Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca6-15-03070/USCOURTS-ca6-15-03070-0/pdf.json

Parties Involved:
Holzer Health Systems
Appellee
Sara Jane Jones-McNamara
Appellant

Document Text:

NOT RECOMMENDED FOR FULL-TEXT PUBLICATION

File Name: 15a0729n.06

No. 15-3070

UNITED STATES COURT OF APPEALS

FOR THE SIXTH CIRCUIT

SARA JANE JONES-MCNAMARA, 

Plaintiff-Appellant,

v.

HOLZER HEALTH SYSTEMS, 

Defendant-Appellee.

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ON APPEAL FROM THE 

UNITED STATES DISTRICT 

COURT FOR THE SOUTHERN 

DISTRICT OF OHIO

Before: SUHRHEINRICH and MOORE, Circuit Judges; VAN TATENHOVE, District Judge*

SUHRHEINRICH, Circuit Judge.

Plaintiff-Appellant Sara Jane Jones-McNamara (“McNamara”) appeals the district court’s 

order granting summary judgment to Defendant-Appellee Holzer Health Systems, Inc. 

(“Holzer”) in her action alleging that Holzer terminated her in violation of the False Claims Act 

(“FCA”)’s anti-retaliation provision, 31 U.S.C. § 3730(h). We affirm, but for reasons different 

than those articulated by the district court. 

I. BACKGROUND

A. Facts

Holzer is a health care delivery system comprised of several hospitals and care facilities 

in southeastern Ohio. ID # 3329-3331. McNamara began work for Holzer as Vice President for 

 

* The Honorable Gregory F. Van Tatenhove, United States District Judge for the Eastern District of 

Kentucky, sitting by designation. 

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Corporate Compliance on March 1, 2010. ID # 79. Shortly after starting work, McNamara 

began investigating allegations that Holzer’s dealings with a patient transport company called 

Life Ambulance (“Life”) violated the Anti-Kickback Statute (“AKS”), 42 U.S.C. § 1320a-7b. 

Holzer and Life had a preferred supplier agreement under which Life promised to make its best 

efforts to be available upon Holzer’s request. ID # 859. This agreement, however, is not what 

sparked McNamara’s concerns about potential AKS violations; in fact, McNamara assumed the 

contract was legal. ID # 861-62. McNamara’s concerns arose when she received a phone call on 

May 8 and an e-mail on May 11 from Tina Baker, a Holzer Emergency Room nurse, alleging 

that “certain hospital ER doctors” received embroidered jackets from Life. ID # 875-77, 4894, 

5084. McNamara ultimately confirmed the receipt of only one such jacket, which she later 

valued at $23.50. ID # 879-80, 2358. Baker also claimed that Holzer employees consistently 

called Life over its competitor MedFlight for ambulance services despite the fact that Life was 

“more than double the distance and time” from Holzer compared to MedFlight. ID # 875-76, 

4894. On May 10, after speaking to Baker on the phone but before receiving her e-mail,

McNamara e-mailed James Phillippe, the President of one of Holzer’s hospitals, to inform him of 

an “[a]llegation of [a] potential kickback issue in [the] ER.” ID # 4899. 

On May 13, McNamara learned from Holzer’s Director of Community and Wellness, 

Bonnie MacFarlane, that Life had provided free hotdogs and hamburgers at Holzer’s employee 

health and wellness fairs in 2008 and 2009, ID # 888, 4888, 4890, 4903 (under seal), 5085. 

McNamara further discovered on May 18 that Life similarly would supply free hotdogs at 

Holzer’s upcoming health and wellness fair the following day. ID # 865, 4889, 4903 (under 

seal), 5086. Despite McNamara’s objection that this event violated the AKS, she allowed the 

event to proceed. ID # 865. 

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Based on this collection of facts—Baker’s unverified allegation that Life was receiving 

preferential referrals, one doctor’s receipt of a $23.50 jacket, and Life’s provision of hotdogs at 

past wellness fairs and the upcoming wellness fair—McNamara sent the following May 18 email to CEO Brent Saunders and Vice President of Human Resources Lisa Halley: “We 

definitely do have an anti-kickback issue with Life and after Wed [the 2010 health and wellness 

fair] I will not ever ok their donating. [sic], sponsoring or equipping, etc. anything at Holzer

again.” ID # 4904. McNamara explained in the e-mail that she would allow the upcoming

wellness fair to proceed because “I decided I should have a solid case before I start banning 

things.” Id. After sending this e-mail, McNamara met in person with Saunders, who instructed 

McNamara not to reduce her conclusions to writing before completing her investigation. ID # 

892, 2617-18, 4934. 

The following day, McNamara verbally reiterated to Saunders her concern that Holzer 

had violated the AKS and needed to pay back the federal government. ID # 900. Following the 

meeting with Saunders, McNamara sent an e-mail to Saunders, Phillippe, and Halley providing 

an update on her investigation and proclaiming “[a]nti-kickback violations (we have one of 

them) are illegal.” Id. Saunders repeated his verbal directive to McNamara not to put 

conclusions of illegal activity in writing before completing her investigation.1 ID # 906-07, 

4934. 

McNamara never clarified for what items or services she believed Holzer needed to 

reimburse the government. At one point, McNamara testified she told Saunders that Holzer 

needed to pay back the government “for all these hot dogs, hamburgers, coats, jackets, and 

 

1

Saunders testifies he gave his second instruction not to reduce conclusions to writing after McNamara 

sent her May 19 e-mail. ID # 2618, 4934. McNamara agrees Saunders gave her this instruction on May 19, but she 

does not say whether he gave it before or after she sent the May 19 e-mail. ID # 900, 906-07.

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stuff.” ID # 1219 (sealed).2 But McNamara also testified that during her investigation she 

thought Holzer might have billed Medicare for Life’s ambulance services, in which case Holzer 

would need to return the government’s payment for any services tainted by kickbacks. ID # 901-

02. McNamara later contradicted her own testimony, however, when she stated that Life, not 

Holzer, billed for ambulance services. ID #1219 (sealed).

Sometime thereafter, McNamara determined based on records of patient transports that 

out of the 102 patient transports Holzer referred to an ambulance company between January and 

April 2010, Holzer referred 93 to Life. Appellant Br. 10; ID # 4892, 4893. McNamara testified 

that she completed her investigation into the anti-kickback violations upon reporting these 

statistics to Saunders. ID # 864, 1005.

On June 30, 2010, Saunders and Halley terminated McNamara’s employment. ID # 3204.

B. Procedural History

McNamara’s amended complaint alleges she was terminated in retaliation for her 

investigation of Holzer’s FCA violations as prohibited by 31 U.S.C. § 3730(h) and raises five 

additional state law claims related to her termination. ID # 68-72. The district court granted 

Holzer’s motion for summary judgment on McNamara’s FCA retaliation claim and declined to 

exercise supplemental jurisdiction over McNamara’s remaining state law claims. ID #5488-89.

The district court’s opinion rests on two primary grounds: lack of direct evidence of 

retaliation, and McNamara’s inability to prove that Holzer’s stated reasons for her termination 

are pretext. In its ruling, the district court assumed McNamara could establish the first two 

elements of her retaliatory discharge claim: 1) protected activity, and 2) Holzer’s knowledge that 

McNamara engaged in protected activity. ID # 5477. The district court instead focused on the 

 

2 This testimony is nonsensical since Holzer would not bill (and thus would not need to reimburse) 

Medicare for hotdogs or other goods received from Life.

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third element of McNamara’s claim, causation, i.e. that Holzer terminated her because of her 

protected activity. Id. The district court rejected McNamara’s “direct” evidence because it

demanded inferences to find that Holzer acted out of impermissible retaliation. ID #5478-82. 

The district court then considered whether, viewing McNamara’s evidence as circumstantial, it 

satisfied the burden-shifting framework of McDonnell Douglas Corp. v. Green, 411 U.S. 792 

(1973). For this purpose, the district court assumed that McNamara established all three 

elements of her prima facie case and allowed the burden of production to shift to Holzer to 

present a legitimate, non-retaliatory reason for McNamara’s discharge. ID # 5482. The district 

court found that Holzer adequately identified lack of professionalism and interpersonal skills as a 

non-retaliatory reason for terminating McNamara, emphasizing McNamara’s insubordination in 

disobeying Saunders’ instruction not to send e-mails indicating a kickback violation had 

occurred without completing her investigation. ID #5483-84. The district court then analyzed 

whether McNamara met her burden of showing Holzer’s offered reasons were pretexts and

ultimately concluded she could not prove Holzer’s reasons were insufficient to motivate her 

termination. ID # 5485. 

McNamara filed a timely notice of appeal of the district court’s grant of summary 

judgment. ID # 5493-94. On appeal, McNamara challenges the district court’s rulings on the 

direct evidence and pretext issues. Appellant Br. 2. This panel has jurisdiction over 

McNamara’s appeal under 28 U.S.C. § 1291.

II. STANDARD OF REVIEW

We review the district court’s grant of summary judgment de novo. Kroll v. White Lake 

Ambulance Auth., 763 F.3d 619, 623 (6th Cir. 2014). Summary judgment is proper where the 

“the movant shows that there is no genuine dispute as to any material fact and the movant is 

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entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). The court must view all evidence 

in favor of the nonmoving party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 255 (1986). 

Once a defendant demonstrates the absence of a genuine dispute of material fact on at least one 

element of the plaintiff’s claim, the plaintiff must present sufficient evidence from which a jury 

could reasonably find in her favor. Emswiler v. CSX Transp., 691 F.3d 782, 788 (6th Cir. 2012). 

“The central issue is ‘whether the evidence presents a sufficient disagreement to require 

submission to a jury or whether it is so one-sided that one party must prevail as a matter of law.’” 

Newell Rubbermaid, Inc. v. Raymond Corp., 676 F.3d 521, 526-27 (6th Cir. 2012) (quoting 

Anderson, 477 U.S. at 251-52). 

III. ANALYSIS

A. Retaliatory Discharge Under the FCA

The FCA prohibits any person from “knowingly present[ing], or caus[ing] to be 

presented, a false or fraudulent claim for payment or approval.” 31 U.S.C. § 3729(a)(1)(A). To 

protect employees who expose fraud against the federal government, the FCA’s anti-retaliation 

provision forbids discharging an employee “because of lawful acts done . . . in furtherance of an 

action under this section or other efforts to stop 1 or more violations of this subchapter.” 

31 U.S.C. § 3730(h).3

Retaliatory discharge claims under the FCA proceed under the same rules applicable to 

other employment-related retaliation claims. Scott v. Metro. Health Corp., 234 F. App’x 341, 

346 (6th Cir. 2007). The plaintiff may establish a case of retaliation by presenting either direct 

or circumstantial evidence of a retaliatory motive. See Spengler v. Worthington, 615 F.3d 481, 

 

3 A slightly different version of § 3730(h) was in effect at the time of McNamara’s termination that 

protected employees from retaliation for “lawful acts done . . . in furtherance of other efforts to stop 1 or more 

violations of this subchapter.” 31 U.S.C. § 3730(h) (effective Mar. 23, 2010 to July 21, 2010). Congress amended 

the language to its present version in July 2010. 

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491 (6th Cir. 2010); Anthony v. BTR Automotive Sealing Sys., Inc., 339 F.3d 506, 514 (6th Cir. 

2003). 

Direct evidence is “evidence, which if believed, does not require an inference that 

unlawful retaliation motivated an employer’s action.” Spengler, 615 F.3d at 491. Where a 

plaintiff produces direct evidence of retaliation, “the burden of both production and persuasion 

shifts to the employer to prove that it would have terminated the employee even if it had not been 

motivated by impermissible discrimination.” Nguyen v. City of Cleveland, 229 F.3d 559, 563 

(6th Cir. 2000).

Where a plaintiff proceeds with circumstantial evidence of retaliation, the burden-shifting 

framework articulated in McDonnell Douglas Corp. v. Green, 411 U.S. 792 (1973) applies. 

Under the McDonnell-Douglas test, the plaintiff bears the initial burden to demonstrate a prima 

facie case of retaliation. Fuhr v. Hazel Park Sch. Dist., 710 F.3d 668, 674 (6th Cir. 2013). To 

establish a prima facie case, the plaintiff must show the following elements: (1) she was engaged 

in a protected activity; (2) her employer knew that she engaged in the protected activity; and (3) 

her employer discharged or otherwise discriminated against the employee as a result of the 

protected activity. Yuhasz v. Brush Wellman, Inc., 341 F.3d 559, 566 (6th Cir. 2003). Once the 

plaintiff establishes this prima facie case, the defendant bears the burden of producing a 

legitimate, nondiscriminatory reason for the adverse employment action. Fuhr, 710 F.3d at 674. 

At that point, the burden again shifts to the plaintiff to demonstrate that the defendant’s proffered 

reason represents a mere pretext for unlawful discrimination. Id.

B. Protected Activity

McNamara contends that she engaged in protected activity by investigating Holzer’s 

ongoing violations of the AKS and the FCA and reporting those violations to Saunders, 

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Phillippe, and Halley. Appellant Br. 19. As noted, the district court assumed McNamara had 

made out a prima facie case and held that McNamara failed to rebut Holzer’s non-discriminatory 

reasons for her discharge with evidence of pretext. ID # 5482, 5485. We conclude that 

McNamara did not establish a prima facie case because she has not created a genuine issue of 

material fact as to whether she engaged in protected activity. Specifically, McNamara failed to

produce sufficient evidence that her investigation and reports of Life’s provision of a jacket and 

hotdogs to Holzer employees rested on a reasonable belief in AKS or FCA violations. 

1. Standard for Protected Activity

The Sixth Circuit held in McKenzie v. BellSouth Telecommunications, Inc., 219 F.3d 508, 

516 (6th Cir. 2000), that internal reports “may constitute protected activity,” provided such 

internal reports “allege fraud on the government.” McKenzie interpreted an earlier version of 

31 U.S.C. § 3730(h) that protected “lawful acts . . . in furtherance of an action under this section 

including investigation for, initiation of, testimony for, or assistance in an action filed or to be 

filed under this section.” 31 U.S.C. § 3730(h) (effective to Mar. 23, 2010). The McKenzie court 

found that internal reports of fraud fell within this language since the expressly listed actions 

were not exclusive. McKenzie, 219 F.3d at 515. Congress later amended the language 

interpreted in McKenzie to protect “lawful acts . . . in furtherance of other efforts to stop 1 or 

more violations of this subchapter,” 31 U.S.C. § 3730(h) (effective Mar. 23, 2010, to July 21, 

2010), rather than those “in furtherance of an action under this section.” 31 U.S.C. § 3730(h) 

(effective to Mar. 23, 2010). This amended language was in effect at the time of McNamara’s 

termination. McKenzie’s recognition of protection for internal reports of fraud still applies under 

the amended version of § 3730(h). Statutory protection for all “efforts to stop” a FCA violation 

simply affirms McKenzie’s understanding that the activities listed in the previous version of 

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§ 3730(h) were not exhaustive and included internal reports of fraud. See Mikhaeil v. Walgreens,

Inc., No. 13-14107, 2015 WL 778179, at *7 (E.D. Mich. Feb. 24, 2015). McNamara’s May 18 

and 19 e-mails to Saunders, Phillippe, and Halley reporting Holzer’s anti-kickback violations 

thus at least superficially constitute protected activity. 

As McNamara asserts, an employee need not complete an investigation into potential 

fraud or uncover an actual FCA violation to undertake protected activity. See Graham Cnty. Soil 

& Water Conservation Dist. v. U.S. ex rel. Wilson, 545 U.S. 409, 416 (2005); U.S. ex rel.

Yesudian v. Howard Univ., 153 F.3d 731, 740 (D.C. Cir. 1998). The FCA’s anti-retaliation 

provision protects employees “while they are collecting information about a possible fraud, 

before they have put all the pieces of the fraud together.” U.S. ex rel. Yesudian, 153 F.3d at 740. 

Furthermore, the Supreme Court stated in Graham County Soil & Water Conservation District v. 

U.S. ex rel. Wilson, 545 U.S. at 416, that a plaintiff claiming retaliation under the FCA may 

engage in protected activity “even if the target of an investigation or action to be filed was 

innocent.” As the Supreme Court observed, it is well-established among the circuits that proving 

a violation of 31 U.S.C. § 3729 is not an element of a § 3730(h) retaliation claim. Id. at 428 n.1. 

Therefore, it is not automatically fatal to McNamara’s claim that she neither pinpointed any Life 

referrals induced by the jackets or food nor located any fraudulent cost reports submitted to the 

government as a result of the purported kickbacks. 

That being said, these lenient standards for establishing protected activity remain subject 

to a reasonable belief requirement. This Court held in McKenzie that for an internal report to 

constitute protected activity under § 3730(h), it “must establish some nexus to the FCA to satisfy 

the ‘in furtherance’ prong of an FCA claim, by reasonably leading to a viable FCA action.” 

McKenzie, 219 F.3d at 517. Under the new version of § 3730(h) extending protection to “lawful 

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acts done . . . in furtherance of an action under this section or other efforts to stop” a FCA 

violation, the requirement that conduct could develop into a “viable FCA action” no longer 

accurately reflects the statutory language. 31 U.S.C. § 3730(h) (emphasis added); see also 

Mikhaeil, 2015 WL 448178, at *7. While the statutory amendment removes McKenzie’s 

requirement that protected conduct could “lead[] to a viable FCA action,” McKenzie’s reasonable 

belief requirement survives the amendment. Now, a plaintiff’s activities must reasonably 

embody “efforts to stop” FCA violations. 31 U.S.C. § 3730(h). The Seventh Circuit’s test for 

protected activity enunciates this reasonableness standard by providing that an employee’s 

investigation into alleged fraud is protected only where: “(1) the employee in good faith believes, 

and (2) a reasonable employee in the same or similar circumstances might believe, that the 

employer is committing fraud against the government.” Fanslow v. Chi. Mfg. Ctr., Inc., 384 F.3d 

469, 480 (2004); see also Wilkins v. St. Louis Hous. Agency, 314 F.3d 927, 933 (8th Cir. 2002); 

Moore v. Cal. Inst. of Tech. Jet Propulsion Lab., 275 F.3d 838, 845 (9th Cir. 2002). Therefore, 

although McNamara need not establish that Holzer actually violated the FCA, she must show 

that her allegations of fraud grew out of a reasonable belief in such fraud.

2. Anti-kickback Violation

McNamara claims her e-mails to Holzer senior management constitute protected activity 

under § 3730(h) because they alleged violations of the AKS that also violated the FCA. AKS 

violations can constitute FCA violations where a claim submitted to the government for 

reimbursement includes items or services resulting from a violation of the AKS, 42 U.S.C. 

§ 1320a-7b(g), or where cost reports submitted to the government for reimbursement include an 

express certification that the underlying claims comply with the AKS, see, e.g., U.S. ex rel. 

Wilkins v. United Health Grp., Inc., 659 F.3d 295, 312-13 (3d Cir. 2011). McNamara’s theory—

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as far as we can tell—is that Life was submitting claims to the federal government that violated

the FCA by seeking reimbursement for ambulance services procured from Holzer through illegal 

bribes: namely, jackets and hot dogs. ID # 900, 1219 (sealed). McNamara thus attempts to 

establish her internal report’s required connection to fraud based on an underlying AKS 

violation, giving rise to the issue whether McNamara reasonably believed Holzer accepted illegal 

kickbacks or bribes under the AKS. 

The AKS prohibits “knowingly and willfully solicit[ing] or receiv[ing] any remuneration 

(including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or 

kind . . . in return for referring 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.” 42 U.S.C. § 1320a-7b(b)(1)(A). The statute defines 

“remuneration” as “transfers of items or services for free or for other than fair market value.” 

42 U.S.C. § 1320a-7a(i)(6). The statute does not, however, define the phrase “in return for.” Yet

courts widely agree that the “‘gravamen of Medicare fraud is inducement.’” See, e.g., U.S. ex 

rel. McDonough v. Symphony Diagnostic Servs., Inc., 36 F. Supp. 773, 777 (S.D. Ohio 2014) 

(quoting Polk Cnty., Tex. v. Peters, 800 F. Supp. 1451, 1455 (E.D. Tex. 1992)).

While not binding, the Office of the Inspector General (“OIG”) for the Department of 

Health and Human Services (“HHS”) has offered further guidance on the meaning of 

“remuneration” and “induce.” The OIG indicated in its Program Guidance for Ambulance 

Suppliers that the term “remuneration” means “virtually anything of value” including goods, 

meals, and gifts. OIG Compliance Program Guidance for Ambulance Suppliers, 68 Fed. Reg. 

14245, 14252 (Mar. 24, 2003). Several courts have affirmed this expansive understanding of 

remuneration as “‘anything of value in any form whatsoever.’” United States v. The Health 

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Alliance of Greater Cincinnati, No. 1:03-CV-00167, 2008 WL 5282139, at *7 (S.D. Ohio Dec. 

18, 2008) (quoting OIG Anti-Kickback Provisions, 56 Fed. Reg. 35952, 35958 (July 29, 1991)); 

see also United States v. Shaw, 106 F. Supp. 2d 103, 114 (D. Mass. 2000). Based on the broad 

meaning of remuneration, the OIG recommends that ambulance suppliers not offer gifts “of 

greater than nominal value to referral sources,” but indicates that “token gifts used on an 

occasional basis to demonstrate good will or appreciation (e.g., logo key chains, mugs, or pens) 

will be considered nominal in value.” OIG Compliance Program Guidance for Ambulance 

Suppliers, 68 Fed. Reg. at 14252. The OIG explained the term “induce” as the necessary intent 

“to lead or move by influence or persuasion.” OIG Anti-Kickback Provisions, 56 Fed. Reg. 

35952, 35938 (July 29, 1991). Although the term “induce” applies to the party offering or 

paying remuneration, it sheds light on the meaning of the phrase “in return for,” which applies to 

the recipient of remuneration, implying that the recipient must be duly induced or “move[d].” 

See 42 U.S.C. § 1320a-7b(1), (2). 

An important aspect of inducement is that the remuneration be directed towards an 

individual or entity “in a position to generate Federal health care program business.” See OIG 

Supplemental Compliance Program Guidance for Hospitals, 70 Fed. Reg. 4858, 4864 (Jan. 31, 

2005). In U.S. ex rel. Perales v. St. Margaret’s Hospital, 243 F. Supp. 2d 843, 852-54 (C.D. Ill. 

2003), referrals to a hospital by a nurse working for a physician who entered into an illegal 

referral agreement with the hospital did not violate the FCA because the referring nurse received 

no remuneration for her referrals. Thus, any claims submitted to the government as a result of 

the nurse’s referrals were not tainted by an illegal inducement under the AKS. Id. at 854. As the 

court explained, the AKS “contemplate[s] that the person receiving the inducement is the one 

prohibited from making the referral to the entity that offered the remuneration.” Id. 

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In short, a kickback violation entails 1) remuneration to a person or entity in a position to 

refer Federal health care program patients 2) that could reasonably induce the person or entity to 

refer such patients. See OIG Supplemental Compliance Program Guidance for Hospitals, 70 Fed. 

Reg. at 4864. McNamara must demonstrate the reasonableness of her belief that these elements 

existed in Holzer’s relationship with Life.

3. Application to McNamara’s Investigation and Internal Reports 

Even if we assume that McNamara had a subjective, good faith belief that Holzer 

employees accepted remuneration as an inducement to refer patients to Life, this belief was not

objectively reasonable based on the facts in McNamara’s knowledge4at the time she reported 

AKS violations to other upper management. See Fanslow, 384 F.3d at 480 (articulating the

reasonableness requirement for protected activity as containing a subjective and objective 

component). Two circumstances make this conclusion clear. 

First, McNamara identified only two gifts delivered to Holzer employees—one jacket5

and some hotdogs and hamburgers at an annual health and wellness fair. It cannot plausibly be 

suggested that one jacket valued at $23.50, ID # 2358, and occasional servings of hotdogs and 

hamburgers, ID # 4888-90, could induce a reasonable person to prefer one provider over another. 

In fact, these items represent such a low monetary value they can only be characterized as 

“token” gestures of good will under OIG guidance. Yet McNamara claims that all free food and 

 

4McNamara submitted additional evidence of the alleged kickback arrangement between Holzer and Life in 

the form of declarations from Life employees Teresa and William Paugh. Because McNamara brings a claim for 

retaliation under § 3730(h) and not a qui tam action under § 3729, only the evidence in McNamara’s knowledge at 

the time of her investigation and internal reports are relevant for purposes of assessing whether she was engaged in 

protected activity. To the extent the Paugh declarations contain allegations beyond what McNamara heard and 

communicated in her e-mails, they will be disregarded.

5 The dissent portrays McNamara’s belief of AKS violations as based on gifts of multiple jackets, noting 

that Baker’s e-mail stated, “SEVERAL people got them,” ID # 4894, and that McNamara testified Dr. Mickunas 

told her “he knew of a few people that had” jackets, ID # 880-81. The record, of course, contains no evidence 

outside McNamara’s subjective mindset to support these statements. Not only did McNamara admit she discovered 

only one such jacket but Baker herself testified that she never saw a Life jacket. ID # 4673, 4701. Dr. Mickanus 

also testified he did not recall anyone else in Holzer’s Emergency Room wearing a Life jacket. ID # 4592, 4599.

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gifts are an inducement for patient referrals, citing to a settlement between the OIG and two 

physicians who allegedly accepted Miami Dolphins football tickets and meals from a medical 

equipment supplier in exchange for referrals. Appellant Reply Br. 5-6 (citing an expert report 

that describes the settlement, reported at the OIG’s website archives, http://oig.hhs.gov/reportsand-publications/archives/enforcement/kickback_archive.asp#2006, as an example of an AKS 

violation resulting in an enforcement settlement). 

Indeed, some cases have ruled that free food and drinks can operate as an inducement for 

referrals, but in those cases the amount and quality of food provided far exceeded Life’s annual 

provision of hotdogs and hamburgers to a miscellaneous set of Holzer employees at a health fair. 

See United States v. Perlstein, 632 F.2d 661, 662-63 (6th Cir. 1980) (affirming conviction of 

nursing home administrator under the AKS for accepting cash payments and $416/month in 

alcoholic beverages in exchange for Medicaid business referrals); U.S. ex rel. Bilotta v. Novartis 

Pharm. Corp., 50 F. Supp. 3d 497, 515 (S.D.N.Y. 2014) (denying a motion to dismiss a qui tam 

complaint alleging the provision of food to physicians at multiple lavish speaker events); U.S. ex 

rel. Bergman v. Abbot Labs., 995 F. Supp. 2d 357, 375 (E.D. Pa. 2014) (denying a motion to 

dismiss a qui tam complaint alleging the provision of meals and sham honoraria funds to 

encourage physicians to prescribe a drug for off-label uses). For example, the court in U.S. ex 

rel. Bilotta v. Novartis Pharmaceuticals Corp., 50 F. Supp. 3d at 515, denied a motion to dismiss 

a complaint alleging underlying AKS violations in the form of “sham speaker events” for doctors 

that “constituted upscale, all-expense paid social outings” at sports bars and restaurants. The 

complaint alleged the defendant had “spent exorbitant amounts of money . . . at both the macro 

level and at the individual event level.” Id. Life’s provision of hotdogs and hamburgers at an 

annual employee health fair bears no resemblance to the gifts provided in these cases. Indeed, it 

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is ludicrous to believe that a person would be tempted to make illegal referrals in exchange for a 

couple hotdogs once a year. McNamara herself must have recognized the token nature of the 

food items because she nonetheless allowed the event to proceed.

Second, and more importantly perhaps, McNamara presented no evidence to suggest a 

connection between the gifts and the Life referrals. As indicated by the OIG guidance and U.S. 

ex rel. Perales, remuneration cannot induce a referral unless it is directed towards a person with 

the power to make referrals. McNamara did not identify a single employee with authority to 

make referrals to Life, let alone one who also attended one of Holzer’s employee wellness fairs 

and consumed a Life-sponsored hotdog or hamburger. The only specific person McNamara 

confirmed received anything from Life was Dr. Mickunas, who admitted to receiving a $23.50

embroidered jacket from Life. ID # 4590. Although McNamara claimed that doctors (like Dr. 

Mickanus) made the ultimate decision about which ambulance provider to call, she never 

produced the testimony or affidavit of any Holzer doctor verifying this understanding. ID # 859. 

In fact, Dr. Mickunas contradicted this belief when he testified that Holzer’s Emergency Room 

doctors rarely call ambulance companies to request a patient transport; according to him, a nurse 

or secretary typically performs that function.

6

ID # 4584-85. Baker, too, testified that 

Emergency Room nurses called the ambulance service. ID # 4678, 4690. Yet McNamara 

identified no nurse or secretary who accepted gifts from Life. At the time McNamara made her 

initial reports to Holzer management, the basis for her belief in anti-kickback violations turned

on her unquestioned, unconfirmed, and thus unreasonable assumption that Dr. Mikanus and other 

 

6 The dissent contends that Dr. Mickunas’ testimony about referral practices is “beside the point” in 

determining the reasonableness of McNamara’s belief that Holzer was violating the AKS. Dissent at 5. This 

analysis ignores the objective component of the protected activity standard. Because the reasonable belief standard 

governing protected activity includes an objective component, evidence outside McNamara’s subjective point of 

view is not only on point but absolutely essential to assessing the reasonableness of her belief.

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doctors not only had the authority but in fact routinely made the decision to refer business to Life

in knowing and willful return for illegal kickbacks.

McNamara also attempts to demonstrate a connection between the gifts and referrals by 

relying on the statistics indicating Holzer called Life more than ninety percent of the time 

between January and April 2010. McNamara did not possess this knowledge when she first 

communicated anti-kickback allegations to Holzer management in the May 18 and 19 e-mails. 

Sometime after making these initial reports, McNamara analyzed the patient transport records

and discovered the ninety percent referral rate to Life, at which point she considered her 

investigation complete. But that statistic is somewhat explained by Holzer’s preferred supplier 

agreement with Life, an agreement McNamara knew about and believed to be legal.

7

 Yet 

McNamara did not show that her concededly complete investigation made any attempt to 

determine whether the ninety percent referral rate was traceable to the preferred supplier 

agreement versus the purported illegal kickbacks.8 McNamara instead fixates on the fact that 

Life’s facility was located farther from Holzer than competing ambulance companies as the 

denouement of her belief that the preference for Life was illegally motivated. Appellant Br. 7. 

But, as Dr. Mickunas pointed out, the choice of an ambulance company is based on multiple 

factors, including distance, availability, weather, and willingness to come. ID # 4596-97. Other 

factors likely include reliability, quality of service, cost to the patient, proximity to Holzer’s 

other hospitals and care centers, and whether the ambulance was needed for an emergency or 

non-emergency transport. McNamara never bothered to investigate whether Life might have 

been receiving the bulk of Holzer’s business because it provided the best and most reliable 

 

7 McNamara does not argue that Life procured its preferred supplier agreement through illegal kickbacks.

8 Although McNamara conducted some investigation into Life’s and MedFlight’s respective credentials, ID 

# 3162-71, 4907, McNamara testified that these efforts focused on evaluating the wisdom of a preferred supplier 

agreement with Life—not discerning whether the referral statistics supported an underlying kickback arrangement. 

ID # 858, 862. 

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service, and apparently she never intended to do so since, according to her, she completed her 

anti-kickback investigation.

9

The dissent argues “[i]t is the province of a jury” to assess whether McNamara’s belief

was reasonable and to weigh her failure to conduct a sensible investigation. Dissent at 4-5.

There may be a jury question as to McNamara’s subjective, good faith belief, but there is no 

proof in the record to establish that McNamara’s belief was objectively reasonable. In

concluding the paltry evidence McNamara presents could justify a jury finding that she 

reasonably believed Holzer committed fraud, the dissent conflates the subjective and objective 

components of the test for protected activity and diverges from our understanding of “objective 

reasonableness.” An objectively reasonable belief requires facts that exist independently of the 

plaintiff’s personal, interior mentality. McNamara produces very few such independent facts to 

support her belief of anti-kickback violations, and those she does produce do not make her belief 

reasonable. A jury could not find McNamara engaged in protected activity when she based her 

allegations of illegal kickbacks solely on a high referral rate to a contractually (and legally) 

preferred supplier who gave a token jacket and hotdogs to unidentified Holzer employees that

may or may not have had referral power. 

In conclusion, because McNamara cannot meet her burden of demonstrating the 

reasonableness of her belief that Holzer violated the AKS, she cannot show she had a reasonable 

belief that Holzer presented or caused false claims to be presented in violation of the FCA. 

 

9 The dissent also attempts to reinforce the statistics by emphasizing McNamara’s understanding of an 

anecdote relayed by Baker about a patient who died after a transportation delay because the nurse in the ER called 

Life instead of the closer ambulance service. Dissent at 6 (quoting ID # 875-76). McNamara’s subjective belief that 

this anecdote raised an anti-kickback issue with Life, however, is not only unsupported but subverted by external 

evidence: Baker stated in her deposition that it was MedFlight who transported the cardiac patient who had died—

not Life. ID # 4668-71.

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McNamara failed to create a genuine issue of material fact that her actions constituted protected 

activity. On this basis, we hold that summary judgment was properly granted to Holzer.

Because we conclude that McNamara did not engage in protected activity, we need not

address the parties’ arguments on the remaining elements of McNamara’s prima facie case. See 

Yuhasz, 341 F.3d at 566-68 (dismissing a FCA retaliation claim for plaintiff’s failure to 

demonstrate just one element of his prima facie case). We similarly decline to address whether 

McNamara produced direct evidence of Holzer’s retaliatory motive because an employer cannot 

engage in forbidden retaliation without an employee’s participation in activity protected by law. 

Because McNamara has not established a prima facie case, it is also unnecessary to address 

pretext. 

CONCLUSION

For these reasons, we AFFIRM the judgment of the district court.

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KAREN NELSON MOORE, Circuit Judge, dissenting. I dissent because Sara JonesMcNamara (“McNamara”) established a prima facie case of retaliation and presented sufficient 

evidence to suggest that Holzer Health Systems’s (“Holzer”) reasons for firing her were 

pretextual. I would therefore vacate the district court’s entry of summary judgment and remand 

for trial.

To establish a prima facie case of retaliatory discharge, McNamara “must show: 

(1) [s]he engaged in a protected activity; (2) h[er] employer knew that [s]he engaged in the 

protected activity; and (3) h[er] employer discharged or otherwise discriminated against [her] as 

a result of the protected activity.” Yuhasz v. Brush Wellman, Inc., 341 F.3d 559, 566 (6th Cir. 

2003). The majority rests its decision on the first prong. Although it is undisputed that 

McNamara investigated allegations of kickbacks and reported her findings to Holzer officials, R. 

102-36 (McNamara Email, 5/18/2010 at 1) (Page ID #4904); R. 102-37 (McNamara Email, 

5/19/2010 at 1–2) (Page ID #4906–07), the majority finds that these actions were not protected 

because McNamara did not have “a reasonable belief in [Anti-Kickback Statute (“AKS”), 

42 U.S.C. § 1320a-7b] or [False Claims Act (“FCA”), 31 U.S.C. § 3729, et seq.] violations.” 

Maj. Op. at 8.

As the majority recognizes, internal reports that “allege fraud on the government” 

constitute protected activity under 31 U.S.C. § 3730(h). See McKenzie v. BellSouth Telecomms., 

Inc., 219 F.3d 508, 516 (6th Cir. 2000); 31 U.S.C. § 3730(h) (effective July 22, 2010) (protecting 

“lawful acts done by the employee, contractor, agent or associated others in furtherance of an 

action under this section or other efforts to stop 1 or more violations of this subchapter”) 

(emphasis added). These reports, however, must “be reasonably connected to the FCA, which 

was designed to encourage and protect federal whistleblowers.” McKenzie, 219 F.3d at 515. 

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The majority is therefore correct that investigating and internally reporting on allegations of 

fraud on the government will be protected if “‘(1) the employee in good faith believes, and (2) a 

reasonable employee in the same or similar circumstances might believe, that the employer is 

committing fraud against the government.’” Maj. Op. at 10 (quoting Fanslow v. Chi. Mfg. Ctr., 

Inc., 384 F.3d 469, 480 (7th Cir. 2004)). This belief need not ultimately be correct, Graham 

County Soil & Water Conservation District v. U.S. ex rel. Wilson, 545 U.S. 409, 416 & n.1 

(2005), and employees retain protection from retaliation “while they are collecting information 

about a possible fraud, before they have put all the pieces of the puzzle together.” U.S. ex rel. 

Yesudian v. Howard Univ., 153 F.3d 731, 740 (D.C. Cir. 1998). Accordingly, the objective 

component of the inquiry considers the reasonableness of the employee’s belief based upon the 

facts available to the employee at the time. See Fanslow, 384 F.3d at 480–81 (reversing grant of 

summary judgment where the record was “unclear” as to whether the employee had the requisite 

belief “at the time of his investigation and whether a reasonable employee in these circumstances 

would have thought the same”). A belief that ultimately turns out to be incorrect may 

nonetheless have been objectively reasonable in the midst of an investigation, based on 

incomplete facts.

McNamara’s belief that she was investigating fraud under the FCA was based upon a 

belief that she had uncovered a violation of the AKS, which prohibits the receipt of remuneration 

as inducement for referral of an individual for federally funded health care services. See 

42 U.S.C. § 1320a-7b(b)(1). As the majority recognizes, remuneration under the AKS may be 

“‘anything of value in any form whatsoever,’” United States v. The Health Alliance of Gtr. 

Cincinnati, No. 1:03-CV-00167, 2008 WL 5282139, at *7 (S.D. Ohio Dec. 18, 2008) (quoting 

OIG Anti-Kickback Provisions, 56 Fed. Reg. 35952, 35958 (July 29, 1991)), yet the majority 

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holds that the items McNamara learned about were of such little value that an investigator could 

never have a reasonable belief in the existence of possible inducement, Maj. Op. at 11–15. The 

majority continues that inducement under the AKS exists when that remuneration is provided 

with the intent “‘to lead or move by influence or persuasion,’” Maj. Op. at 12 (quoting OIG AntiKickback Provisions, 56 Fed. Reg. 35952, 35958 (July 29, 1991)), and is “directed towards an 

individual or entity ‘in a position to generate Federal health care program business,’” id. (quoting 

OIG Supplemental Compliance Program Guidance for Hospitals, 70 Fed. Reg. 4858, 4864 (Jan. 

31, 2005)), but the majority finds unreasonable McNamara’s belief that the items were being 

given to doctors with authority to refer business to Life Ambulance (“Life”) because McNamara 

did not sufficiently investigate the issue, id. at 15–16. But McNamara need not prove that an 

actual violation of the AKS occurred. See Graham Cnty., 545 U.S. at 416 n.1 (holding that 

“proving a violation . . . is not an element of a § 3730(h) cause of action”). The question is much 

more tentative: Did she put forth evidence from which a jury could find that she had an 

objectively reasonable belief as she was conducting the investigation and making her internal 

reports that she was “collecting information about a possible fraud.” Yesudian, 153 F.3d at 740. 

I would conclude that she did.

Baker reported to McNamara in May 2010 that Life had given jackets with its logo on 

them “to certain hospital ER doctors,” stated that “SEVERAL people got them,”1and noted 

 

1

The majority treats the issue as involving only one jacket, Maj. Op. at 13, and 

McNamara did testify that she ultimately confirmed the existence of only one such jacket, R. 71-

1 (McNamara Dep. at 113:13–114:11) (Page ID #2358–59), but the report from Baker was not so 

limited. See R. 102-31 (Baker Email) (Page ID #4894). Moreover, McNamara testified that 

when she interviewed Dr. Mickunas during her investigation, he said that “he knew of a few 

people that had” jackets. R. 50-1 (McNamara Dep. at 205:23–206:1) (Page ID #880–81). The 

majority brushes aside this information, stating that “[t]he record, of course, contains no 

evidence outside McNamara’s subjective mindset to support these statements,” Maj. Op. at 13 

n.5, but the record in fact contains such evidence. McNamara received an email from Baker and 

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concerns with Holzer using Life frequently, given that “Life Air [was] more than double the 

distance and time” from Holzer than Medflight. R. 102-31 (Baker Email) (Page ID #4894); see 

also R. 50-1 (McNamara Dep. at 200:21–201:10) (Page ID #875–76) (describing a situation in 

which a patient had been transported from Holzer to another facility and “had died, and 

reportedly, the doctors were upset because there was a delay in transport,” which Baker 

attributed “perhaps” to the fact that “the nurse in the ER was forced to not call the closest 

ambulance but to call Life”).2 Soon after, McNamara learned that Life had also provided free 

hot dogs and hamburgers for barbeques at Holzer’s health and wellness fair. R. 105 (Sealed 

McNamara Notes at 5) (Page ID #5139); see also R. 102-26 (2010 Health Fair Notice) (Page ID 

#4889); R. 102-28 (2009 Health Fair Notice) (Page ID #4891). After sending her May 18 and 

May 19 emails to Holzer officials regarding her concerns, McNamara determined that from 

January to April 2010, Holzer used Life Ambulance more than 90 percent of the time an 

 

testified to having received a statement from Mickunas. Because the objective-reasonableness 

inquiry judges the reasonableness of an employee’s belief based upon the information that was 

available to the employee at the time, Fanslow, 384 F.3d 480–81 (test is “whether a reasonable 

employee in these circumstances would have thought the same”), these are external sources that 

a jury could find were sufficient to support a reasonable belief in the midst of an ongoing 

investigation. That Baker and Mickunas later testified to having no personal knowledge of these 

additional jackets does not affect the reasonableness of McNamara’s reliance on their statements 

to her unless McNamara knew this additional information at the time. Far from conflating the 

subjective and objective components of the test, this recognition is necessary to avoid 

transforming the objective component from requiring an objectively reasonable belief to an 

objectively correct belief.

2 As the majority notes, Maj. Op. at 17 n.9, Baker testified during her deposition that it 

was a different ambulance provider that had been responsible for the transportation of the patient 

who died. See R. 100-1 (Baker Dep. at 29:2–31:18) (Page ID #4669–71). But Baker’s email to 

McNamara did not mention this fact and McNamara’s testimony indicates that Baker told her 

that Life was the provider. The majority treats this as constituting an unreasonable belief as a 

matter of law because McNamara may ultimately have been incorrect, but the issue, again, is 

whether a jury could find that her belief at the time, given the information available to her, was 

objectively reasonable.

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ambulance company was used to transport patients. R. 102-29 (Chart) (Page ID #4892).3 She 

then reported these figures to Holzer CEO Brent Saunders. See R. 50-1 (McNamara Dep. at 

347:10–23) (Page ID #1005). From these facts, a jury could find that it was reasonable for 

McNamara to conclude that it was possible that Holzer was “receiv[ing] . . . remuneration . . . in 

return for referring” its patients to Life Ambulance. 42 U.S.C. § 1320a-7b(b)(1). The majority 

notes decisions finding an FCA or AKS violation that involved more expensive food and drinks, 

Maj. Op. at 14, but the issue in this case is whether McNamara had, during the course of an 

incomplete investigation, a reasonable belief in the possibility of a violation. It is the province of 

a jury to weigh the value of the items given, Holzer’s near-exclusive use of Life, the reasons why 

Life was arguably not the best choice, and any other relevant facts to assess the reasonableness 

of McNamara’s belief.

It is also for a jury to determine the reasonableness of McNamara’s understanding that it 

was “the call of the doctor” to decide which ambulance provider to use, R. 50-1 (McNamara 

Dep. at 184:3–14) (Page ID #859)—and therefore that remuneration to doctors could induce a 

referral. The testimony of others that doctors did not usually refer in this manner, R. 99-1 

(Mickunas Dep. at 27:17–28:6) (Page ID #4584–85), is beside the point. The issue is whether 

the information available to McNamara at the time could support a finding that she reasonably 

believed that the individuals she suspected were receiving remuneration from Life were in a 

position to refer business to Life. McNamara’s understanding that doctors were given referral 

authority was bolstered by the information she received from Baker that Life was giving jackets 

 

3

The majority emphasizes that Holzer had a preferred-supplier agreement with Life, as a 

likely explanation for the disparity. Maj. Op. at 16. Even so, McNamara testified that the choice 

of whom to call remained nonetheless in the hands of the doctor. See R. 50-1 (McNamara Dep. 

at 184:3–14) (Page ID #859).

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to doctors and receiving business from Holzer that Baker believed was unwarranted, R. 102-31 

(Baker Email) (Page ID #4894), including one situation in which a patient had died after a 

transportation delay, which Baker attributed “perhaps” to the fact that “the nurse in the ER was 

forced to not call the closest ambulance but to call Life.” R. 50-1 (McNamara Dep. at 200:21–

201:10) (Page ID #875–76). McNamara’s suspicion was also supported by her later discovery 

that Life received over 90 percent of Holzer’s business. See R. 102-29 (Chart) (Page ID #4892).4 

The majority criticizes McNamara for “never produc[ing] the testimony or affidavit of any 

Holzer doctor verifying this understanding,” Maj. Op. at 15, but such evidence—although 

certainly helpful to her case—is not necessary to avoid summary judgment in light of other 

evidence that provides an arguable basis for McNamara’s belief. McNamara need not prove a 

violation of the False Claims Act, so long as her belief arising during the course of her 

investigation was objectively reasonable. See Graham Cnty., 545 U.S. at 416 & n.1; Yesudian, 

153 F.3d at 740.

McNamara’s belief arose in the context of an apparently ongoing investigation,5and was 

not unreasonable as a matter of law. Her failure to investigate further, then, is not a basis for 

summary judgment, even if it could convince a jury that she could not have reasonably believed 

 

4 Although McNamara learned these statistics after her May 18 and May 19 emails, she 

reported them to Brent Saunders in person. See R. 50-1 (McNamara Dep. at 347:10–23) (Page 

ID #1005).

5 McNamara testified that her investigation was “stopped,” but then indicated that she 

“completed the anti-kickback violation” but “did not complete the investigation of the – the 

emergency room issues.” See R. 50-1 (McNamara Dep. at 188:18–189:18) (Page ID #863–64). 

Later, she testified again that her investigation had been “interrupted.” Id. at 202:16–204:18 

(Page ID #877–79). She later stated that the investigation concluded when she “showed Mr. 

Saunders the chart . . . showing that we had, in fact, been using [Life] six times more than 

others.” Id. at 347:16–20 (Page ID #1005). In any event, her investigation remained unfinished 

at the time she engaged in the activity she claims was protected—reporting regarding what she 

viewed as AKS violations and looking into the issues she had uncovered.

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that anyone was being induced. The majority states: “A jury could not find McNamara engaged 

in protected activity when she based her allegations of illegal kickbacks solely on a high referral 

rate to a contractually (and legally) preferred supplier who gave a token jacket and hotdogs to 

unidentified Holzer employees that may or may not have had referral power.” Maj. Op. at 17. 

But a jury could find that she engaged in protected activity because her allegations were based 

upon that high referral rate, a report that the supplier was giving jackets to various doctors and 

obtaining referrals despite arguably being an inferior option, and McNamara’s separate 

understanding (bolstered by these facts) that doctors did have referral power. A jury could, of 

course, find that McNamara’s belief was not objectively reasonable—either because the jackets 

and food were of too little value to signify a potential inducement or because her understanding 

of doctors’ referral authority was unreasonable absent further investigation at that time. But it is 

not our job at the summary-judgment stage to decide these fact disputes.

I would therefore hold that McNamara demonstrated a sufficient basis for a jury to find 

that her belief that she was investigating a possible AKS violation was reasonable. McNamara 

also demonstrated a basis from which a jury could infer that she reasonably viewed that 

suspected AKS violation as an FCA violation, thereby triggering the protections of § 3730(h). 

Although AKS violations are not always FCA violations, “[a] claim that includes items or 

services resulting from a violation of [the AKS] constitutes a false or fraudulent claim for 

purposes of [the FCA].” 42 U.S.C. § 1320a-7b(g). McNamara testified that, at the time of the 

investigation and internal reporting, she “didn’t know if we were billing for these patients that 

flew, or the ambulance company was, or if we billed for part of them and they billed part of 

them.” R. 50-1 (McNamara Dep. at 226:24–227:2) (Page ID #901–02). At least, her belief that 

Holzer might bill Medicare directly for ambulance services was not unreasonable as a matter of 

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law. If Holzer was billing Medicare for those services, that could have provided a basis for an 

FCA violation because Holzer would have been making a claim to the federal government for 

services tainted by an AKS violation. The record does not reveal when McNamara learned that 

Holzer does not actually bill Medicare for services provided by Life, R. 51-1 (McNamara Sealed 

Dep. at 246:18–21) (Page ID #1219), and thus does not compel a finding that McNamara lacked 

a belief in the existence of an AKS violation at the time of her investigation and reports, or that 

such a belief would have been unreasonable. McNamara therefore has created a genuine issue of 

fact as to whether her actions were protected under § 3730(h). Because the majority’s 

affirmance of the district court’s grant of summary judgment to Holzer is based solely on a 

finding that McNamara’s investigative and reporting activity was not protected, I respectfully 

dissent.

McNamara also demonstrated genuine issues of fact relevant to the other elements of a 

prima facie case under § 3730(h). She pointed to sufficient evidence that she put Holzer on 

notice that she was undertaking activities to stop an FCA violation.6 McNamara additionally has 

 

6 Our decision in Yuhasz, 341 F.3d 559, interpreted § 3730(h) before it was amended and 

therefore Yuhasz’s interpretation of the notice requirement does not control this case. In Yuhasz, 

we held that a plaintiff had failed to allege that he satisfied the notice requirement of an FCA 

retaliation claim because his normal job duties involved investigating potential fraud. Id. at 567. 

We explained that “[i]n light of their ordinary responsibilities, however, such persons 

[employees charged with investigating potential fraud] must make clear their intentions of 

bringing or assisting in an FCA action in order to overcome the presumption that they are merely 

acting in accordance with their employment obligations.” Id. at 568 (internal quotation marks 

omitted). Given that the current version of § 3730(h) no longer limits protected activity to 

actions in furtherance of potential FCA actions, Yuhasz’s requirement that employees involved in 

investigating potential fraud must “make clear their intentions of bringing or assisting in an FCA

action,” id., is no longer required by the statutory text. See, e.g., Mikhaeil v. Walgreens Inc., No. 

13-14107, 2015 WL 778179, at *9 (E.D. Mich. Feb. 24, 2015) (reasoning that Yuhasz no longer 

applies in light of the amendments to § 3730(h)); Manfield v. Alutiiq Int’l Solutions, Inc., 851 F. 

Supp. 2d 196, 204 (D. Me. 2012) (“Under the new statute, an employer’s knowledge still mirrors 

the kind of activity in which the plaintiff must be engaged. Since a plaintiff now engages in 

protected conduct whenever he engages in an effort to stop an FCA violation, the act of internal 

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pointed to sufficient evidence to create a genuine dispute whether her FCA investigation was the 

but-for cause of her termination.

Finally, McNamara has created a genuine dispute of material fact whether Holzer’s 

asserted reasons for firing her were pretextual. It bears emphasizing that Holzer articulated 

primarily subjective reasons for McNamara’s termination—that she was not a “good fit.” We 

have held “that decisions made on the basis of subjective criteria, such as whether an employee 

is an effective manager, can provide a ready mechanism for discrimination, and thus such 

decisions are carefully scrutinized.” Idemudia v. J.P. Morgan Chase, 434 F. App’x 495, 504 

(6th Cir. 2011) (internal quotation marks omitted). McNamara did sufficiently dispute whether 

three of the asserted reasons had a basis-in-fact or were sufficient to warrant her termination. 

Beyond that, McNamara pointed to other evidence to suggest that Holzer’s articulated reasons 

were pretext. First, she produced evidence that creates a genuine dispute whether Holzer failed 

to follow its own policies in terminating her. We have held that “an employer’s failure to follow 

a policy that is related to termination or demotion can constitute relevant evidence of pretext.” 

DeBoer v. Musashi Auto Parts, Inc., 124 F. App’x 387, 394 (6th Cir. 2005). Second, McNamara 

argues that “[n]early all of the eight reasons given by Holzer . . . were offered for the first time 

post-hoc during this litigation.” Appellant Br. at 35. Here, the only record evidence 

documenting why McNamara was fired when she was fired is her employee evaluation form, and 

the only specific negative feedback on that form is a “Poor” rating for “Situational Leadership.” 

R. 73-2 (Employee Eval. Rep. at 1) (Page ID #3203). We have held that evidence that an 

employer’s asserted legitimate reasons for firing a plaintiff were concocted after-the-fact can be 

 

reporting itself suffices as both the effort to stop the FCA violation and the notice to the 

employer that the employee is engaging in protected activity.”).

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No. 15-3070, Jones-McNamara v. Holzer Health Systems 

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evidence of pretext. See, e.g., Gaglioti v. Levin Grp., Inc., 508 F. App’x 476, 482 (6th Cir. 

2012); Wheet v. Greenwood Ford, Inc., No. 96-5368, 1997 WL 589270, at *3–4 (6th Cir. Sept. 

23, 1997).

In sum, the evidence that McNamara introduced is sufficient to raise disputes of material 

fact regarding the elements of a prima facie case of retaliatory discharge and whether Holzer’s 

asserted reasons for terminating her were pretextual. I therefore dissent from the majority’s 

affirmance of the district court’s entry of summary judgment.

 Case: 15-3070 Document: 26-2 Filed: 11/02/2015 Page: 28