claims, that alone might merit dismissal of the supplemental 

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claims; the District Court should not have “tolerate[d] [Ameritox’s] effort to impose 

upon it what is in effect” made-up state-law claims. Id., 86 S. Ct. at 1140.

Despite this, Ameritox would essentially have us hold that once a court has 

poured sufficient resources into a case, we should hesitate before writing off that 

investment. If we hold that considerations of judicial economy favor retaining 

jurisdiction, we would provide litigants with perverse incentives to sandbag their own 

cases in the hope that courts spend enough resources to make decisions to exercise 

supplemental jurisdiction effectively unreviewable. See Parker, 972 F.2d at 587 (“[A] 

court cannot obtain jurisdiction over a case merely by trying it; otherwise, its decision 

to retain jurisdiction would be, effectively, unreviewable.”). This we cannot tolerate. 

As our sister circuit put it, “[e]valuating considerations of judicial efficiency and 

duplication of judicial effort is not just a matter of toting up months or motions or the 

page counts of judicial orders.” RWJ Mgmt. Co. v. BP Prods. N. Am., Inc., 672 F.3d 

476, 481 (7th Cir. 2012). Ameritox’s argument does not take into account that the 

parties are responsible for waste. Dismissing the supplemental claims at this point 

would not waste resources; the waste occurred long ago. Ameritox advanced 

outlandish legal theories and Millennium went along with it. Either party could have 

halted this farce long ago. Under these circumstances, we find that considerations of 

judicial economy do not favor retaining jurisdiction over the state-law claims.

By contrast, considerations of convenience favor retaining jurisdiction. It is 

true that, as far as the parties are concerned, it would be most convenient to try every 

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claim in a single forum. Accordingly, considerations of convenience weigh in favor 

of retaining jurisdiction over the supplemental state-law claims.

Considerations of fairness, however, do not support continued exercise of 

jurisdiction. Ameritox has only itself to blame for the problems inherent in its Stark 

and AKS theory. No one forced Ameritox to introduce novel and complex legal 

theories. And, as other circuits have pointed out, every litigant who brings 

supplemental claims in court knowingly risks the dismissal of those claims. See, e.g., 

Annulli v. Panikkar, 200 F.3d 189, 203 (3d. Cir. 1999) (noting that it was not unfair to 

dismiss supplemental claims because the “Annulli and his lawyers knowingly risked 

dismissal of [Annulli’s] pendent claims when they filed suit in federal district court 

and invoked the Court’s discretionary supplemental jurisdiction power”); Pitchell v. 

Callan, 13 F.3d 545, 549 (2d Cir. 1994) (noting that declining to exercise jurisdiction 

was not an abuse in part because “[w]hen Pitchell brought his state-law claims in 

federal court, he must have realized that the jurisdiction he invoked was pendent and 

possibly tentative”).

To the extent our decision benefits Millennium, it does so only by eliminating a 

judgment patently unsupported by actual law. Furthermore, Millennium has certainly 

suffered insofar as it massively wasted resources arguing that it did not violate Stark 

or AKS when it could have moved to dismiss Ameritox’s various theories for failure 

to state a claim. See Fed. R. Civ. P. 12(h)(2) (“Failure to state a claim upon which 

relief can be granted . . . . may be raised . . . by a motion under Rule 12(c); or . . . at 

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trial.”). At the end of the day, the attorneys here left their clients with gargantuan

legal bills and “a tale/ Told by an idiot, full of sound and fury,/ Signifying nothing.” 

William Shakespeare, Macbeth, act 5, sc. 5.

Well, perhaps they have something. Both parties are free to use evidence 

obtained during discovery to pursue their state-law claims in a proper forum. See 

Annulli, 200 F.3d at 203 (noting that discovery obtained prior to dismissal of 

supplemental claims may be utilized in later suits). This is not a case where retrial 

will necessarily impose extraordinary burdens on the litigants. See Redondo Constr. 

Corp. v. Izquierdo, 662 F.3d 42, 49–50 (1st Cir. 2011) (holding that exercising 

supplemental jurisdiction was proper where the parties had conducted extensive 

discovery in English and the need to translate all documents and testimony into 

Spanish to retry the case in Puerto Rico’s courts would “impose huge burdens,” and 

the state-law claims were neither novel nor complex). Under these circumstances, 

fairness concerns do not weigh in favor of retaining jurisdiction.

This brings us to comity. It is a bedrock principle that “[n]eedless decisions of 

state law should be avoided both as a matter of comity and to promote justice between 

the parties, by procuring for them a surer-footed reading of applicable law.” Gibbs, 

383 U.S at 726, 86 S. Ct. at 1139. “State courts, not federal courts, should be the final 

arbiters of state law” in our federalist system. Baggett, 117 F.3d at 1353; see Hardy v. 

Birmingham Bd. of Educ., 954 F.2d 1546, 1553 (11th Cir. 1992) (noting that “[s]tate 

courts, not federal courts, are the final expositors of state law” in its decision not to 

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exercise pendent jurisdiction). It is for this reason that our usual procedure when 

confronted with a case that requires the resolution of a novel or complex question of 

state law, we certify such questions to a State’s highest court. See, e.g., Tyne v. Time 

Warner Entm’t Co., 336 F.3d 1286, 1291 (11th Cir. 2003) (“Substantial doubt about a 

question of a state law upon which a particular case turns should be resolved by 

certifying the question to the state supreme court.” (quotation marks omitted)). 

Federal courts are (and should be) loath to wade into uncharted waters of state law, 

and should only do so when absolutely necessary to the disposition of a case. See, 

e.g., Price v. Time, Inc., 416 F.3d 1327, 1334 (11th Cir. 2005) (expressing 

disappointment that a state Supreme Court had declined to answer a certified question, 

thereby leaving “the district court with no choice but to answer the state law question 

itself”).

Allowing the judgment below to stand would be to ratify the District Court’s 

(perhaps inadvertent) pronouncement that nine separate states—Arizona, California, 

Florida, New Hampshire, New York, Oregon, Tennessee, Texas, and Washington—

accept proof of a Stark or AKS violation as sufficient to prove the sine qua non

element of various statutory and common-law unfair competition laws. It would 

directly contravene Gibbs’s bedrock teaching that courts should not unnecessarily 

decide questions of state law. See Gibbs, 383 U.S. at 726, 86 S. Ct. at 1139. And, 

while a needless decision of law in one state is bad, creating law in nine states is 

beyond the pale. Affirming the decision would be an open invitation to litigants 

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everywhere to find a way into the Eleventh Circuit to take advantage of almost 

certainly erroneous constructions of state law—at least, until the relevant states are 

forced to action to prevent such mischief. See Arizonans for Official English v. 

Arizona, 520 U.S. 43, 79, 117 S. Ct. 1055, 1074, 137 L. Ed. 2d 170 (1997) (noting 

that a “federal tribunal risks friction-generating error when it endeavors to construe a 

novel state Act not yet reviewed by the State’s highest court”); see also Mosher v. 

Speedstar Div. of AMCA Int’l, Inc., 52 F.3d 913, 917 (11th Cir. 1995) (“[S]tate law is 

what the state supreme court says it is, and a state supreme court’s pronouncements 

are binding on every state and federal judge.” (quoting Sultenfuss v. Snow, 35 F.3d 

1494, 1504 (11th Cir. 1994) (en banc) (Carnes, J., dissenting))). This invitation would 

ultimately tax the judiciary’s resources, requiring our courts to consider claims that 

state courts may decide are not cognizable. It would also signal disrespect towards 

our state-court brethren who stand ready and able to tackle novel issues. Allowing the 

judgment below to stand would reward the parties for what is either misplaced 

tenacity or blissful ignorance of the law and would needlessly damage the judiciary, 

both state and federal.

Convenience is the only factor weighing in favor of retaining jurisdiction. 

Concerns regarding judicial economy, fairness, and comity favor dismissal. However, 

we do not review the District Court’s decision de novo. That these considerations 

would have lead us to relinquish jurisdiction does not mean the District Court 

necessarily abused its discretion when it decided (without explanation) to retain 

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jurisdiction. Rather, it is the fact that the District Court effectively rewarded either 

ignorant or duplicitous parties by ratifying new legal theories in nine different states 

that leads us to the conclusion that the District Court abused its discretion. Allowing 

the state-law claims to be tried using the Stark/AKS theory was egregious, 

constituting a clear error of judgment. See Estate of Amergi ex. rel. Amergi, 611 F.3d 

at 1365 (“A district court does not abuse its discretion when it has a range of choices 

and the court’s choice does not constitute a clear error of judgment.” (quotation marks 

omitted)). 

III.

The doctrine of supplemental jurisdiction is “designed to enable courts to 

handle cases involving state-law claims in the way that will best accommodate the 

values of economy, convenience, fairness, and comity” and to allow “the Judicial 

Branch . . . to shape and apply the doctrine in that light.” Carnegie-Mellon Univ. v. 

Cohill, 484 U.S. 343, 351, 108 S. Ct. 614, 619, 98 L. Ed. 2d 720 (1988). The District 

Court’s decision here to retain jurisdiction did not further these goals. Rather, it 

resulted in the needless creation of new law for nine states and permitted parties that 

were either ignorant of the law or disingenuous to waste scarce judicial resources. We 

conclude that the District Court’s decision to retain supplemental jurisdiction over the 

state-law claims was an abuse of discretion. 

We also explicitly note that we express no opinion whatsoever as to whether 

the FCAs violate Stark, AKS, or some other state law. We also express no view as to 

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whether it would be wise to allow Stark and AKS violations to prove, as a matter of 

law, elements of state unfair competition law. It certainly does not require any great 

leap of logic to believe that a company that profits by declining to comply with 

government regulations enjoys an unfair advantage vis-à-vis its competitors who 

choose to obey the law. We hold only that exercising supplemental jurisdiction under 

these (perhaps sui generis) circumstances was an abuse of discretion.

We VACATE the judgment below and REMAND with instructions to dismiss 

the state-law claims without prejudice so that the parties can litigate their claims in a 

proper forum.

SO ORDERED.

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