UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF OHIO

WESTERN DIVISION

UNITED STATES OF AMERICA ex 

rel. JOHN N. KRAMER, D.D.S.,

Plaintiff, 

v.

ROBERT A. DOYLE, JR., D.M.D., et 

al.,

Defendants.

Case No. 1:18-cv-373

JUDGE DOUGLAS R. COLE

OPINION AND ORDER

This matter comes before the Court on (1) Defendants’ Robert A. Doyle, Jr.,

D.M.D., Complete Dental Care Calcutta, LLC (“CDC Calcutta”), Complete Dental 

Care Champion Heights, LLC (“CDC Champion Heights), Complete Dental Care

Dennison, LLC (“CDC Dennison”), Complete Dental Care Martins Ferry, LLC (“CDC 

Martins Ferry”), Complete Dental Care Newcomerstown, LLC (“CDC 

Newcomerstown”), Complete Dental Care Shadyside, LLC (“CDC Shadyside”), and 

Complete Dental Care Steubenville, LLC (“CDC Steubenville”) (together, the “CDC 

Defendants”) Motion to Dismiss (Doc. 48); (2) Defendants’ North American Dental 

Group, LLC (“NADG”) and North American Dental Management, LLC (“NADM”)

(together, the “NADG Defendants”) Motion to Dismiss (Doc. 49); (3) Plaintiff John N. 

Kramer, D.D.S.’s Motion for Leave to File Fourth Amended Complaint (Doc. 57); and 

(4) the NADG Defendants’ Partially Unopposed Motion for Leave to File Surreply 

Brief, Instanter (Doc. 62). For the reasons that follow, the Court GRANTS IN PART

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and DENIES IN PART the CDC Defendants’ Motion to Dismiss (Doc. 48). The Court 

GRANTS the NADG Defendants’ Motion to Dismiss (Doc. 49) in its entirety. Because 

further amendment would be futile, the Court also DENIES Kramer’s Motion for 

Leave to File Fourth Amended Complaint (Doc. 57). Accordingly, the Court DENIES 

AS MOOT the NADG Defendants’ Partially Unopposed Motion for Leave to File 

Surreply Brief, Instanter (Doc. 62). The Court DISMISSES WITH PREJUDICE all 

claims against Doyle, CDC Calcutta, CDC Champion Heights, CDC Dennison, CDC 

Newcomerstown, CDC Shadyside, and the NADG Defendants. 

BACKGROUND

For purposes of the instant motions to dismiss, the Court accepts as true the 

factual allegations in the operative Third Amended Complaint (Doc. 37). Thus, the 

Court reports and relies on those allegations here, but with the disclaimer that these 

facts are not yet established, and may never be.

On May 31, 2018, Kramer, a dentist who practices in Martins Ferry, Ohio, filed 

the original Complaint as the Relator in this qui tam action. (See Doc. 1). Kramer

filed an Amended Complaint (Doc. 11) on March 6, 2019, and a Second Amended 

Complaint (Doc. 14) on June 4, 2019. On November 8, 2019, the United States 

declined to intervene. (See Doc. 26). Both sets of Defendants filed Motions to Dismiss 

(Docs. 28, 31) the Second Amended Complaint on November 12, 2019. Shortly 

thereafter, on December 3, 2019, Kramer filed a Third Amended Complaint (Doc. 37), 

which is now the operative complaint in this action.

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In general terms, the Third Amended Complaint alleges that all Defendants 

violated the False Claims Act (“FCA”) by submitting or causing submission to the 

Ohio Medicaid program of insurance claims for dental procedures, particularly root

canals, that were not medically necessary or for which the individual who performed 

the procedure was not properly licensed. As to the former, Kramer recites that the 

Ohio Medicaid program requires any medical provider to enter a Provider Agreement

that includes a requirement “[t]o render medical services as medically necessary for 

the patient and only in the amount required by the patient.” (Third Am. Compl., Doc. 

37, #459 (quoting Ohio Admin. Code 5160-1-17.2)). Medical necessity means that the 

treatment “[m]eets generally accepted standards of medical practice,” “[i]s the lowest 

cost alternative that effectively addresses and treats the medical problem,” and is 

“[n]ot provided primarily for the economic benefit of the provider.” (Id. at #462 

(quoting Ohio Admin. Code 5160-1-01(C))).

In addition to these general criteria, Kramer explains that Ohio Medicaid 

imposes certain specific requirements regarding root canals. First, root canals are 

“covered only when the overall health of the teeth ... is good except for the indicated 

tooth or teeth.” (Id. at #467 (quoting Ohio Admin. Code 5160-5-01(F)(1), App’x A at 

7)). Second, “[t]he patient must experience chronic pain (as evidenced by sensitivity 

to hot or cold or through percussion or palpation), or there must be a fistula present 

that is associated with tooth infection or chronic systemic infection.” (Id.). Third, if 

an x-ray or other “image” does not show a need for a root canal, “then the need for [a 

root canal] must be substantiated by clinical documentation.” (Id.). 

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As for his licensing allegations, Kramer notes that Medicaid regulations limit 

reimbursement for dental services to those services that are provided by properly 

licensed dentists. (Id. at #463 (citing Ohio Admin. Code 5160-5-01(C)(1)(a), (C)(1)(b))). 

To be properly licensed, the dentist must hold a “current license from the state dental 

board.” (Id. at 463–64 (citing Ohio Rev. Code 4715.09(A))). Among other things, nondentists may not perform root canals or cut into teeth. (Id. at #494–95 (citing Ohio 

Rev. Code 4715.64(A))). Ohio Medicaid considers “[b]illing for services that are 

outside the current license limitations, scope of practice, or specific parameters of the 

person supplying the service” to be “fraud, waste, and abuse.” (Id. at #495 (citing Ohio 

Admin. Code 5160-1-29(C)(9))). 

Against that regulatory backdrop, the core theory of Kramer’s Third Amended 

Complaint is that “the business practice and policy of Complete Dental Care is to 

submit false claims for medically unnecessary services to the Ohio Medicaid Program 

for federal funds.” (Id. at #509). In support of this claim, Kramer makes allegations 

regarding eight specific patients who received or sought dental care from CDC 

Martins Ferry or CDC Steubenville, all of whom Kramer subsequently treated, and 

all of whom were Medicaid patients except one. Kramer alleges that the care his eight 

example patients received from (or, as to two patients, was offered by) CDC Martins 

Ferry or CDC Steubenville did not conform to either the general standards of the 

Ohio Medicaid program or its specific requirements regarding root canals. More 

specifically, Kramer alleges that each example patient actually received (or was 

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offered) one or more medically unnecessary root canals, and that some dental

procedures were performed by individuals who were not licensed to perform them.

Kramer makes the following specific allegations with respect to each patient:

(1) CDC Martins Ferry performed seven root canals “of very poor quality” on 

Patient One over a period of three months without gathering preoperative x-rays, 

clinical tests, or any documentation of trauma or infection. (See id. at #470, 475–76).

Less than two years later, personnel at CDC Martins Ferry recommended extraction 

of the same teeth on which the patient had previously received root canals. (See id.

at #479). For Patient One only, Kramer identifies the date of each dental procedure, 

billing codes, and amounts paid by the Ohio Medicaid program. (Id. at #481–82). 

(2) CDC Steubenville performed four medically inappropriate root canals on 

Patient Two’s “grossly decayed” upper front teeth, teeth numbers 7–10, even though 

Patient Two did not want root canals and instead asked for removal of those teeth. 

(Id. at #483–84). When Patient Two sought removal instead of root canals, the CDC 

Steubenville dentist became angry and “threw instruments on the table.” (Id. at 

#483). Performance of those root canals without placing crowns on the teeth “only 

delayed” extraction, which was inevitably necessary. (Id. at #484). 

(3) During a single appointment, CDC Martins Ferry personnel performed six 

“poor quality” root canals for Patient Three on teeth that showed no need for that 

procedure in x-rays Kramer reviewed shortly afterward, and for which Patient Three

had reported no pain, trauma, or signs of infection. (See id. at #485–88). CDC Martins 

Ferry personnel also failed to provide Patient Three or Kramer (as Patient Three’s 

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subsequent dentist) with the preoperative x-rays or other documentation required for 

a root canal procedure by Ohio Medicaid. (Id. at #486).

(4) CDC Martins Ferry personnel proposed a medically unnecessary root canal 

on Patient Four, a child who was not a Medicaid beneficiary, for a tooth that showed 

no sign of need for such procedure in x-rays, and in which the child had no pain. (Id.

at #492–93). Patient Four did not receive that root canal. (See id.).

(5) CDC Martins Ferry personnel performed three medically unnecessary root 

canals on Patient Five. (See id. at #497–98). In violation of Ohio licensure law, a nondentist was the one who filled the root canals on two of the teeth with gutta-percha. 

(Id. at #496–97). CDC Martins Ferry personnel performed the root canal on the third 

tooth without informing Patient Five that it would do so. (Id. at #498). The third tooth 

subsequently required “extensive work” due to the poor quality of the unnecessary 

root canal. (Id.). 

(6) Patient Six received a medically unnecessary root canal on one tooth and 

also received fillings on approximately twelve other teeth. (See id. at #500–02). Nondentists cut into the teeth as part of the filling procedures in violation of Ohio 

licensure law. (See id. at #501–02). 

(7) Patient Seven, a child, had pain in only one tooth, but CDC Martins Ferry 

personnel recommended “four or five” root canals, two of which they in fact performed. 

(Id. at #504–05). The procedures left an “inappropriate gap” between those two teeth, 

putting the patient at risk of infection. (Id. at #506). A non-dentist cut into a tooth in 

violation of Ohio licensure law. (Id. at #506–07). 

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(8) CDC Martins Ferry personnel told Patient Eight that he needed eighteen

(18) root canals, nine of which it proposed to do the same day. (Id. at #507). According 

to Kramer, several of these teeth were so decayed that root canals would likely be 

unsuccessful and they would need to be extracted anyway. (Id. at #508). On the other 

hand, many of the remaining teeth showed no signs of needing root canals in 

Kramer’s subsequent x-rays. (Id. at #509). Patient Eight did not receive root canals

at CDC Martins Ferry.

With respect to the CDC Defendants other than CDC Martins Ferry and CDC 

Steubenville, Kramer alleges that Doyle owns all seven CDC branches named in the 

Third Amended Complaint, with sixteen other dentists working under Doyle’s 

direction at the various locations. (See id. at #448). Kramer further alleges that “[a]s 

the owner and ‘mentor’ in control of all Complete Dental Care practices, Doyle 

directed the shared practices, procedures, and financial goals that drive the 

unnecessary and unlicensed dental procedures that Complete Dental Care inflicts on 

Medicaid patients at all of its locations.” (Id. at #449). Kramer also alleges that Doyle

sometimes calls employees of CDC practices on the phone if they do not make their 

daily revenue goals, although “not much” otherwise happens to such employees. (Id.

at #491).

And as for the NADG Defendants, Kramer alleges that the parent company, 

NADG, “purchased or acquired a management interest in Dr. Doyle’s Complete 

Dental Care practices” sometime in late 2018. (Id. at #453). This suggests that NADG 

had “purchased or acquired” that otherwise unspecified “management interest” by 

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the time Patients Six and Seven, and possibly Patient Five, received treatment at 

CDC Martins Ferry. Kramer alleges that the NADG Defendants knew the CDC 

Defendants could not maintain the revenue they were generating without continuing 

Doyle’s practices of performing medically unnecessary dental procedures and of 

having non-dentists perform procedures that only dentists may perform under Ohio 

law. (Id. at #454). But Kramer alleges that the NADG Defendants nevertheless not 

only continued these practices but financially incentivized them by offering equity to 

dentists who met certain revenue targets. (Id.). 

THE PENDING MOTIONS

On December 24, 2019, the CDC Defendants and the NADG Defendants each 

moved to dismiss under Federal Rule of Civil Procedure 12(b)(6). (Docs. 48, 49). The 

CDC Defendants argue that Kramer fails to state a claim against CDC Martins Ferry 

and CDC Steubenville because he only alleges that he disagrees with the medical 

treatment that the example patients were offered or received at those locations. (CDC 

Mot. to Dismiss (“CDC Mot.”), Doc. 48, #556). The CDC Defendants also argue that 

Kramer has failed to identify any specific false claim or statement by Doyle and the 

five corporate CDC Defendants other than CDC Martins Ferry and CDC 

Steubenville. (Id. at #555). The NADG Defendants argue primarily that Kramer has 

failed to allege that any of them submitted or caused submission of a false claim or

statement. (See NADG Mot. to Dismiss (“NADG Mot.”), Doc. 49, #580). Kramer 

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responded in opposition (Doc. 54) on January 23, 2020,1 and both sets of Defendants 

replied in support (Docs. 55, 56) on February 6, 2020.

On February 14, 2020, Kramer filed a Motion for Leave to File Fourth 

Amended Complaint (Doc. 57), to which he attached his Proposed Fourth Amended 

Complaint (see Docs. 57-1, 57-2). The Proposed Fourth Amended Complaint adds

general factual allegations that Doyle directly instructed non-dental employees at 

CDC locations to add services to some patients’ treatment plans that were not 

approved by the patient’s treating dentist. (See Prop. Fourth Am. Compl., Mot. to 

Amend Ex. B, Doc. 57-2, #1093). Kramer’s source for this information is “[a] former 

Complete Dental Care employee who worked at several Complete Dental Care offices 

in 2017, including Martins Ferry and Shadyside.” (Id. at #1092). Another former 

employee, this one from NADG’s Refresh Dental Office in Shaker Heights, Ohio, 

reported to Kramer that the NADG Defendants have sent Doyle to that location to 

lead an “Optimization Team” instructing dentists to perform medically unnecessary 

root canals and belittling dentists who refuse to do so. (See generally id. at #1095–

98). Both sets of Defendants responded in opposition (Docs. 59, 60) to Kramer’s 

Motion to Amend on March 6, 2020. Kramer replied in support (Doc. 61) on March 

20, 2020.

1 On the same day, the United States also responded in opposition (Doc. 53) to exercise its

statutory veto power over the NADG Defendants’ Motion to Dismiss to the extent that the

NADG Defendants argue that the FCA’s public disclosure bar is grounds for dismissal of 

Kramer’s claims. (See U.S. Resp. in Opp’n to NADG Mot., Doc. 53, #599 (citing 31 U.S.C. 

§ 3730(e)(4)(A))). The NADG Defendants do not contest that exercise of the government’s 

statutory power in their Reply. (See Doc. 55, #902). Accordingly, the Court does not consider 

the public disclosure bar as a basis for dismissal here. 

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On April 2, 2020, the NADG Defendants filed a Partially Unopposed Motion 

for Leave to File Surreply Brief, Instanter (Doc. 62) in connection with Kramer’s 

Motion to Amend. The NADG Defendants argue that a surreply is appropriate 

because Kramer’s Reply in support of his Motion to Amend makes new arguments 

regarding the legal standard for liability under the FCA and attaches a then-recent

USA Today article about the NADG Defendants’ patient care practices. (See Mot. for 

Leave to File Surreply (“Surreply Mot.”), Doc. 62, #1270–71). Kramer responded in 

opposition (Doc. 63) on April 23, 2020, opposing the NADG Defendants’ Motion only 

in part. Specifically, Kramer does not oppose the NADG Defendants’ request to file a 

surreply with respect to the USA Today article. (Resp. in Opp’n to Surreply Mot., Doc. 

63, #1289). But Kramer does oppose granting the NADG Defendants leave to file a 

surreply in all other respects. (See id.). 

LEGAL STANDARD

At the motion to dismiss stage, a complaint must “state[] a claim for relief that 

is plausible, when measured against the elements” of a claim. Darby v. Childvine, 

Inc., 964 F.3d 440, 444 (6th Cir. 2020) (citing Binno v. Am. Bar Ass’n, 826 F.3d 338, 

345–46 (6th Cir. 2016)). “To survive a motion to dismiss, in other words, [plaintiffs]

must make sufficient factual allegations that, taken as true, raise the likelihood of a 

legal claim that is more than possible, but indeed plausible.” Id. (citations omitted).

In making that determination, the Court must “construe the complaint in the 

light most favorable to the plaintiff, accept its allegations as true, and draw all 

reasonable inferences in favor of the plaintiff.” Bassett v. Nat’l Collegiate Athletic 

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Ass’n, 528 F.3d 426, 430 (6th Cir. 2008) (internal quotation omitted). That is so, 

however, only as to factual allegations. The Court need not accept as true a plaintiff’s 

legal conclusions. Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (citing Bell Atlantic Corp. 

v. Twombly, 550 U.S. 544, 555 (2007)). 

Moreover, the well-pled facts must be sufficient to “raise a right to relief above 

the speculative level,” such that the asserted claim is “plausible on its face.” Iqbal, 

556 U.S. at 678; Twombly, 550 U.S. at 546–47. Under the Iqbal/Twombly plausibility 

standard, courts play an important gatekeeper role, ensuring that claims meet a 

threshold level of factual plausibility before defendants are subjected to the potential 

rigors (and costs) of the discovery process. “Discovery, after all, is not designed as a 

method by which a plaintiff discovers whether he has a claim, but rather a process 

for discovering evidence to substantiate plausibly-stated claims.” Green v. Mason, 504 

F. Supp. 3d 813, 827 (S.D. Ohio 2020).

The plausibility requirement has additional teeth as to claims, such as those 

here, that assert fraud. That is because, under Federal Rule of Civil Procedure 9(b),

a party alleging fraud must “state with particularity the circumstances constituting 

fraud,” but “conditions of a person’s mind may be alleged generally.” That means that 

“a plaintiff, at a minimum, must ‘allege the time, place, and content of the alleged 

misrepresentation on which he or she relied; the fraudulent scheme; the fraudulent 

intent of the defendants; and the injury resulting from the fraud.’” United States ex 

rel. Bledsoe v. Cmty. Health Sys., Inc. (“Bledsoe I”), 342 F.3d 634, 643 (6th Cir. 2003) 

(quoting Coffey v. Foamex L.P., 2 F.3d 157, 161–62 (6th Cir. 1993)). Stated another 

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way, a plaintiff must identify the “‘who, what, when, where, and how’ of the alleged 

fraud.” Sanderson v. HCA-The Healthcare Co., 447 F.3d 873, 877 (6th Cir. 2006) 

(quoting United States ex rel. Thompson v. Columbia/HCA Healthcare Corp., 125 

F.3d 899, 903 (5th Cir. 1997)).

Because this case involves multiple defendants, another aspect of Federal Rule 

of Civil Procedure 9(b) also come into play. Specifically, the particularity requirement 

prohibits plaintiffs from relying on “group pleading.” That is, “[a] complaint may not 

rely upon blanket references to acts or omissions by all of the defendants.” See, e.g., 

Bledsoe I, 342 F.3d at 643. Rather, under Rule 9(b), “each defendant named in the 

complaint is entitled to be apprised of the circumstances surrounding the fraudulent 

conduct with which he individually stands charged.” Id; see also United States ex rel. 

Bledsoe v. Cmty. Health Sys., Inc. (“Bledsoe II”), 501 F.3d 493, 510 (6th Cir. 2007) 

(“[I]mproperly pled allegations of fraud do not become adequate merely by placing 

them in the same complaint with allegations that are sufficient .... Allowing such a 

complaint to go forward in toto would not provide defendants with the protections 

that Rule 9(b) was intended to afford them ....”). Or phrased slightly differently, “[t]he 

prohibition on group pleading under Rule 9(b) prevents a plaintiff from simply 

lumping multiple defendants together without explaining each defendant’s culpable 

role.” Sugarlips Bakery, LLC v. A&G Franchising, LLC, No. 3:20-cv-00830, 2022 WL 

210135, at *10 (M.D. Tenn. Jan. 24, 2022).

The Sixth Circuit has also interpreted Rule 9(b) to impose another requirement 

specific to FCA cases. To state a claim against a defendant for violating 31 U.S.C. 

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§ 3729(a)(1)(A), a plaintiff who alleges a fraudulent scheme “must also identify a 

representative false claim that was actually submitted to the government.” 

Chesbrough v. VPA, P.C., 655 F.3d 461, 470 (6th Cir. 2011). That is because the FCA 

“attaches liability, not to the underlying fraudulent activity or to the government’s 

wrongful payment, but to the claim for payment.” Sanderson, 447 F.3d at 877–78

(citation omitted). Accordingly, “Rule 9(b) does not permit a False Claims Act plaintiff 

merely to describe a private scheme in detail but then to allege simply that claims 

requesting illegal payments must have been submitted, were likely submitted or 

should have been submitted to the Government.” Id. at 877. Instead, the false claim 

itself is “the sine qua non of a False Claims Act violation.” Id. at 878.

To “identify” a specific claim, a plaintiff must include details such as claim 

submission dates or amounts that would allow the defendant “reasonably to pluck 

out” the allegedly fraudulent representative claim or claims “from all the other claims 

[it] submitted.” See United States ex rel. Owsley v. Fazzi Assocs., Inc., 16 F.4th 192, 

197 (6th Cir. 2021). The Sixth Circuit has characterized this requirement as 

“stringent” at the pleading stage. United States ex rel. Ibanez v. Bristol-Myers Squibb 

Co., 874 F.3d 905, 914 (6th Cir. 2017). 

Finally, because Kramer has requested that this Court grant him leave to file 

his Proposed Fourth Amended Complaint in lieu of granting dismissal, another set of 

standards also comes into play. (See Resp. in Opp’n to Mots. (“Opp’n”), Doc. 54, #650; 

see also Mot. for Leave to File Fourth Am. Compl. (“Mot. to Amend”), Doc. 57). Under 

Federal Rule of Civil Procedure 15, a party may amend only with the opposing party’s 

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written consent (which was not forthcoming here), or leave of the Court. As to the 

latter, although the question is committed to the trial court’s discretion, the “court 

should freely give leave when justice so requires.” Foman v. Davis, 371 U.S. 178, 182 

(1962). When assessing whether to grant leave, the Court should consider whether 

there has been “undue delay in filing, lack of notice to the opposing party, bad faith

by the moving party, repeated failure to cure deficiencies by previous amendments, 

undue prejudice to the opposing party, or whether the amendment would be futile.” 

Gen. Elec. Co. v. Sargent & Lundy, 916 F.2d 1119, 1130 (6th Cir. 1990) (citation and 

internal quotation marks omitted).

LAW AND ANALYSIS

This case turns largely on Federal Rule of Civil Procedure 9(b)’s requirement 

to allege fraud with particularity. As discussed above, in the context of FCA cases, 

the Sixth Circuit has interpreted Rule 9(b) to require a plaintiff to identify a specific 

representative false claim that was actually submitted to the government.2 That is 

sometimes called the “presentment” requirement. See, e.g., United States ex rel. 

Prather v. Brookdale Senior Living Cmtys., Inc., 838 F.3d 750, 768 (6th Cir. 2016).

2 There is an exception to this requirement for plaintiffs who allege that they have “personal 

knowledge” of a defendant’s billing practices, sometimes dubbed “the Prather exception.” See 

United States ex rel. Prather v. Brookdale Senior Living Cmtys., Inc., 838 F.3d 750, 769 (6th 

Cir. 2016); Ibanez, 874 F.3d at 915. Such a plaintiff may allege facts supporting a strong 

inference that claims were submitted to the government without identifying a specific claim.

See Prather, 838 F.3d at 769. Kramer does not allege personal knowledge of the Defendants’ 

billing practices and apparently disavows reliance on the Prather exception. (See Reply in 

Supp. of Mot. for Leave to File Fourth Am. Compl., Doc. 61, #1172). Moreover, as discussed 

in more detail below, Kramer does identify some representative claims with sufficient 

particularity as to some Defendants. For these reasons, the Court does not consider whether 

the Prather exception might be an alternative avenue to liability for any Defendant here.

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The parties do not dispute that the presentment requirement applies in this case. But 

they do dispute, at least implicitly, how the presentment requirement applies to

multi-defendant cases such as this one. For example, the CDC Defendants argue that 

dismissal of Kramer’s claims against Doyle and five of the seven corporate CDC 

Defendants is warranted because Kramer fails to tie those Defendants to an 

identified representative false claim. (CDC Mot., Doc. 48, #555–56). By contrast, 

Kramer argues that he need only identify a single representative claim in order to 

allege the entire scheme as to all Defendants. (Opp’n, Doc. 54, #644). 

Thus, before turning to the sufficiency of the allegations against each 

Defendant here, the Court must confront a pure question of law. In a multi-defendant

FCA case, must a plaintiff identify a representative claim submitted, or caused to be 

submitted, by each defendant in order to state a claim against that defendant? Or is 

it enough to identify a representative claim submitted, or caused to be submitted, by 

some, but not all, defendants, and then allege that the remaining defendants were 

part of the fraudulent scheme, without tying them to the identified representative

claim?

To the Court’s knowledge, neither the Sixth Circuit nor any district court in 

this circuit has explicitly addressed this issue thus framed. Still, there is considerable 

case law on the pleading standards applicable in FCA cases more generally, and the 

Court finds that precedent instructive here. Based on binding Sixth Circuit case law, 

the Court concludes that to state a claim against a given defendant, a complaint must 

identify a specific false claim submitted, or caused to be submitted, by that defendant. 

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In other words, a complaint that identifies one or more representative claims with 

sufficient particularity, but then connects only some, but not all, of the defendants to 

those identified claims, fails to state a claim against the defendants whose connection 

to the identified claims it has not adequately pled. 

That is not to say that the particular defendant him, her, or itself must have 

actually presented the identified claim. Rather, it is enough if that defendant has a 

causal link to the submission of the claim. Thus, for example, if a business owner uses 

his managerial authority to cause a claim to be submitted, the owner may be on the 

hook under the FCA. Conversely, though, identifying a claim that one entity 

submitted would not suffice to state an FCA claim against another affiliated entity 

on the theory that the latter entity was under common operational control, and thus 

likely submitted false claims, as well. 

The Court finds such a claim-by-claim, rather than complaint-by-complaint, 

approach to the presentment requirement more compatible with Sixth Circuit case 

law. For one thing, as discussed above, the Sixth Circuit has repeatedly emphasized 

that Rule 9(b) prohibits group pleading in complaints alleging fraud. See, e.g., Bledsoe 

I, 342 F.3d at 643. Put another way, a plaintiff may not rely on allegations of fraud 

that lump all defendants together, without separately explaining each defendant’s 

role in the alleged fraudulent conduct. See Sugarlips, 2022 WL 210135, at *10. The 

Sixth Circuit has emphasized that at least part of the rationale for the rule against 

group pleading is that each defendant is entitled to notice of the specific fraudulent 

conduct in which the plaintiff alleges that he individually engaged. Bledsoe I, 342 

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F.3d at 643. Thus, the presence of allegations in a complaint that are adequately pled 

as to some defendants does not lower the bar to state a claim against the remaining 

defendants. Cf. Bledsoe II, 501 F.3d at 510 (“[I]mproperly pled allegations of fraud do 

not become adequate merely by placing them in the same complaint with allegations 

that are sufficient ....”). 

To be sure, bootstrapping additional defendants onto identified claims whose 

submission those defendants did not cause might not be group pleading in the 

narrowest sense, at least insofar as a plaintiff also alleges the role that those 

additional defendants played in the fraudulent scheme more generally. But the Court 

finds that the rule against group pleading logically extends to the applicability of the 

presentment requirement to each defendant in a multi-defendant case. The Court 

sees nothing in the case law to indicate that what it takes to state a claim against a

given defendant in an FCA case should depend on how many other defendants a 

complaint also names. To the contrary, the Sixth Circuit has repeatedly said the 

opposite—Rule 9(b) requires plaintiffs to allege fraud with particularity on a 

defendant-by-defendant basis, and not generally as to all defendants. See Bledsoe I, 

342 F.3d at 643; Bledsoe II, 501 F.3d at 510. In the same vein, the Sixth Circuit has 

stated that a plaintiff who alleges that a defendant submitted or caused submission 

of false claims must “identify the entire chain—from start to finish” that connects the 

defendant to an identified representative claim. Ibanez, 874 F.3d at 914. The case law 

contains no suggestion that this requirement is diminished where a complaint names 

more than one defendant. Thus, the Court holds that Rule 9(b) requires a plaintiff to 

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adequately allege each element of the FCA claim, including identifying a 

representative claim actually submitted or caused to be submitted by the defendant

in question, in order to state a claim against that defendant.

The Court finds further support for its interpretation of the pleading standard 

for presentment in multi-defendant FCA cases in Sixth Circuit precedent that 

actually applies the presentment requirement in such contexts. For example, in 

Owsley, the plaintiff alleged that a single third-party medical coding company 

prepared fraudulent materials used by each of several home-health agencies owned 

by a common parent. 16 F.4th at 195. However, the plaintiff only provided example

claims from the agency where she had worked, not the other sister agencies. See id.

at 197. The Sixth Circuit determined that dismissal of the claims against the other 

agencies was appropriate because the plaintiff had not fulfilled the presentment 

requirement as to those agencies. Id.

Thus, in Owsley, common ownership and a common connection to the billing

company that allegedly facilitated the fraudulent scheme apparently did not 

substitute for fulfilling the presentment requirement as to each defendant. While this 

conclusion was arguably dicta, because the Sixth Circuit also found that the plaintiff 

did not fulfill the presentment requirement with respect to even the home-health 

agency where she worked, see id., it nevertheless illustrates that the Owsley court

apparently contemplated full applicability of the presentment requirement to each 

defendant in a multi-defendant case.3 

3 Judge Clay’s partial dissent in United States ex rel. Branhan v. Mercy Health System of 

Southwest Ohio, 188 F.3d 510 (Table), 1999 WL 618018, at *10 (6th Cir. Aug. 5, 1999),

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Kramer’s argument to the contrary rests on an unwarranted extension of the 

notion of a “fraudulent scheme” as a means of satisfying Rule 9(b). To be sure, the 

Sixth Circuit has said that a plaintiff who adequately identifies a single 

representative claim may proceed to discovery on “the entire fraudulent scheme.”

Bledsoe II, 501 F.3d at 510. But as explained in more detail below, in context, this 

holding allows plaintiffs to aggregate false claims of the same kind submitted by a 

given defendant, not to bring in additional defendants without otherwise satisfying 

the presentment requirement as to those defendants. 

In Bledsoe II, the plaintiff adequately identified a representative claim in 

which a hospital added extra diagnosis codes to a patient’s principal diagnosis code 

in order to fraudulently increase the amount of claims submitted for that patient. 501 

F.3d at 514–15. The Sixth Circuit held that this single representative false claim was 

enough for the case to proceed as to all alleged false claims of that kind submitted by 

the same defendants. Id. at 515. In other words, a plaintiff who adequately alleges a 

representative claim is not limited to seeking relief with respect to only that one 

identified claim, but may pursue his case against the defendant who submitted the

identified claim with respect to similar claims also submitted by that defendant.

provides further support for strictly applying the presentment requirement to each defendant 

in a multi-defendant case. There, despite concluding, contrary to the majority, that the 

plaintiff had met the presentment requirement as to one hospital, he nonetheless agreed that 

the plaintiff had failed to state a claim on presentment grounds as to the other hospitals, all 

of whom the plaintiff had alleged were under common control and part of the same fraudulent 

billing scheme. Id. Like the Owsley court, Judge Clay thus apparently assumed that the

presentment requirement applies with full force to each defendant in a multi-defendant case. 

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Allowing a plaintiff who alleges a fraudulent scheme by a defendant to identify 

only one or a subset of representative claims submitted by that defendant makes 

sense. In the absence of such an aggregating principle, many cases alleging false 

claims would either be miniscule in scope, since they would only pertain to one or a 

few alleged false claims identified in a complaint, or prohibitively unwieldy, since a 

plaintiff alleging a vast scheme would have to describe every one of potentially 

hundreds or thousands of similar false claims before even proceeding to discovery.

See id. at 509 (“Where the allegations in a relator’s complaint are complex and farreaching, pleading every instance of fraud would be extremely ungainly, if not 

impossible.”) (citation and internal quotation marks omitted). But allowing a plaintiff 

who identifies a representative claim by one defendant to also pursue other alleged 

false claims by that same defendant is a far cry from saying that a plaintiff need not 

satisfy the presentment requirement at all with respect to other defendants who did 

not submit (or cause submission of) the identified claim.

Kramer’s view also leaves key questions unanswered. Just how does a plaintiff 

tie a defendant to an alleged fraudulent scheme, if not by identifying a representative 

false claim that the defendant in question submitted or caused to be submitted? In 

Bledsoe II, the Sixth Circuit undertook a painstaking claim-by-claim analysis of a 

range of allegations about different kinds of fraudulent claims, finding the 

presentment requirement fulfilled as to one of those categories (or “schemes”), but 

not the others. For example, the presentment requirement was met as to a scheme 

involving adding diagnosis codes, as discussed above, but was not met as to a scheme 

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involving unnecessary glucometer and heel sticks. 501 F.3d at 512, 514. Thus, even 

in the context of a single defendant, the Sixth Circuit limited the scope of a 

“fraudulent scheme” to include only alleged false claims sufficiently like the identified 

claim at issue. See id. at 510 (“We conclude that the concept of a fraudulent scheme 

should be construed as narrowly as is necessary to protect the policies promoted by 

Rule 9(b).”). More specifically, the Sixth Circuit said that the identified claim must 

be “representative” of the category of claims that allegedly comprise the fraudulent 

scheme. Id.

If alleging a fraudulent scheme were an avenue for bringing in additional 

defendants, and not only additional false claims by a given defendant, the Court

would expect to find some similar limiting principle for determining when a 

defendant is sufficiently tied to a fraudulent scheme. But Kramer cites, and the Court 

has found, no precedent that provides any general standard to guide such a 

determination. In the Court’s view, the most likely explanation for that absence is 

that alleging a fraudulent scheme is not an alternative to fulfilling the presentment 

requirement as to each defendant in a multi-defendant case, but only a vehicle for 

aggregating false claims made by a given defendant.

In reaching this result, the Court acknowledges it is perhaps reading too much 

into Owsley’s tea leaves. One could imagine, for example, an alternative approach 

where a plaintiff need only identify one or more representative claims by a given 

defendant, coupled with allegations that show it was likely that the other defendants 

in the “scheme” themselves submitted similar claims. For example, imagine a single 

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owner of five affiliated business entities, all operating in the same field. The owner 

has a uniform operations manual that it uses for each entity. The plaintiff plausibly 

alleges that the manual’s procedures cause Entity 1 to submit false claims, of which 

the plaintiff provides one or more representative examples in her complaint. The 

plaintiff then also alleges that all five entities use the same operations manual, and 

that they submit claims, but the plaintiff does not allege any representative claims 

submitted by the remaining entities. The Court could conceive of pleading rules 

where such allegations would suffice to state a plausible claim against all five 

entities. But the Court declines to adopt that rule here, largely because that approach 

appears to the Court inconsistent with both (1) Owsley, which seems to require 

allegations tying each defendant to the submission of one or more representative false 

claims identified in the complaint, and (2) the Sixth Circuit’s admonition to construe

“the concept of a fraudulent scheme” “as narrowly as is necessary to protect the 

policies promoted by Rule 9(b).” Bledsoe II, 501 F.3d at 510. 

Based on that understanding, the Court will proceed on a defendant-bydefendant basis, in each case asking whether Kramer adequately alleges that that 

defendant has submitted, or caused to be submitted, a false claim that Kramer has 

identified with sufficient particularity. The Court finds that Kramer has met this 

requirement with respect to two of the seven corporate CDC Defendants, but not with 

respect to Doyle, the other five corporate CDC Defendants, or the NADG Defendants. 

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A. The Third Amended Complaint States A Claim Against CDC Martins 

Ferry.

The Court begins with the dental practice that Kramer alleges submitted false 

claims for five patients whom Kramer himself subsequently treated, CDC Martins 

Ferry. As discussed in more detail above, Kramer alleges that CDC Martins Ferry 

conducted medically unnecessary or unlicensed dental procedures on Patients One, 

Three, Five, Six, and Seven, all Medicaid beneficiaries, and submitted claims for 

those procedures to Medicaid. For Patient One only, Kramer also provides exact

service dates, billing codes, and amounts for the alleged false claims. For the reasons 

that follow, these allegations suffice to state FCA claims for both submission of a false 

claim and false statement against CDC Martins Ferry. 

1. The Third Amended Complaint Adequately Alleges Submission 

Of False Claims By CDC Martins Ferry.

Anyone who “knowingly presents, or causes to be presented, a false or 

fraudulent claim for payment or approval” to the United States government has 

violated the FCA. See 31 U.S.C. § 3729(a)(1)(A). Under the “implied certification” 

theory of liability, a claim may be “false or fraudulent” if it “makes specific 

representations about the goods or services provided, but knowingly fails to disclose 

the defendant’s noncompliance with a statutory, regulatory, or contractual 

requirement.” Universal Health Servs., Inc. v. United States, 579 U.S. 176, 181 (2016).

However, “[a] misrepresentation about compliance with a statutory, regulatory, or 

contractual requirement must be material to the Government’s payment decision in 

order to be actionable under the False Claims Act.” Id.

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Here, Kramer’s detailed allegations that CDC Martins Ferry performed 

medically unnecessary and unlicensed procedures on Patients One, Three, Five, Six, 

and Seven, combined with his identification of service dates, billing codes, and 

amounts paid for Patient One, suffice to state a claim for submission of a false claim 

to the Ohio Medicaid program under an implied certification theory. The Third 

Amended Complaint alleges that Kramer personally examined the patients who 

received these procedures at CDC Martins Ferry and learned facts about each that 

support not only a general absence of medical necessity, but also failure to conform 

to the specific requirements for root canals as indicated in the Provider Service 

Agreement and Ohio Administrative Code. For example, the Third Amended 

Complaint alleges that some Medicaid patients had no pain or infection and that CDC 

Martins Ferry failed to conduct x-rays or collect other documentation as required 

before proceeding with a root canal. (See, e.g., Third Am. Compl., Doc. 37, #475, 489).

The Third Amended Complaint further alleges that non-dentists performed 

procedures on Medicaid patients, such as cutting into teeth, that only dentists were 

to perform under Ohio law. (See id. at #501). Notably, for Patient One, the Third 

Amended Complaint also identifies the date of service submitted to the Ohio Medicaid 

program for each procedure at issue, the amount of reimbursement, and the billing 

code. (Id. at #481–82).

Together, these allegations state that CDC Martins Ferry submitted Ohio 

Medicaid claims for root canals and other dental procedures that concealed violations

of statutory, regulatory, and contractual requirements. These requirements included

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Ohio Medicaid’s medical necessity requirement reflected in the Service Provider 

Agreement, the specific documentation and symptom requirements of the Ohio 

Administrative Code, and Ohio’s dental licensure requirements. See Ohio Admin. 

Code 5160-5-01(F)(1). It is plausible that all of these requirements are material to 

the government’s payment decision regarding claims submitted for dental services.

See, e.g., United States v. Bertram, 900 F.3d 743, 749 (6th Cir. 2018) (lack of medical 

necessity of urinalysis tests material); United States ex rel. Doe v. Heart Solution, PC, 

923 F.3d 308, 317 (3d Cir. 2019) (lack of licensure to perform neurological test 

material). Kramer also identifies specific false claims by date, billing code, and 

amount paid for Patient One, thus satisfying the requirement to identify “a 

representative false claim that was actually submitted to the government.” See 

Chesbrough, 655 F.3d at 470. To be sure, at an appropriate stage of this litigation, 

CDC Martins Ferry might be able to show that it did comply with the requirements 

at issue, that its noncompliance was not material, or that it did not submit the claims 

Kramer alleges. If so, then summary judgment might be appropriate. For purposes of 

a motion to dismiss, however, Kramer’s allegations against CDC Martins Ferry 

suffice to state a claim. 

The CDC Defendants urge a different result, arguing that Kramer’s allegations 

amount to mere disagreement with the dental treatments that CDC Martins Ferry 

offered, which is insufficient to support a claim for violation of the FCA. (See CDC 

Mot., Doc. 48, #556–57). But the Third Amended Complaint alleges more than a mere 

difference of opinion. For one thing, it alleges that CDC Martins Ferry violated Ohio 

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Medicaid’s express requirements by performing root canals and other dental 

procedures without x-rays or other documentation showing their medical necessity, 

in the absence of pain, infection, or trauma to the tooth, and with non-dentists 

performing tasks only a licensed dentist may perform under Ohio law. (See Third Am. 

Compl., Doc. 37, #466–68). Thus, Kramer does not merely allege that CDC Martins

Ferry performed shoddy work, but rather that it billed Ohio Medicaid for work that 

did not materially comply with that program’s express requirements. 

Moreover, as the Sixth Circuit has recently stated, “opinions may trigger 

liability for fraud when they are not honestly held by their maker, or when the 

speaker knows of facts that are fundamentally incompatible with his opinion.” United 

States v. Paulus, 894 F.3d 267, 275 (6th Cir. 2018). The Third Amended Complaint

plausibly alleges that CDC Martins Ferry submitted claims for dental procedures 

that the performing dentist did not honestly believe were medically necessary, or at 

the very least in spite of the employee’s knowledge of facts that were fundamentally 

incompatible with the medical necessity of those procedures. For example, it is 

plausible that the CDC Martins Ferry’s treating dentists knew that patients whose 

teeth were free of pain, infection, or trauma did not need root canals. (See Third Am. 

Compl., Doc. 37, #475, 489). Again, if Kramer cannot ultimately prove such 

knowledge, then summary judgment may be appropriate. But the Third Amended 

Complaint adequately alleges, at the pleading stage, knowing submission of a false 

claim by CDC Martins Ferry. See Fed. R. Civ. P. 9(b) (knowledge may be alleged 

generally). Accordingly, the Court DENIES the CDC Defendants’ Motion to Dismiss 

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(Doc. 48) Kramer’s Third Amended Complaint (Doc. 37) with respect to Kramer’s 

claim for submission of false claims against CDC Martins Ferry.

2. The Third Amended Complaint Adequately Alleges False 

Statements By CDC Martins Ferry.

Separately, a person violates the FCA if he or she “knowingly makes, uses, or 

causes to be made or used, a false record or statement material to a false or fraudulent 

claim.” 31 U.S.C. § 3729(a)(1)(B). For many of the same reasons discussed above, 

Kramer states a claim against CDC Martins Ferry for violation of this statutory 

provision under an implied certification theory. Kramer plausibly alleges that, in

submitting the indicated claims for Patients One, Three, Five, Six, and Seven to the 

Ohio Medicaid program, CDC Martins Ferry impliedly certified, for example, that the 

dental procedures at issue were medically necessary, supported by appropriate 

documentation, and performed by licensed professionals. The CDC Defendants’ 

argument against this conclusion is that Kramer has failed to allege that any 

violations of statutory, regulatory, or contractual requirements of the Ohio Medicaid 

program were material. (See CDC Mot., Doc. 48, #560). At this stage, though, that 

argument fails for the reasons discussed above. See Bertram, 900 F.3d at 749; Doe, 

923 F.3d at 317. Accordingly, the Court DENIES the CDC Defendants’ Motion to 

Dismiss (Doc. 48) Kramer’s Third Amended Complaint (Doc. 37) with respect to 

Kramer’s claim for false statement against CDC Martins Ferry.

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B. The Third Amended Complaint States A Claim Against CDC 

Steubenville.

As in the case of CDC Martins Ferry, Kramer alleges that he personally treated 

one former patient of CDC Steubenville, namely Patient Two. (See Third Am. Compl., 

Doc. 37, #483–85). And Kramer’s allegations about dental procedures performed on 

Patient Two are similar to his allegations about the five former patients of CDC 

Martins Ferry. Specifically, Kramer alleges that CDC Steubenville performed, and 

billed Ohio Medicaid for, “poor quality” root canals on four “grossly decayed” teeth, 

teeth numbers 7–10, that required extraction anyway. (Id. at #484, 485). Thus, 

Kramer alleges that the dental procedures at issue did not conform to Ohio Medicaid’s

reimbursement criteria, which require that a procedure “[m]eets generally accepted 

standards of medical practice,” “[i]s the lowest cost alternative that effectively 

addresses and treats the medical problem,” and is “[n]ot provided primarily for the 

economic benefit of the provider.” See Ohio Admin. Code 5160-1-01(C). Much like the 

allegations regarding procedures performed by CDC Martins Ferry discussed above, 

these alleged shortcomings are plausibly material for purposes of both 31 U.S.C. 

§§ 3729(a)(1)(A) and (B). See Bertram, 900 F.3d at 749; Doe, 923 F.3d at 317. 

Moreover, Kramer also identifies the representative false claims with respect 

to Patient Two with sufficient specificity. While Kramer does not allege the exact date 

on which CDC Steubenville performed the dental procedures at issue on Patient Two, 

instead stating only that they happened in “winter 2017/2018” (id. at #483), Kramer 

does describe Ohio Medicaid claims for root canals on four “grossly decayed” teeth, 

teeth numbers 7–10, and provides a total amount of $990.52 for the alleged false 

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claims. (See id. at #484). That is enough detail to enable CDC Steubenville 

“reasonably to pluck out” these claims “from all the other claims [it] submitted.” See 

Owsley, 16 F.4th at 197. Accordingly, the Court DENIES the CDC Defendants’ 

Motion to Dismiss (Doc. 48) Kramer’s Third Amended Complaint (Doc. 37) with 

respect to Kramer’s claims for both submission of a false claim and false statement 

against CDC Steubenville. 

C. The Third Amended Complaint Fails To State A Claim Against The 

Other CDC Defendants.

Unlike the case with CDC Martins Ferry and CDC Steubenville, the Third 

Amended Complaint does not allege that Kramer treated patients who received root 

canals or other dental procedures at any of the other five corporate CDC Defendants. 

Nor does Kramer point to any other information suggesting that any specific claim 

for reimbursement that those other CDC Defendants submitted was false. Nor does

the Third Amended Complaint specifically allege how Doyle himself was involved in 

the allegedly false claims that Kramer identifies CDC Martins Ferry and CDC 

Steubenville as having submitted. Rather, Kramer seeks to paint with a broad brush. 

He essentially alleges that, because Doyle was the owner and operator of the various 

CDC sites, it is plausible to assume that if dentists at one or more CDC sites were 

submitting false claims, so were dentists at the other CDC sites. For the reasons 

previewed above, and further discussed below, the Court concludes that this amounts 

to a form of “group pleading” that Rule 9(b) prohibits. 

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1. The Third Amended Complaint Fails To Allege A False Claim Or 

False Statement By Doyle.

The Third Amended Complaint fails to allege that Doyle submitted or caused 

submission of any specific false claim to the Ohio Medicaid program. As noted, 

Kramer alleges facts generally showing that CDC Martins Ferry and CDC 

Steubenville submitted false claims. He then alleges that Doyle owned and 

“mentored” the CDC entities and was responsible for the “shared practices, 

procedures, and financial goals” that allegedly encouraged submission of false claims, 

including sometimes calling employees on the phone if they failed to make their 

revenue targets. (See Third Am. Compl., Doc. 37, #449, 491). But the problem is that 

Kramer does not tie these broad oversight allegations to any specific false claim or 

statement identified in the Third Amended Complaint. For example, as to the CDC 

Martins Ferry and CDC Steubenville claims discussed above, Kramer does not allege 

that Doyle treated those patients, submitted those claims, or indeed played any role 

in them or even knew about them. See Branhan, 1999 WL 618018, at *10 (Clay, J., 

concurring in part) (plaintiff did not adequately plead parent company’s connection 

to fraudulent claims submitted by one subsidiary); Ibanez, 874 F.3d at 915 (affirming 

dismissal of FCA claim involving alleged complex scheme for failure to “cover the 

ground from one end of this scheme ... to the other” with respect to identified claim).

True, the FCA applies to individual defendants who “cause” submission of false 

claims even if they were not personally involved in submitting the claims at issue. 

See, e.g., United States v. SouthEast Eye Specialists, PLLC, No. 3:17-cv-00689, 2021 

WL 5150687, at *15 (M.D. Tenn. Nov. 5, 2021). But liability under the FCA still 

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requires “some action by the defendant whereby the claim is presented or caused to 

be presented.” United States v. Murphy, 937 F.2d 1032, 1039 (6th Cir. 1991). While 

the Sixth Circuit apparently has not addressed the precise causation standard that 

applies, other circuit courts have held that the FCA requires “proximate causation.”

See Ruckh v. Salus Rehab., LLC, 963 F.3d 1089, 1106–07 (11th Cir. 2021); United 

States ex rel. Sikkenga v. Regence Bluecross Blueshield of Utah, 472 F.3d 702, 714–

15 (10th Cir. 2006), abrogated on other grounds by Cochise Consultancy, Inc. v. United 

States ex rel. Hunt, 139 S. Ct. 1507 (2019); see also United States v. Luce, 873 F.3d 

999, 1012 (7th Cir. 2017) (FCA damages provision requires proximate causation); 

United States v. Miller, 645 F.2d 473, 475–76 (5th Cir. 1981) (same); United States v. 

Hibbs, 568 F.2d 347, 354 (3d Cir. 1977) (same). Specifically, “a defendant’s conduct 

may be found to have caused the submission of a claim for [Medicaid] reimbursement 

if the conduct was (1) a substantial factor in inducing providers to submit claims for 

reimbursement, and (2) if the submission of claims for reimbursement was 

reasonably foreseeable or anticipated as a natural consequence of defendants’ 

conduct.” Ruckh, 963 F.3d at 1107. 

Considered under these principles, the Third Amended Complaint’s allegations 

against Doyle on the causation front are too general and conclusory to state with 

particularity that Doyle proximately caused the submission of any of the identified 

false claims by CDC Martins Ferry or CDC Steubenville. In other words, the Third 

Amended Complaint fails to identify the “who, what, when, where, and how” of 

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Doyle’s role in the submission of any identified false claim. See Sanderson, 447 F.3d 

at 877.

The Third Amended Complaint’s apparent theory of causation is that Doyle set 

“financial goals” for the practices (Doc. 37, #449) and sometimes pursued those 

financial goals by making phone calls to employees who did not meet them (id. at 

#491). But Kramer fails to provide any detail that would connect those general goals

and practices to the representative false claims the Third Amended Complaint

identifies. Cf. United States v. Anesthesia Servs. Assocs., PLLC, Case No. 3:16-cv0549, 2019 WL 7372511, at *7–8 (M.D. Tenn. Dec. 31, 2019) (broad allegations that 

individual doctor in managerial role “pressured” providers to increase revenue failed 

to state claim). Kramer does not allege, for example, that any employee who treated 

one of the example patients ever received a phone call from Doyle about revenue, nor 

does he provide even approximate timing, content, or participants in any specific 

phone call. Kramer also provides no specifics about how or when Doyle personally set 

or communicated pertinent revenue targets to employees. Nor does Kramer allege 

that Doyle instructed employees to provide unnecessary or unlicensed services or 

created incentives tied to providing specific services. Cf. United States ex rel. Norris 

v. Anderson, 271 F. Supp. 3d 950, 955 (6th Cir. 2017) (doctor told staff to use 

fraudulently high billing code); SouthEast Eye, 2021 WL 5150687, at *15 (identified 

optometrists received financial inducements tied to specific referrals in kickback 

scheme). Without something along those lines, the Third Amended Complaint fails to 

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allege with particularity that Doyle individually caused submission of an identified

false claim to the Ohio Medicaid program. 

To the extent Kramer instead is relying on some kind of veil-piercing theory to 

reach Doyle, that fails, as well. To start, Kramer does not mention veil-piercing by 

name, either in the Third Amended Complaint or in his briefing. But more to the 

point, the Third Amended Complaint fails to make the kinds of allegations that would 

support Doyle’s liability on a veil-piercing theory. For example, Kramer does not 

allege facts suggesting that Doyle ignored or misused the corporate form. See United 

States v. Dynamic Visions, Inc., 220 F. Supp. 3d 16, 25 (D.D.C. 2016) (“In determining 

whether to pierce the corporate veil, the Court asks: (1) is there such a unity of 

interest and ownership that the separate personalities of the corporation and the 

individual no longer exist?; and (2) if the acts are treated as those of the corporation 

alone, will an inequitable result follow?”). 

In short, the allegations against Doyle do not sufficiently connect him to any 

identified false claim to support liability. Likewise, Kramer identifies no specific false 

statements by Doyle himself in connection with any of his example patients or in any 

other connection. Thus, the Third Amended Complaint also fails to state a claim 

against Doyle for false statement in violation of 31 U.S.C. § 3729(a)(1)(B). 

Because the Third Amended Complaint does not allege facts that state with 

particularity that Doyle was responsible for any false claim or false statement, the 

Court GRANTS the CDC Defendants’ Motion to Dismiss (Doc. 48) the Third 

Amended Complaint (Doc. 37) with respect to Doyle. 

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2. The Third Amended Complaint Fails To Identify Any Specific

False Claim By CDC Calcutta, CDC Champion Heights, CDC 

Dennison, CDC Newcomerstown, Or CDC Shadyside. 

As discussed above, a plaintiff alleging a fraudulent scheme to submit false 

claims in violation of the FCA must identify at least one representative claim for 

payment that was actually submitted to the government, and that is somehow 

attributable to the defendant. Chesbrough, 655 F.3d at 470. Kramer fails to do this 

for the five corporate CDC Defendants other than CDC Martins Ferry and CDC 

Steubenville. That is fatal to his claims against those Defendants. 

Again, Kramer argues that he need not allege a false claim by each corporate 

CDC Defendant because he is alleging a fraudulent scheme involving all of them. (See

Opp’n, Doc. 54, #644). But, as discussed in more detail above, the Court determines 

that alleging a fraudulent scheme is only a way of aggregating false claims of the 

same kind submitted by the same defendant, not a vehicle for bringing in additional

defendants with respect to whom a plaintiff otherwise fails to identify a specific claim. 

Accordingly, the Court holds that Kramer fails to state a claim for violation of 31 

U.S.C. § 3729(a)(1)(A) against the corporate CDC Defendants other than CDC 

Martins Ferry and CDC Steubenville. 

Moreover, even if a plaintiff could satisfy Rule 9(b)’s pleading requirement by 

identifying a false claim by one entity, and then alleging facts sufficient to show that 

other affiliated entities likely made similar false claims (e.g., because of common 

operational rules among the entities), the Court concludes that Kramer has failed to 

provide such allegations here. That is, the inference Kramer presumably would want 

the Court to draw is that Doyle caused the false claims to be submitted at CDC 

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Martins Ferry and CDC Steubenville, and thus it is plausible to conclude that he 

likewise caused false claims to be submitted by the other corporate CDC Defendants. 

As set forth immediately above, though, the Court concludes that Kramer fails to link 

Doyle to the representative claims the Complaint identifies, meaning in turn that 

Kramer cannot rely on Doyle as the bridge to connect the other corporate CDC 

Defendants to those allegedly fraudulent claims.

Accordingly, for both of these reasons, the Court GRANTS the CDC 

Defendants’ Motion to Dismiss (Doc. 48) with respect to this claim against those five 

other corporate CDC Defendants in the Third Amended Complaint (Doc. 37).

For similar reasons, the Third Amended Complaint also fails to state a claim 

against the five CDC Defendants other than CDC Martins Ferry and CDC 

Steubenville for false statement in violation of 31 U.S.C. § 3729(a)(1)(B). Kramer does 

not allege that these entities made any statements with respect to the specific false 

claims (by CDC Martins Ferry and CDC Steubenville) that Kramer identifies in the 

Third Amended Complaint. Nor does he identify any other specific false statements 

by the five other corporate CDC Defendants (in large part, no doubt, because he fails 

to identify any false claims those five entities submitted). Accordingly, the Court 

GRANTS the CDC Defendants’ Motion (Doc. 48) with respect to Kramer’s claim for 

false statement in violation of 31 U.S.C. § 3729(a)(1)(B) in the Third Amended 

Complaint (Doc. 37) against the five corporate CDC Defendants other than CDC 

Martins Ferry and CDC Steubenville. 

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D. The Third Amended Complaint Fails To State A Claim Against The 

NADG Defendants.

It is undisputed that the NADG Defendants had no business relationship with 

the CDC Defendants when several of Kramer’s example patients received treatment 

at CDC Martins Ferry or CDC Steubenville. But the Third Amended Complaint 

alleges that the NADG Defendants did have a business relationship with the CDC 

Defendants by the time Patients Six and Seven, and perhaps Patient Five, received 

treatment at CDC Martins Ferry. (See Doc. 37, #453, 496, 500, 504). Much as with 

respect to Doyle, though, the problem is that Kramer fails to allege that the NADG 

Defendants played any role in the submission of false claims or statements for those 

patients. For example, Kramer does not allege that the NADG Defendants or their 

employees actually submitted claims to Ohio Medicaid, either in general or for the 

example patients mentioned in the Third Amended Complaint. Nor does Kramer 

allege any act by the NADG Defendants that caused the submission of a specific false 

claim.

Instead, Kramer refers to the claims for payment as “Complete Dental Care’s 

claims,” and only alleges generally that “[b]y virtue of its control over Complete 

Dental Care’s dental practice and its encouragement of Doyle’s schemes, North 

American Dental Group also caused the submission of these false claims.” (Id. at 

#502, 506). Kramer attempts to substantiate this “control” by alleging that the NADG 

Defendants continued the CDC Defendants’ allegedly unrealistic revenue targets, 

kept track of individual dentists’ revenue, and rewarded those dentists who met their 

revenue targets. (Id. at #454). But, much as with Doyle, these allegations do not 

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suggest that the NADG Defendants played a role in the submission of false claims, 

or that they were responsible for any false statements with respect to the alleged false 

claims, for Patients Five, Six, and Seven specifically, the only relevant patients for 

whom Kramer identifies specific false claims. See Ibanez, 874 F.3d at 915; Branhan, 

1999 WL 618018, at *10 (Clay, J., concurring in part); Anesthesia Servs., 2019 WL 

7372511, at *7–8. Kramer also does not provide any specific facts about how or when

the NADG Defendants caused employees of CDC Martins Ferry to perform allegedly 

unnecessary dental procedures or submit false claims for Patients Five, Six, and 

Seven.

As in the case of Doyle, Kramer’s allegations also fall far short of what would 

be required to plausibly suggest that Kramer could reach the NADG Defendants on 

a veil-piercing theory. That is especially true given the Third Amended Complaint’s 

lack of clarity as to whether the NADG Defendants are the “owner” or only the 

“partner” of the corporate CDC Defendants, as well as its vague allegations that both

Doyle and the NADG Defendants “control” the corporate CDC Defendants. (See Third 

Am. Compl., Doc. 37, #449, 453, 503). Accordingly, the Court GRANTS the NADG 

Defendants’ Motion (Doc. 49) in its entirety, and DISMISSES the claims against 

NADG in the Third Amended Complaint (Doc. 37) WITH PREJUDICE. 

E. The Court Denies Kramer’s Motion For Leave To Amend Because 

Further Amendment Would Be Futile.

Because the Court finds that the Third Amended Complaint fails to state a 

claim against several of the Defendants in this action, the Court also must consider 

Kramer’s Motion for Leave to File Fourth Amended Complaint in lieu of dismissing

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Kramer’s claims against those Defendants. For the reasons that follow, the Court 

DENIES Kramer’s Motion for Leave to File Fourth Amended Complaint (Doc. 57) in 

its entirety.

At the outset, the Court notes that this would be Kramer’s fifth attempt to 

state a claim against all Defendants in this action. Accordingly, even if the Fourth 

Amended Complaint did successfully state a claim against some or all of the 

Defendants as to whom the Third Amended Complaint fails, the Court might still be 

inclined to deny leave to amend on grounds of “repeated failure to cure deficiencies 

by previous amendments” and “undue prejudice to the opposing part[ies].” See Gen. 

Elec. Co., 916 F.2d at 1130. Ultimately, though, the Court need not rely on this 

rationale, because the Fourth Amended Complaint in any event fails to remedy the 

deficiencies of the Third Amended Complaint with respect to all Defendants at issue. 

1. The Proposed Fourth Amended Complaint Would Fail To State 

A Claim Against Doyle.

The new allegations concerning Doyle in Kramer’s Proposed Fourth Amended 

Complaint do not remedy Kramer’s failure to state a claim against Doyle in his Third 

Amended Complaint. Kramer alleges that a former Complete Dental Care employee 

who worked at “several” CDC locations, “including Martins Ferry and Shadyside,” 

told him that Doyle often instructs non-dentists to add items to patient treatment 

plans that the assigned dentist never approved. (See Prop. Fourth Am. Compl., Mot. 

to Amend Ex. B, Doc. 57-2 #1092–95). To be sure, these allegations may substantiate 

a greater role for Doyle in the alleged provision of unnecessary dental services by 

other dentists than was apparent from Kramer’s Third Amended Complaint. But they 

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do not get Kramer across the finish line because they still fail to tie Doyle to any 

specific false claim that the Proposed Fourth Amended Complaint identifies. As 

noted, a qui tam plaintiff must identify a claim representing the allegedly fraudulent 

conduct with sufficient specificity to allow defendant “reasonably to pluck out” that 

claim “from all the other claims [he] submitted.” See Owsley, 16 F.4th at 197. As 

applicable here, then, Kramer must identify one or more claims in which the alleged 

changes to treatment plans made at Doyle’s instruction led to submission of a false 

claim. 

Measured against that standard, the Proposed Fourth Amended Complaint 

falls short. For example, it does not allege that Doyle modified the treatment plans 

for any of the specific example patients Kramer identifies (which modification might 

then have caused the submission of the identified false claims for those patients to 

Ohio Medicaid).4 Nor does it identify any other specific instance in which a Doyleinstructed change resulted in Medicaid being billed at all. Accordingly, however 

troubling Doyle’s alleged conduct, Kramer again has failed to tie that conduct to any 

identified false claim or statement Doyle made or caused to be made to the 

government. See Sanderson, 447 F.3d 877–78 (the FCA “attaches liability, not to the 

underlying fraudulent activity or to the government’s wrongful payment, but to the 

4 Indeed, the Proposed Fourth Amended Complaint instead alleges that Doyle’s practice of 

changing patient treatment plans did not begin until September 2017, more than two years 

after the identified claims submitted for Patient One by CDC Martins Ferry. (See Doc. 57-2, 

#1092). Moreover, the Proposed Fourth Amended Complaint does not allege that the 

employee on whom Kramer relies for the information about Doyle changing treatment plans 

ever worked at CDC Steubenville, such that she could have observed Doyle changing the 

treatment plan for Patient Two, the only identified patient who allegedly received improper 

dental care at that location. (See id.).

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claim for payment”) (citation and internal quotation marks omitted). For these 

reasons, the Court DENIES Kramer’s Motion for Leave to File Fourth Amended 

Complaint (Doc. 57) with respect to Doyle and accordingly DISMISSES WITH 

PREJUDICE all claims against Doyle.

2. The Proposed Fourth Amended Complaint Would Fail To State A 

Claim Against CDC Calcutta, CDC Champion Heights, CDC 

Dennison, CDC Newcomerstown, or CDC Shadyside.

Kramer’s Proposed Fourth Amended Complaint adds no new allegations of

specific false claims or statements by corporate CDC Defendants other than CDC 

Martins Ferry or CDC Steubenville. Thus, for the reasons already discussed above in 

connection with Kramer’s Third Amended Complaint, Kramer’s Fourth Amended 

Complaint still fails to state a claim against these other entities. To wit, the Court 

interprets Sixth Circuit case law to require allegations of presentment as to each of 

the corporate CDC Defendants, which Kramer’s Proposed Fourth Amended 

Complaint still fails to provide. Moreover, even if some inference arising from the 

common ownership or control by Doyle could be a permissible basis for extending FCA 

liability to the other corporate CDC Defendants, that linchpin is missing here, 

because the Proposed Fourth Amended Complaint fails to adequately allege Doyle’s 

own connection to the identified false claims, as discussed immediately above.

Accordingly, the Court DENIES Kramer’s Motion for Leave To File Fourth Amended 

Complaint (Doc. 57) with respect to the five CDC Defendants other than CDC Martins 

Ferry and CDC Steubenville and DISMISSES Kramer’s claims against those five

CDC Defendants WITH PREJUDICE. 

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3. The Proposed Fourth Amended Complaint Would Fail To State 

A Claim Against the NADG Defendants.

Stated briefly, Kramer’s new allegations about the NADG Defendants are that 

a former employee of NADG’s Refresh Dental office in Shaker Heights, Ohio (not 

otherwise affiliated with Doyle or CDC), told Kramer that the NADG Defendants 

have sent Doyle to that location to lead an Optimization Team to increase revenue by 

encouraging medically unnecessary dental procedures. (See Prop. Fourth Am. 

Compl., Mot. to Amend Ex. B, Doc. 57-2, #1095–98). These new allegations, which do 

not concern the scheme in which all Defendants are allegedly participating together,

do not remedy the deficiencies in Kramer’s Third Amended Complaint as to the 

NADG Defendants. Kramer’s new allegations do nothing to tie the NADG Defendants 

to the specific false claims for dental treatment that Kramer alleges CDC Martins 

Ferry and CDC Steubenville submitted to Ohio Medicaid, which are still the only 

specific alleged false claims Kramer identifies. See Chesbrough, 655 F.3d at 470; 

Ibanez, 874 F.3d at 915. Accordingly, the Court DENIES Kramer’s Motion for Leave 

to File Fourth Amended Complaint (Doc. 57) with respect to the NADG Defendants 

and therefore DISMISSES Kramer’s claims against the NADG Defendants WITH 

PREJUDICE. 

F. The NADG Defendants’ Partially Unopposed Motion For Leave To File 

Surreply, Instanter, Is Moot.

Because the Court denies Kramer’s Motion for Leave to File Fourth Amended 

Complaint (Doc. 57) in its entirety, the Court also DENIES AS MOOT the NADG 

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Defendants’ Partially Unopposed Motion for Leave to File Surreply Brief, Instanter

(Doc. 62). 

CONCLUSION

For the foregoing reasons, the Court GRANTS IN PART and DENIES IN 

PART the CDC Defendants’ Motion to Dismiss (Doc. 48). Specifically, the Court 

DENIES the Motion (Doc. 48) with respect to all claims against CDC Martins Ferry 

and CDC Steubenville. The Court GRANTS the Motion (Doc. 48) in all other respects. 

Accordingly, the Court DISMISSES WITH PREJUDICE all claims against CDC 

Calcutta, CDC Champion Heights, CDC Dennison, CDC Newcomerstown, CDC 

Shadyside, and Doyle. The Court also GRANTS the NADG Defendants’ Motion to 

Dismiss (Doc. 49) in its entirety, and thereby DISMISSES WITH PREJUDICE all 

claims against the NADG Defendants. The Court DENIES Kramer’s Motion for 

Leave to File Fourth Amended Complaint (Doc. 57). The Court therefore also 

DENIES AS MOOT the NADG Defendants’ Partially Unopposed Motion for Leave 

to File Surreply Brief, Instanter (Doc. 62). The Court DIRECTS the Clerk to 

TERMINATE Doyle, CDC Calcutta, CDC Champion Heights, CDC Dennison, CDC 

Newcomerstown, CDC Shadyside, and the NADG Defendants from this action. This 

action will proceed as to all claims against CDC Martins Ferry and CDC Steubenville.

SO ORDERED. 

April 21, 2022 

DATE DOUGLAS R. COLE

 UNITED STATES DISTRICT JUDGE

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