FI LED U. S . COURT OF AP PE ALS E L E V E N T H C IR C U IT D e c e m be r 30, 2005 T HOM AS K. KAHN CL E RK [ P UB L I S H] I N THE UN I TE D STATE S C OU RT OF APPE ALS F O R T H E E L E V E N T H C IR C U IT

________________________ N o. 04- 15283

________________________ D . C. D o c k e tN o . 0 2 - 0 0 1 3 1 - CV - O C- 1 0 - G RJ U N I T E D S T A T E S , e x r e l., P l ai nt i ff , K A R Y N L . W A L K E R , a. k. a. K aryn L . D enk-W al ker, P l a i nt i f f - A ppe l l a nt C ross -A pp el l ee , ve r s us R & F P R O P E R T I E S O F L A K E C O U N T Y , I N C ., A F l or i da P r of

e s s i ona l A s s oc i a t i on, D ef endant -A pp el l ee C r o s s - A p p e lla n t.

________________________ A pp ea l s f

rom the U ni t ed S t at es D i stri ctC ou rt f orthe M i ddl e D i s tr i c tof F l or i da

_________________________ ( D e c e m be r30, 2005) B efo re B IR C H , W IL S O N an d C O X , C i rcu i tJu d g es. C O X , C i rc ui tJudg e:2

P l ai nt i ff K aryn L . W al ker i s a q u ita m r e l a t or , s e e ki ng r e c ove ry on be ha l f of the U ni t ed S t at es pu rs uantt o the F al se C l ai m s A ct , 31 U . S . C . § 3 72 9. W al ker appe a l s a s um m a ry j udgm e ntgr a nt e d t o D e f e nda ntR & F P r ope r t i e s of L a ke C ou nty, Inc. , form er l y kno w n as L ee sburg F am i l y M edi ci ne, (L F M ). A nd W al ker c ont e nds tha tthe di s tr i c tc our te rr e d i n l i m i t i ng the s c ope of i nf or m a t i on di s c ove r abl e i n the c a s e t o tha ti nf or m a t i on r e l e va ntt o the t i m e pe r i od dur i ng w h i ch sh e w as em p l o yed b y L F M as a n u rse p ract i t i o n er. L F M cro ss-ap p eal s, co n ten d in g th at th e d istrict co u rt er re d in d en yin g it s m o ti o n to d ism iss W alk er ’s A m e n d e d C o m p la in t. W e c onc l ude tha tthe di s tr i c tc our te rr e d i n hol di ng tha tW a l ke rha d not p ro d u ced su ffi ci en tev i d en ce o f th e fal si ty o f th e cl ai m s su b m i tt ed b y L F M t o resi st su m m ary j u d g m en t . T h erefo re, w e rev erse th e d i stri ctco u rt ’ s j u d g m en t . W e al so f i nd e rr ori n the di s tr i c tc our t ’ s or de rl i m i t i ng di s c ove ry . W e f i nd no e rr ori n the d i stri ctco u rt ’ s d en i al o f L F M ’ s m o t i o n t o d i sm i ss.

I . BA CK G RO U N D & PRO CED U RA L H I STO RY T he M e di c a r e P r ogr a m i s a s y s t e m of he a l th i ns ur a nc e a dm i ni s t e r e d by the U ni t e d S t a t e s D e pa r tm e ntof H e a l th a nd H um a n S e r vi c e s , thr ough the C e nt e rf or M e d ic a r e a n d M e d ic a id S e r v ic e s ( C M S ) . C M S w a s f o r m e r ly k n o w n a s th e H e a lth C a r e F in a n c in g A d m in is tr a tio n ( H C F A ) . M e d ic a r e P a r t B is a f e d e r a lly s ubs i di z e d, vol unt a ry he a l th i ns ur a nc e pr ogr a m tha tpa y s a por t i on of the c os t s of3

ce rt ai n h ea l th servi ce s, i ncl ud i ng the cost s of c l i ni c vi si t s t o h ea l thcar e provi ders ( a m o n g th e m , p h y s ic ia n s , p h y s ic ia n a s s is ta n ts , a n d n u r s e p r a c titio n e r s ) . R e im b u r s e m e n t f

o rM e d ic a r e P a r t B c la im s is m a d e th r o u g h C M S , w h ic h c o n tr a c ts w i th p ri vat e i nsurance c arri er s throu gh ou tthe U ni t ed S t at es t o adm i ni st erand p ay cl ai m s w i thi n thei r r egi on s f rom the M edi ca re T rustF un d. T hese i nsurance ca rr i er s a re kn ow n as F i sc al Int erm edi ar i es , or F Is . In general , w hen a heal thcar e se rvi ce i s r endered t o a pat i entcovered by M edi ca re P artB , the heal thcar e provi der bi l l s M e di c a r e / C M S thr ough the F I . T he F I r e vi e w s the bi l l a nd pa y s the he a l thc a r e pr ovi de r . C M S publ i s he s a s e r i e s of m a nua l s tha tpr ovi de bi l l i ng a nd pa y m e nti ns truc t i ons t o the M e di c a r e c om m uni ty . A m ong the s e m a nua l s a r e the M e di c a r e C a rr i e r ’ s M a nua l , di r e c t e d t o the F I s , a nd the P r ovi de rR e i m bur s e m e nt M an u al , d i rect ed t o h eal th care p ro v i d ers. L F M o p erat es m ed i cal cl i n i cs i n L eesb u rg an d L ad y L ak e, F l o ri d a. A tth ese cl i ni cs , ph ys i ci ans, ph ys i ci an as si st ant s, and n urse prac t i t i on er s provi de m edi ca l s e r vi c e s t o the c om m uni ty . M a ny , i f notm os t , of

L F M ’ s pa t i e nt s a r e c ove r e d by M edi ca re P artB . L F M subm i t s c l ai m s f or M edi ca re re i m bu rs em entfor hea l thcar e s e r v ic e s r e n d e r e d b y p h y s ic ia n s , p h y s ic ia n a s s is ta n ts a n d n u r s e p r a c titio n e r s to its F I , B l ue C r os s B l ue S hi e l d of F l or i da , pur s ua ntt o a c ontr a c tbe tw e e n L F M a nd B lu e C r o s s B lu e S h ie ld . T h e s e c la im s a r e m a d e o n H C F A 1 5 0 0 f o r m s in e le c tr o n icFor the re levant time period prior to J anuar y 1, 2002, 42 CFR § 410.26 stated: 1 4 fo rm , as r eq u ired b y th e M ed icar e r eg u lati o n s, an d sig n ed elec tro n ically b y L F M ’s p h ysi ci an s. E ach H C F A 1 5 0 0 fo rm st at es:

SI GN ATURE OF P HY SI CI AN OR SUPP LI ER ( ME DI C AR E , C HA MP US , F E C A A ND B L AC K L UN G) I c e r tif y th a t th e s e r v ic e s s h o w n o n th is f o r m w e r e m e d ic a lly i nd i ca t ed and n ec es sa ry for the heal th o f the pat i entand w er e p e r s o n a l l y f

u rn i s h e d b y me o rw e r e f u rn i s h e d i n c i d e n tt o my profes si on al se rvi ce by m y e m pl oyee un der m y i m m edi at e per sonal s upe r vi s i on, e xc e pta s othe rw i s e e xpr e s s l y pe r m i tt e d by M e di c a r e or C H A M P U S reg u l at i o n s. F o r s er v ices to b e c o n sid er ed “i n cid en t” to a p h ys ician ’s p ro fe ss io n al se rv ice, 1 ) th ey m u st b e r en d er ed u n d erth e p h ys ician ’s i m m e di a t e pe r s ona l s upe r vi s i on by hi s /he re m pl oy e e , 2) the y m us tbe an i nt egra l , al tho ug h i nci dent al partof a c ov er ed ph ys i ci an’ s s ervi ce , 3 ) th ey m u stb e o f k i n d s co m m o n l y fu rn i sh ed i n p h ysi ci an ’ s o ffi ces, a nd 4) the s e r vi c e s of

nonphy s i c i a ns m us tbe i nc l ude d on the p h ysi ci an ’ s b i l l s. ( R .2 - 7 9 E x . G .) H ea l thcar e provi ders m ay bi l l M edi ca re P artB for the se rvi ce s of physi ci an a s s i s t a nt s a nd nur s e pr a c t i t i one r s i n one of tw o w a y s ; the a m ountof r e i m bur s e m e nt the pr ovi de r s r e c e i ve i s de pe nde nton the bi l l i ng m e thod. P hy s i c i a n a s s i s t a ntor nu rs e pra ct i t i on erse rvi ce s m ay be bi l l ed as se rvi ce s “ i nci dentt o the se rvi ce of a phy s i c i a n. ” 42 C F R §§ 410. 10, 410. 26. T o be c orr e c t l y bi l l e d i n thi s m a nne r , the ph ys i ci an as si st antor nu rs e pra ct i t i on erse rvi ce s m usthave been prov i ded u nd er ce rt ai n ci rc um st ance s. W hen p hysi ci an as si st antor nu rs e pra ct i t i on erse rvi ce s a re 1(a) Medica re Par t B pa ys for ser

vi ce s and supplies incident to a physic ian’ s p ro fe ssi on al serv ic e s, inc ludingdr ug s and bio log ic als that cannot beself-administ ere d, if the ser vices or supplies a

re of the ty pe that arecommonly

furnished in a

physician’s off

ice or clinic, and are commonly furnished either without c harg e, or inc luded in the physician’s bill. Ef fe c tiv eJanu ary

1, 20 02 , 4 2 CF R § 4 10 .2 6 w a s amend e d tore a d, in re le va nt p art : (b) Me dicare P art B pays for ser vices a nd supplies incident to the serviceof a physician (or other practitioner). (1) Ser vices a nd suppl i es must be furnished in a no nin sti tution al settingto n onins tit uti on al patients . (2) Services and supplies must be a n integral, tho u gh inc idental, p art

of theserv ic eof a physic ian ( or oth e r p rac tition e r) in thec ours eof

diagno sis or

tre atment o f a

n in jur y or illne ss. (3) Se rv i ces a

nd supplies must be commonly furnished without charg e or inc luded in the b ill of a physician (or other prac titioner). (4 ) S e rv ic e s and su

pp lie s must be of a ty

pethat arec omm on ly furnished in the office or clinic of a physician (or

other practitioner). (5) Ser vices a nd supplies must be f

urnished under thedirec t supervision of the physician (or other prac titioner). The physician (or other practitioner) dire ctly supervisingthe auxili ary personne l need no t bethesamephysic ian ( or oth e r p rac ti ti on er) up on wh os e profe ssional servicethe incident to servic e is based.

. . . “ Dire ct superv is io n, ”a s u se d in 42 CF R § 4 10 .2 6, is de fine d b y re ferenc eto 4 2 CF R § 41 0. 32 (b )( 3) (i i) , a

prov isi on

that, s inc e19 98 , s tate s: Direct superv ision in the officesetting me ans the physician must be pr e se nt i nth eo f

f i c es u i t ean d

i mm e di at e l y

av ai l a b l et o f ur n i sh assistanceand dire ctio n

th rough out the perf

ormanc e of theproce dure. It does not mean that the physician must be pre sent in the room when the proc edureis perfor

med. 5 bi l l ed as “ i nci dentt o the se rvi ce of a physi ci an, ” the ph ys i ci an’ s U ni qu e P rovi der I d e n tif ic a tio n N u m b e r( U P I N ) is u s e d o n th e b ill s u b m itte d to th e F I . A l t ern at i v el y, a p ro v i d er m ay b i l l M ed i care fo r p h ysi ci an assi st an tan d n u rse6

p r a c t i t i o n e rs e r v i c e s u n d e rth e p h y s i c i a n a s s i s t a n t ’ s o rn u r s e p r a c t i t i o n e r ’ s o wn U P I N . B i l l i ng M e di c a r e i n thi s s e c ond w a y i ndi c a t e s tha tthe phy s i c i a n a s s i s t a ntor n u rse p ract i t i o n er h as p erfo rm ed th e serv i ce u n d er so m e l ev el o f su p erv i si o n b y a p h y s ic ia n , b u t th e r e q u ir e m e n ts o f 4 2 C F R § 4 1 0 .2 6 h a v e n o t n e c e s s a r ily b e e n m e t. F ors e r vi c e s bi l l e d unde ra phy s i c i a n a s s i s t a nt ’ s ornur s e pr a c t i t i one r ’ s U P I N , the F I p ay s 8 5 % o f w h at itw o u ld p ay fo r th e s am e s er v ices b il led u n d era p h ys ician ’s UP I N. W al k er w o rk ed fo r L F M fro m F eb ru ary 1 9 9 7 u n t i l M ay 1 9 9 9 as a n u rse p r a c titio n e r . D u r in g th a t tim e , th e r e w e r e m a n y o c c a s io n s w h e n s h e s a w p a tie n ts i n d ep en d en t l y w i th o u tp h ysi ci an su p erv i si o n . P h ysi ci an s w ere n o tal w ays ph ys i ca l l y pre se nti n the L F M cl i ni c w hi l e W al ker a nd other nurse prac t i t i on er s a nd phy s i c i a n a s s i s t a nt s s a w pa t i e nt s , butphy s i c i a ns w e r e a l w a y s a va i l abl e f or consul t at i on by pager and t el epho ne.

I I . CONTENTI ON S OF T HE PART I ES W al ker bri ng s thi s s ui tas a q u ita m r e l a t orunde rthe F a l s e C l a i m s A c t . S he a l l e ge s tha tL F M f

i l e d f a l s e c l a i m s f

orM e di c a r e r e i m bur s e m e ntby bi l l i ng M e d ic a r e f

o rs e r v ic e s r e n d e r e d b y n u r s e p r a c titio n e r s a n d p h y s ic ia n a s s is ta n ts a s if thos e s e r vi c e s w e r e r e nde r e d “ i nc i de ntt o the s e r vi c e of aphy s i c i a n, ” e ve n though L F M kn ew thatthe nu rs e pra ct i t i on erand p hysi ci an as si st antse rvi ce s di d n otm ee t se v er al o f th e c riteria n ec es sa ry fo r b il li n g in th at m an n er . C h ief a m o n g W alk er ’s7

com pl ai nt s i s thatL F M bi l l ed al l nu rs e pra ct i t i on erand p hysi ci an as si st antse rvi ce s a s “ i nc i de ntt o the s e r vi c e of a phy s i c i a n, ” e ve n though the nur s e pr a c t i t i one r s a nd ph ys i ci an as si st ant s oft en tre at ed pat i ent s a tL F M ’ s c l i ni cs w hen n o p hysi ci an w as ph ys i ca l l y pre se nti n the cl i ni c. S he cont ends thata physi ci an’ s physi ca l pres ence w i thi n the of

f i c e s ui t e w a s r e qui r e d i n or de rf orthe nur s e pr a c t i t i one r ’ s or ph ys i ci an as si st ant ’ s s ervi ce t o h ave been re nd er ed “ i nci dentt o the se rvi ce of a p h y s ic ia n ,” a s u s e d in 4 2 C F R § 4 1 0 .2 6 a n d “u n d e rth e p h y s ic ia n ’s im m e d ia te p e r s o n a l s u p e r v is io n ” a s c e r tif ie d b y th e p h y s ic ia n o n e a c h H C F A 1 5 0 0 c la im form . W al ker f

urther c on t ends thatL F M kn ew thati t s bi l l i ng prac t i ce w as fr audu l entand t hatL F M kn ew the prop erw ay t o b i l l the se rvi ce s ( as se rvi ce s re nd er ed di re ct l y by the nu rs e pra ct i t i on eror ph ys i ci an as si st antra ther than as s e r vi c e s “ i nc i de ntt o the s e r vi c e of a phy s i c i a n” ) . W a l ke ra l l e ge s tha t , a s a r e s ul tof the fr audu l entm anner i n w hi ch L F M bi l l ed M edi ca re , L F M w as pai d 1 5% m ore than i tshou l d h ave been pai d for nu rs e pra ct i t i on erand p hysi ci an as si st antse rvi ce s t o M ed i care p at i en t s. L F M a d m its th a t p h y s ic ia n s w e r e n o t a lw a y s p h y s ic a lly p r e s e n t in th e c lin ic w h i l e n u rse p ract i t i o n ers an d p h ysi ci an assi st an t s treat ed p at i en t s. L F M al so a dm i t s tha ti ts ubm i tt e d H C F A 1500 f or m s t o B l ue C r os s B l ue S hi e l d r e que s t i ng M edi ca re re i m bu rs em entfor s ervi ce s of nurse prac t i t i on er s a nd ph ys i ci an assi st an t s p erfo rm ed “ i n ci d en tt o th e serv i ce o f a p h ysi ci an , ” ev en i f th e n u rseAcc ordingto LFM, however, this is a hy pothetical. LFM contends that Walker’s Amended 2 Com plaint do e s n ot p roperly

ple a d a ny c a us e of a c tio n re g ardinga

ny tim eperi od

and that it sh ould have be en dismissed by

the di s tri ct court be causeit is notspecificenough to satisfy the pleading 8 prac t i t i on erand p hysi ci an as si st antse rvi ce s w er e per form ed w hi l e no p hysi ci an w a s phy s i c a l l y pr e s e nti n the L F M of f i c e s ui t e . L F M f

ur the rc onc e de s tha tthe s ubm i s s i on of

the H C F A 1500 f

or m s c ons t i tut e s the pr e s e nt a t i on of c l a i m s f or p u rp o s e s o f

th e F a l s e C l a i m s Ac t . Ho we v e r , L F M a r g u e s th a t , a s a m a tt e ro f l a w, these cl ai m s c ou l d n othave been fal se w i thi n the m ea ni ng of the F al se C l ai m s A ct b e c a u s e th e p h r a s e “in c id e n t to th e s e r v ic e o f a p h y s ic ia n ” w a s , a t le a s t u n til Ja nu ary 1, 20 02 , vagu e a nd subj ec tt o rea sonabl e i nt erpret at i on s other than t hat cham pi on ed by W al ker. Itfurther a rgues thatthe “ i m m edi at e per sonal s upe r vi s i on” l a ngua ge i n the H C F A 1500 c e r t i f i c a t i on i s s i m i l a r l y va gue a nd th e r e f o r e , a s a ma tt e ro f

l a w , c a n n o tb e th e b a s i s f o ra f a l s e c l a i m. T h e p a r tie s a ls o d is a g r e e ab o u t th e tim e p e r io d r e le v a n t to W a lk e r ’s la w s u it. W al k er m ai n t ai n s th atL F M m ad e fal se cl ai m s fo r p h ysi ci an assi st an tan d n u rse p r a c titio n e rs e r v ic e s p e r f o r m e d f r o m th e tim e it f

ir s t h ir e d a p h y s ic ia n a s s is ta n t in 19 94 throu gh the dat e W al ker f i l ed her com pl ai nt , and she ar gu es thather com pl ai ntprop er l y a l l eges the exi st ence of fa l se cl ai m s throu gh ou tthi s e nt i re p e r io d . L F M , o n th e o th e rh a n d , c o n te n d s th a t W a lk e rc o u ld a lle g e p r o p e r ly o n ly thatfa l se cl ai m s w er e pre se nt ed fr om F ebruary19 97 throu gh M ay 19 99 , the dat es o f h e re m p l o y m e n ta tL F M. 2requirements of Fe deral Rule of Civil Procedure 9(b) . 9 T he di stri ctcourtgrant ed L F M sum m ary j ud gm entbecause i tfoun d that L F M ’ s r e que s t s f

orr e i m bur s e m e ntc oul d notbe f a l s e a s a m a tt e rof

l a w . T he di stri ctcourtre as on ed that , because the M edi ca re st atut es and regul at i on s i n eff ec t dur i ng the pe r i od of

W a l ke r ’ s e m pl oy m e ntw i th L F M di d nota de qua t e l y de f i ne the p h r a s e “in c id e n t to th e s e r v ic e o f a p h y s ic ia n ” a n d b e c a u s e th e te r m s “im m e d ia te ,” “in te g r a l,” a n d “in c id e n ta l” a s u s e d o n th e H C F A 1 5 0 0 f o r m “a r e in h e r e n tly i m pr e c i s e , ” L F M ’ s i nt e rpr e t a t i on of the t e r m s ( tha tnur s e pr a c t i t i one r s a nd ph ys i ci an as si st ant s c ou l d see pat i ent s i nd ependent l y s o l on g as aph ys i ci an w as a v a ilab le b y p a g e ra n d te le p h o n e ) m u s t b e a c c e p te d a s r e a s o n ab le . I n o p p o s itio n to L F M ’ s m ot i on f

ors um m a ry j udgm e nt , W a l ke rof f e r e d e vi de nc e of

how the r e g u la to ry la n g u a g e a n d th e H C F A 1 5 0 0 c e r tif ic a tio n la n g u a g e w e r e in te rp r e te d in th e M e d ic a r e c o m m u n ity . W a lk e rc o n te n d s th a t th is e v id e n c e w o u ld s u p p o r t a fi nd i ng thatthe cl ai m s s ub m i tt ed w er e f al se . H ow ever , the di stri ctcourt c ons i de r e d the e vi de nc e i ns uf f i c i e ntt o pr e s e nta n i s s ue of f a c ta s t o the m e a ni ng of th e te r m s . I I I . I S S UE S ON AP P E AL T o d e te r m in e w h e th e rth e d is tr ic t c o u r t e rr e d in g r a n tin g s u m m a ry ju d g m e n t, w e m ustdeci de w hether the M edi ca re re gu l at i on s a nd H C F A 15 00 form ar e10

u n cl ear reg ard i n g th e cri t eri a th atm u stb e fu l fi l l ed i n o rd er fo r serv i ces o f a n u rse pr a c t i t i one rorphy s i c i a n a s s i s t a ntt o be bi l l e d a s s e r vi c e s “ i nc i de ntt o the s e r vi c e of a physi ci an. ” I f w e dec i de thatthey a re un cl ea r, w e m ustthen d ec i de w hether a c o u r t m a y lo o k to e v id e n c e o th e rth a n th e la n g u a g e o f th e r e g u la tio n a n d f

o r m to d e te r m in e w h e th e ra c la im , a lle g e d ly s u b m itte d in v io la tio n o f th a t la n g u a g e , is fa l se w i thi n the m ea ni ng of the F al se C l ai m s A ct . If w e dec i de thata c ou rtm ay l ook t o e vi de nc e out s i de the l a ngua ge a ti s s ue , w e m us tde t e r m i ne w he the rthe e vi de nc e W a l ke rpr e s e nt e d i n oppos i t i on t o L F M ’ s m ot i on f ors um m a ry j udgm e nt is s u f f ic ie n t to c r e a te a n is s u e o f f a c t a s to th e f

a ls ity o f th e c la im s L F M m a d e to M e d ic a r e . W e a l s o de c i de w he the rthe di s tr i c tc our te rr e d i n l i m i t i ng di s c ove ry i n the ac t i on t o i nform at i on re l evantt o the t i m e per i od du ri ng w hi ch W al ker w as e m p lo y e d b y L F M . F in ally, t o d ec id e L F M ’s cr o ss -a p p ea l, w e d eter m in e w h eth erW alk er ’s A m ended C om pl ai ntsa t i sf i es the re qu i re m ent s of R ul e 9(b). I V. ST AN DA RDS OF R EVI EW W e r e vi e w the di s tr i c tc our t ’ s gr a ntof s um m a ry j udgm e ntde novo, appl y i ng the s a m e l e ga l s t a nda r ds tha tbound tha tc our ta nd “ vi e w i ng a l l f a c t s a nd r e a s o n ab le in f

e r e n c e s in th e lig h t m o s t f a v o r ab le to th e n o n m o v in g p a r ty .” Str i c kland v . W

at e rW ork s and Se w e rB d. of

the C i t y of B i r m i ngham , 239 F . 3d11

1199, 1203 ( 11th C i r . 2001) . S um m a ry j udgm e nti s appr opr i a t e w he n “ the r e i s no ge nui ne i s s ue a s t o a ny m a t e r i a l f a c ta nd . . . the m ovi ng pa r ty i s e nt i t l e d t o a j ud gm entas a m att erof l aw . ” F ed. R . C i v. P . 56 (c ). T h e d is tr ic t c o u r t’s d is c o v e ry d e c is io n s a r e r e v ie w e d f o rab u s e o f

d is c r e tio n . See B urger Ki ngC orp. v. W eave r , 1 6 9 F .3 d 1 3 1 0 , 1 3 1 5 ( 1 1 th C ir . 1 9 9 9 ) . W e r e v ie w d e n o v o th e d e n ia l o f a m o tio n to d is m is s . Se e N ol e n v . J ac k s on , 10 2 F . 3d 11 87 , 11 90 (11t h C i r. 19 97 ). V. DI S C US S I ON T h e F al se C l ai m s A ctst at es: A ny pe r s on w ho . . . know i ngl y pr e s e nt s , orc a us e s t o be pres ent ed, t o an o ff

i ce r or e m pl oyee of the U ni t ed S t at es G ove rnm e nt. . . a f

a l s e orf r a udul e ntc l a i m f

orpa y m e ntor appr ova l . . . i s l i abl e t o the U ni t e d S t a t e s G ove rnm e ntf or a c i vi l penal ty of notl es s than $ 5, 00 0 and no tm ore than $10, 000, pl us 3 t i m e s the a m ountof da m a ge s w hi c h the G o v e rn m e n t s u s ta in s b e c a u s e o f th e a c t o f

th a t p e r s o n . . . . 31 U . S . C . § 3729( a ) . T he F a l s e C l a i m s A c ta uthor i z e s pr i va t e c i t i z e ns t o br i ng ac t i on s on b ehal f of the U ni t ed S t at es . 31 U . S . C . § 3 73 0(b). T hese pl ai nt i ff s a re k n o w n as quitam r e l a t o r s . To e s t ab l i s h a c a u s e o f a c t i o n u n d e rth e Fa l s e Cl a i ms A ct , a r el at or m ustprov e three el em ent s: (1) afa l se or fr audu l entcl ai m ; (2) w hi ch w a s pr e s e nt e d, orc a us e d t o be pr e s e nt e d, by the de f e nda ntt o the U ni t e d S t a t e s f or p a y m e n t o rap p r o v a l; ( 3 ) w ith th e k n o w le d g e th a t th e c la im w a s f a ls e . 3 1 U .S .C . § 3729( a ) . R e c ove ry unde rthe F a l s e C l a i m s A c ti s notm e a s ur e d by the a m ountof12

any a ctual dam age are l at or m i gh thave sust ai ned p er sonal l y a s are sul tof a defe nd ant ’ s f

al se cl ai m . R ather, the re l at or st ands i n the shoes of the U ni t ed S t at es gove rnm e nt . S he c a n pr os e c ut e the l a w s ui ton the U ni t e d S t a t e s ’ be ha l f , a nd r e c ove r , f

orthe U ni t e d S t a t e s , the l os s e s a ttr i but abl e t o a ny f r a udul e ntc l a i m a nd the c i vi l pe na l ty a uthor i z e d by the s t a tut e . 31 U . S . C . § 3730. A . T he G r a ntof

S um m a ry J udgm e nt I n th is c a s e , th e d is tr ic t c o u r t g r a n te d s u m m a ry ju d g m e n t f o rL F M b e c a u s e it f ound tha t , a s a m a tt e rof l a w , W a l ke r ’ s c om pl a i nta nd e vi de nc e di d notpr e s e ntthe pos s i bi l i ty of

a f a l s e orf r a udul e ntc l a i m . A s s t a t e d above , the di s tr i c tc our tf ound th a tth e r e g u l a t o ry l a n g u a g e th a tW a l k e rc l a i me d w a s v i o l a t e d w h e n LFM s u b m i tt e d i t s c l a i m s wa s a m b i g u o u s a n d th e r e f o r e c o u l d n o t , a s a m a tt e ro f l a w, se rv e a s th e p re d icate f

o r a fa lse c laim s a ctio n . W e f in d er ro r in th e d istrict co u rt’s r e a s o n in g . F i r s t , w e not e tha tthe di s tr i c tc our tgr a nt e d L F M s um m a ry j udgm e nton W al ker’ s e nt i re com pl ai nteven tho ug h a subsetof the cl ai m s a l l eged by W al ker w e r e a l l e ge dl y s ubm i tt e d a f t e rthe M e di c a r e r e gul a t i on ha d be e n a m e nde d a nd c la r if ie d . Se e s upr a n. 1. A s of J anuary 1, 20 02 (f ou r m on ths before W al ker f i l ed he ror i gi na l c om pl a i nti n thi s c a s e ) , the r e gul a t i on pr ovi di ng c ondi t i ons f or coverage of s ervi ce s r endered “ i nci dentt o the se rvi ce of a physi ci an” w as cl ea r ab o u t th e m e a n in g o f

th a t p h r a s e . A s o f

th a t d a te , a ll s e r v ic e s b ille d a s “in c id e n t to13

the se rvi ce s of aph ys i ci an” m usthave been rendere d u nd era physi ci an’ s “ di re ct supervi si on . ” 42 C F R § 4 10 . 26 (b)( 5) (200 2). In order t o sat i sf y thi s “ di re ct supervi si on ” r equi re m ent , “ the ph ys i ci an m ust[have been] pres enti n the offi ce s ui t e a nd i m m e di a t e l y a va i l abl e t o f urni s h a s s i s t a nc e a nd di r e c t i on thr oughoutthe p e r f o rm a n c e o f

th e p r o c e d u r e .” 4 2 C F R § 4 1 0 .2 6 ( a ) ( 2 ) ( 2 0 0 2 ) , 4 1 0 .3 2 ( b ) ( 3 ) ( ii) ( 2002) . T hi s r e gul a t ory l a ngua ge una m bi guous l y r e qui r e s tha ta phy s i c i a n be pr e s e nti n the of

f i c e . F ur the r m or e , thi s ne w r e gul a t ory l a ngua ge i l l um i na t e s the m ea ni ng of the ph ys i ci an ce rt i fi ca t i on on the H C F A 15 00 form thatthe bi l l ed s e r v i c e s “ w e r e p e r s o n a l l y f u rn i s h e d b y me o rw e r e f u rn i s h e d i n c i d e n tt o my p r o f e s s io n a l s e r v ic e b y m y e m p lo y e e u n d e rm y im m e d ia te p e r s o n a l s u p e r v is io n ,” a t le a s t a s o f

J a n u a ry 1 , 2 0 0 2 . M e di c a r e c l a i m s m a y be f a l s e i f the y c l a i m r e i m bur s e m e ntf ors e r vi c e s or c o s ts th a t e ith e ra r e n o t r e im b u r s ab le o rw e r e n o t r e n d e r e d a s c la im e d . See U ni t ed Stat e s v . C alhoon , 9 7 F .3 d 5 1 8 , 5 2 4 ( 1 1 th C ir . 1 9 9 6 ) ; P eter son v. W ei nb er ger , 508 F . 2d 45 , 52 (5th C i r. 19 75 ). G i ven t he cl ea r def i ni t i on of se rvi ce s r endered

“ i nc i de ntt o the s e r vi c e of a phy s i c i a n” tha tbe c a m e e f f e c t i ve J a nua ry 1, 2002, W al ker s ho ul d b e perm i tt ed t o p re se ntevi dence t o a fa ct -f i nd ersupp ort i ng her a lle g a tio n s th a t a n y M e d ic a r e c la im s L F M s u b m itte d f r o m J a n u a ry 1 , 2 0 0 2 u n til th e d a te o f

h e rc o m p la in t f

o rs e r v ic e s o f

n u r s e p r a c titio n e r s o rp h y s ic ia n a s s is ta n ts14

“ i nci dentt o the se rvi ce of a physi ci an, ” w er e not , i n fac t , re nd er ed i n com pl i ance w i th the appl i cabl e M edi ca re re gu l at i on and, there fore , w er e f al se . A n i ss ue of fa ct a l s o e x i s t s a s t o w h e th e rLFM p h y s i c i a n c e r t i f i c a t i o n s o n th e H CFA 1 5 0 0 f o r ms subm i tt ed fr om Ja nu ary 1, 20 02 un t i l the dat e of W al ker’ s c om pl ai ntw er e f al se . A ddi t i ona l l y , the di s tr i c tc our te rr e d by hol di ng tha ta ny a m bi gui ty i n the e a r lie rv e r s io n o f

4 2 C F R § 4 1 0 .2 6 a n d th e H C F A 1 5 0 0 c e r tif ic a tio n n e c e s s a r ily f o r e c lo s e s , a s a m a tte ro f la w , th e f

a ls ity o f c la im s s u b m itte d b y L F M p r io rto J a nua ry 1, 2002. W e a gr e e tha tthe r e gul a t ory l a ngua ge i n e f f e c tunt i l J a nua ry 1, 20 02 w as am bi gu ou s. B utw e di sa gree as t o the l egal si gn i fi ca nce of that am bi gu i ty. In op po si t i on t o L F M ’ s m ot i on for s um m ary j ud gm ent , W al ker su b m i tt ed p ro v i si o n s fro m th e M ed i care C arri er’ s M an u al , M ed i care b u l l et i n s, s e m i na rpr ogr a m s , a nd e xpe r tt e s t i m ony r e ga r di ng pr ope rbi l l i ng “ i nc i de ntt o the s e r v i c e o f

a p h y s i c i a n , ” a s u s e d i n 4 2 U. S . C . § 4 1 0 . 2 6 . S h e a l s o p r e s e n t e d two n o te s w r itte n b y L F M ’s e m p lo y e e th a t p a r ap h r a s e a b illin g c o n s u lta n t’s a d v ic e . A l l of the s e s our c e s w e r e of

f e r e d t o s how the m e a ni ng of the l a ngua ge i n the re gu l at i on and o n the H C F A 15 00 form and t he re as on abl enes s of L F M ’ s c l ai m ed u n d e r s ta n d in g o f

th a t la n g u a g e . A t le a s t s o m e o f th e s e s o u r c e s w o u ld s u p p o r t a fi nd i ng that , i n the M edi ca re com m un i ty, the l angu age w as un ders t oo d t o m ea n thata physi ci an had t o b e physi ca l l y pre se nti n the offi ce sui t e a nd otherw i se m ore15

i nv ol ved i n a pat i ent ’ s c ou rs e of c ar e than t he L F M ph ys i ci ans w er e. T he di stri ct c our tc ons i de r e d thi s e vi de nc e i rr e l e va nta nd he l d tha t , be c a us e none of i the l d the f o r c e o f la w , it c o u ld n o t b e th e b a s is f o ra f a ls e c la im . A s the di stri ctcourtre cogn i ze d, the S up re m e C ou rthas s t at ed thatagency i nt e rpr e t a t i ons c ont a i ne d i n pol i c y s t a t e m e nt s , m a nua l s , a nd e nf or c e m e nt g u id e lin e s a r e n o t e n title d to th e f o r c e o f la w . C h r is te n s e n v . H

a r r is C o u n ty , 529 U . S . 576, 587, 120 S . C t . 1655, 1662 ( 2000) . F ortha tr e a s on, w e a gr e e w i th the di stri ctcourtthatevi dence of a def endant ’ s f

ai l ure t o com pl y w i th an adm i ni stra t i ve gu i del i ne do es no tnece ss ar i l y e st abl i sh thatthe defendantpres ent ed l egal l y f al se cl ai m s–cl ai m s i n v i ol at i on of a s t atut e or r egul at i on –t o the U ni t ed S t at es . B utthati s notthe i ss ue here. W hati s a ti ss ue i s w hether a ny evi dence out s i de the l a ngua ge of

a M e di c a r e r e gul a t i on ( i nc l udi ng gui da nc e i s s ue d by the gove rnm e nt a l a ge nc y c ha r ge d w i th a dm i ni s t e r i ng the r e gul a t ory s c he m e ) c a n be c ons ul t e d t o unde r s t a nd the m e a ni ng of tha tr e gul a t i on. W e hol d tha ti tc a n. T h e S u p r e m e C o u r t h a s h e ld th a t a g e n c y in te rp r e ta tio n s a r e “e n title d to re spec t. . . t o the ext entthattho se i nt erpret at i on s have the po w ert o p er suade. ” I d. , 120 S . C t . a t1663 ( c i t i ng Ski dm or e v . Sw i f t & C o. , 3 2 3 U .S . 1 3 4 , 1 4 0 , 6 5 S . C t. 1 6 1 , 1 6 4 ( 1 9 4 4 ) ) . O u rp r e c e d e n t is c o n s is te n t. I n d e e d , w e h a v e f o llo w e d th is ru le i n th e c o n t e x to f

M e d i c a r e f

a l s e c l a i ms c a s e s . I n a f f i r mi n g a c r i mi n a l f

a l s e c l a i ms16

c onvi c t i on, thi s c our tl ooke d t o a m a nua l publ i s he d by H C F A t o de t e r m i ne the m ea n in g o f a M ed icar e r eg u lati o n an d es tab li sh th e f alsity o f th e d ef

en d an t’ s c la im s f o rM e d ic a r e r e im b u r s e m e n t. Se e C alhoon , 97 F . 3d a t526 ( c ons ul t i ng the P rovi der R ei m bu rs em entM anual t o d ef i ne the m ea ni ng of a phras e i n the M edi ca re r e g u la tio n s ) . T h e f

a c t th a t th e M e d ic a r e C a rr ie r ’s M a n u a l w a s n o t is s u e d to D ef endant s does notnegat e i t s probat i ve val ue re gardi ng the m ea ni ng of a M e d ic a r e r e g u la tio n . Se e U n ite d S ta te s v . G o ld , 74 3 F . 2d 80 0, 81 6 (11 th C i r. 1984) ( a f f i r m i ng c r i m i na l c onvi c t i on of e y e doc t orf

orM e di c a r e f

r a ud a nd approv i ng adm i ss i on of M edi ca re C arri er ’ s M anual prov i si on s a s e vi dence of w hat types of cl ai m s w er e properl y pay abl e und erM edi ca re ). In a c as e r em arkabl y s i m i l art o thi s one, the E i gh th C i rc ui tre ce nt l y hel d, “ If a s t at em ental l eged t o b e f al se i s a m bi gu ou s, the go vernm ent(or her e, the re l at or) m u s t e s tab lis h th e d e f

e n d a n t’s k n o w le d g e o f

th e f a ls ity o f th e s ta te m e n t, w h ic h it c a n do by i ntr oduc i ng e vi de nc e of how the s t a t e m e ntw oul d ha ve be e n unde r s t ood i n con t ext . ” Mi nne s ota A s s oc . of N urs e A ne s the t is t

s v . A l l i na H

e al th Sys t e m C or

p. , 276 F . 3d 1032, 1053 ( 8th C i r . 2002) ( e m pha s i s a dde d) . I n the M i nne s ot a c a s e , the r e la to ra lle g e d th a t a n e s th e s io lo g is ts b ille d M e d ic a r e a s if th e y h a d “p e r s o n a lly pe r f or m e d” a n e nt i r e a ne s the s i a c a s e orw e r e “ c ont i nuous l y i nvol ve d” i n the pe r f or m a nc e of

tha tc a s e w he n, i n f

a c t , the y w e r e notc ont i nuous l y pr e s e ntdur i ngThe pa rties agreethat, throughout the time period re levant to this lawsuit (wh at ever that 3 might be) , the Medica

re Car rier’ s M anu al s et forth fivecriteria for a serviceto be covered a s “i n ci d entt o th e s erv i ce s o f ap hys i ci an . ” T o b e c o v er ed , a s erv i ce mu s t : (1 ) b e ani nt egr al , al th o u gh i n ci d ent al , p arto f th e p hys i ci an ’s p ro fe s s i o n al s erv i ce ; (2 ) b e c o mm o n l y re n d er edwi th o utch arge or included in the physician’s bill; (3) be of the ty pe commonly

furnished in physicians’ off ices or 17 th e c a s e a n d w e r e in s te a d s im u lta n e o u s ly e n g a g e d in o th e ra c tiv itie s . I d. a t1037, 10 38 . A di stri ctcourtgrant ed the defendant s s um m ary j ud gm entbecause the court c ons i de r e d the M e di c a r e r e gul a t i on’ s phr a s e s “ pe r s ona l l y pe r f or m e d” a nd “c o n tin u o u s ly in v o lv e d ” to b e a m b ig u o u s . I d. a t 1 0 5 2 - 1 0 5 3 . T h e E ig h th C ir c u it r e v e r s e d , s ta tin g , “I f

th e [ r e la to r ] s h o w s th e d e f e n d a n ts c e r tif

ie d c o m p lia n c e w ith the re gu l at i on kn ow i ng thatthe H C F A i nt erpret ed the re gu l at i on s i n a ce rt ai n w ay a nd tha tthe i ra c t i ons di d nots a t i s f y the r e qui r e m e nt s of

the r e gul a t i on a s the H C F A i nt e rpr e t e d i t , a ny pos s i bl e a m bi gui ty of the r e gul a t i ons i s w a t e runde rthe bri dg e. ” I

d. a t1053. T he E i ghth C i r c ui tf ound tha te vi de nc e pr e s e nt e d by the r e la to r( in c lu d in g th e d e f e n d a n ts ’ a tto rn e y ’s a d v ic e , H C F A m e m o r a n d a , a b u lle tin pu bl i shed by the F I, and an A m er i ca n S oci ety of A nesthesi ol og i st s new sl ett er ) w as re l evantt o a det erm i nat i on of the M edi ca re re gu l at i on ’ s m ea ni ng and t hatthere w a s a que s t i on of

f a c ta s t o the de f

e nda nt s ’ unde r s t a ndi ng of the m e a ni ng of

the r e g u la to ry la n g u a g e . I

d. a t1053- 54. In op po si t i on t o L F M ’ s m ot i on for s um m ary j ud gm ent , W al ker pres ent ed p r o v i s i o n s f

r o m th e M e d i c a r e Ca rr i e r ’ s M a n u a l i n u s e d u r i n g th e r e l e v a n tt i me peri od , bu l l et i ns pu bl i shed by the F I ( and rece i ved and m ai nt ai ned b y L F M ) that

3clinics; (4) befurnished under the direc t personal supervision of a physician; and (5) be fur nished by a physic ian o r a

n emp lo yee of a physic ian. Me dic areCarriersMa nu al Part 3, Claims Proc e ss Pub. 14-3 (MCM), § 2050, at 2-19. Th ep arti e s als o agre eth at, s in c eat l e a s t 1 9 9 2 , th eM CMh a s d e f in e d “ dire c t p e r s onal supervision in the offic e setting” to require that “the physician must be present in the officesuite and immediately

availableto provide assistanceand dire ction throughout the time the aide is performing serv ic e s. ”MCM , § 2050.1.B. at 2-20. Th epa rtie s disagre e , h ow e ver, re g ardingtheme ani ngof oth e r l anguag ein t

heMCM , pa rticula rly thelanguag ein M CM, § 2 05 0. 2, that st ate s “ theremus t ha vebe e n a dire c t, p e rs on al, profe ssional servicefurnished by the physician to initiate the cour s e of tre atment of whic h the servicebeingperf

ormed by the nonphysician practitioner is an incidental part, and there must be subsequent ser

vices by the physician of a

frequ en cy

that ref lects his or her

continuing active participation in and manag ement of thecourseof treatment.” Id. at 2-21. 18 pr ovi de gui da nc e on pr ope r“ i nc i de ntt o the s e r vi c e of a phy s i c i a n” bi l l i ng, pr ogr a m s f

ors e m i na r s a tt e nde d by L F M pe r s onne l tha tr e vi e w e d i nf or m a t i on on prop er“ i nci dentt o the se rvi ce of a physi ci an” bi l l i ng , and cop i es of no t es h a n d w r i tt e n b y LFM p e r s o n n e l d o c u me n t i n g c o n v e r s a t i o n s b e tw e e n LFM a dm i ni s tr a t i ve pe r s onne l a nd a bi l l i ng c ons ul t a ntr e ga r di ng the ne e d f orU P I N s f

or p h y s ic ia n a s s is ta n ts a n d n u r s e p r a c titio n e r s . E a c h o f th e s e p ie c e s o f

e v id e n c e is re lev an t t o th e m ea n in g o f th e M ed icar e r eg u lati o n at issu e a n d L F M ’s u n d e r s ta n d in g o f

th a t m e a n in g . Se e G o ld , 7 4 3 F .2 d at 8 1 6 (M ed icar e C ar rier ’s M anual and F I l ett ert o p rovi der properl y a dm i tt ed i nt o evi dence). T aken t og ether, th e y a r e s u f

f ic ie n t to s u p p o r t f

in d in g s th a t th e M e d ic a r e r e g u la tio n r e q u ir e d th a t a phy s i c i a n be phy s i c a l l y pr e s e nti n the of f i c e s ui t e a nd othe rw i s e m or e i nvol ve d i n a p at i en t ’ s co u rse o f care than th e L F M p h ysi ci an s w ere an d th atL F M k n ew o f th ese r e qui r e m e nt s . T hus , the y r a i s e a n i s s ue of f a c ta s t o the f

a l s i ty of L F M ’ s bi l l i ng f

orWalker raise d this i ssu ein h e r ini tial bri e f, but LF M did n ot re sp on d o r o therwisea dd re ss 4 the argument in any

of its briefing . 19 nu rs e pra ct i t i on erand p hysi ci an as si st antse rvi ce s “ i nci dentt o the se rvi ce of a ph ys i ci an. ” S um m ary j ud gm entw as i napp ropri at e. B . T he L i m i ton D i sc ov ery W a l ke ra l s o c ha l l e nge s the di s tr i c tc our t ’ s de c i s i on t o l i m i tdi s c ove ry i n the c a s e t o the da t e r a nge of he re m pl oy m e nta s a nur s e pr a c t i t i one ra tL F M . S he corr ec t l y s t at es that , i f, i n l i m i t i ng the t em po ra l sc op e of di sc ov ery, the di stri ct court“ m ade acl ea r e rr or of j ud gm ent. . . or . . . appl i ed an i ncorrec tl egal s ta n d a r d ,” w e m u s t r e v e r s e th a t d e c is io n . P eat , Inc. v. V

an gu ard R es earc h, Inc. , 378 F . 3d 1154, 1159 ( 11th C i r . 2004) ( c i t i ng A lex a n de rv . Fu lto n C o u n ty , 207 F . 3d 13 03 , 13 26 (11t h C i r. 20 00 )) . 4 W e f in d th a t th e d is tr ic t c o u r t m is c o n s tru e d th e F a ls e C la im s A c t w h e n it l i m i t e d di s c ove ry t o the t e r m of W a l ke r ’ s e m pl oy m e nt . W e the r e f or e r e ve r s e the di sc ov ery order . U nd erthe F al se C l ai m s A ct , any per son m ay se rve a s a quitam r e l a t or . 31 U . S . C . § 3730( b) . T he r e l a t orne e d notha ve a ny r e l a t i on a ta l l t o the d e f e n d a n t. I

d . N e i the ri s the r e a r e qui r e m e nttha tthe r e l a t ors uf f e ri nj ury a tthe h a n d s o f th e d e f e n d a n t in o r d e rto s ta te a c la im u n d e rth e F a ls e C la im s A c t. I d.

“ Th e U n i t e d St a t e s i s th e r e a l p a r ty i n i n t e r e s ti n a q u i t a m a c t i o n u n d e rth e FCA even i f i ti s notcont rol l i ng the l i t i gat i on . ” U ni t ed Stat es ex re l . D i m art i no v.Walker a rgue s th at di sc ov e ry sh ould be allo we d from a s fa r bac k a s 1 99 4, wh e n LF M f ir st 5 hired a physician assist an t (a fa ct that Walker lea rned f rom deposition testimony of LFM’s of

fice administrator). How ever , the Amende d Complaint does not make any alleg ation that a physician assistant or nurse practitioner w as employed at LFM prior to Febr uary 1997. 20 Int el l i gentD ec isi on s, Inc. , 308 F . S upp. 2d. 1318, 1322 n. 8 ( M . D . F l a . 2004) ( c i t i ng U ni t e d Stat e s ex r e l . R odge rs v . A rkans as , 15 4 F . 3d 86 5, 86 8 (8t h C i r. 19 98 ); U ni t e d Stat e s ex r e l . H

y at t v . N or thr op C or

p. , 9 1 F .3 d 1 2 1 1 , 1 2 1 7 n . 8 ( 9 th C ir .1 9 9 6 ) ; U

ni t e d Stat e s ex r e l . Mi lam v . U ni v e rs i t y of T ex as M. D . A nde rs on C an ce r C ent er , 9 6 1 F .2 d 4 6 , 4 8 - 4 9 ( 4 th C ir .1 9 9 2 ) ) . U n d e rth e F e d e r a l R u le s o f C iv il P r o c e d u r e , d is c o v e ry is lim ite d to “m a tte r [ s ], n o t p r iv ile g e d , th a t [ a r e ] r e le v a n t to th e c la im o rd e f e n s e o f a n y p a r ty . .

. . R el evanti nform at i on need no tbe adm i ss i bl e a tthe tri al i f the di sc ov ery app ea rs r e a s o n ab l y c a l c u l a t e d t o l e a d t o th e d i s c o v e ry o f a d mi s s i b l e e v i d e n c e . ” Fe d . R. C iv . P . 2 6 ( b ) ( 1 ) . T h u s , W a lk e rs h o u ld h a v e b e e n p e r m itte d d is c o v e ry o f a ll i n f o r ma t i o n r e l e v a n tt o h e rc l a i ms , o n b e h a l f o f th e U n i t e d St a t e s , th a tf a l s e c l a i ms f o rp a y m e n t w e r e m a d e b y L F M . A n e x a m in a tio n o f

th e A m e n d e d C o m p la in t, th e o p e r a tiv e p le a d in g in th is ca se , dem on stra t es thatW al ker a l l eges thatL F M subm i tt ed fa l se cl ai m s f rom at l e a s tthe t i m e of

W a l ke r ’ s hi r i ng i nt o the unde f i ne d f utur e . P a r a gr aph 11 of

the 5 A m e n d e d C o m p la in t r e c o u n ts a c o n v e r s a tio n th a t W a lk e ra lle g e d ly h a d w ith L F M ’s o f

f ic e m a n a g e r , G a il M a y e r . A s p a r t o f th a t c o n v e r s a tio n , M a y e ra lle g e d ly21

t ol d W a l ke rtha tL F M “ ne ve r ” bi l l e d nur s e pr a c t i t i one ra nd phy s i c i a n a s s i s t a nt s e r vi c e s a s i nde pe nde nts e r vi c e s butr a the ra l w a y s bi l l e d the m a s s e r vi c e s “ i nc i de nt t o the se rvi ce of a physi ci an” a nd thati f L F M w er e t o b i l l the nu rs e pra ct i t i on er a n d p h y s ic ia n a s s is ta n t s e r v ic e s a s in d e p e n d e n t s e r v ic e s , “it c o u ld n o t a f f o r d to em pl oy [W al ker] . ” A m ended C om pl ai nt¶ 1 1. T he sa m e par agraph further a lle g e s , “L F M ’s M e d ic a r e b illin g p r a c tic e s d id n o t c h a n g e s u b s e q u e n t to [W al ker’ s] conv er sa t i on w i th G ai l M ay er . ” I d. P ar agraph 9 o f the A m ended C om pl ai ntst at es , “ S i nce [ W al ker’ s] em pl oym entw i th L F M , L F M has e m pl oyed at l e a s ttw o m or e nur s e pr a c t i t i one r s a nd tw o m or e phy s i c i a n’ s a s s i s t a nt s . ” T hus , the A me n d e d Co mp l a i n td o e s n o tl i mi tth e a l l e g a t i o n s o f f a l s e c l a i ms t o th e t i me pe r i od dur i ng w hi c h W a l ke rw a s e m pl oy e d by L F M . R a the r , i ta l l e ge s a n ongoi ng prac t i ce of fa l se bi l l i ng fr om the t i m e W al ker began w orki ng as a nurse prac t i t i on er atL F M , i n F ebruary19 97 . T he prop ert em po ra l ra ng e f or di sc ov ery i s F ebruary 1 9 9 7 th r o u g h th e d a te o f th e o r ig in a l c o m p la in t. C . T h e D en i al o f th e M o t i o n t o D i sm i ss F i na l l y , L F M c r os s - appe a l s , a r gui ng tha tthe di s tr i c tc our te rr e d i n de ny i ng L F M ’ s F eder al R ul e of C i vi l P roce du re 12 (b)( 6) m ot i on t o d i sm i ss the A m ended C om pl ai nt . T he m ot i on w as grou nd ed on the as se rt i on thatthe A m ended C om pl a i ntf

a i l e d t o pl e a d f

r a ud w i th pa r t i c ul a r i ty a s r e qui r e d by F e de r a l R ul e of C iv il P r o c e d u r e 9 ( b ) . W e f in d th is a r g u m e n t m e r itle s s .22

T hi s i s nota c as e l i ke U n i t ed S ta t es ex rel . C la u sen v. L a b o ra to ry C orpo rat i on of

A m er i ca, Inc. , 290 F . 3d 1301 ( 11th C i r . 2002) , i n w hi c h a

“ corporat e out si der” m ade s pecul at i ve as se rt i on s thatcl ai m s “ m usthave been s ubm i tt e d, w e r e l i ke l y s ubm i tt e d ors houl d ha ve be e n s ubm i tt e d t o the G ove rnm e nt . ” 290 F . 3d at13 11 . N ei ther i s thi s c as e l i ke C orse l l o v. L i ncare, Inc. , 4 2 8 F .3 d 1 0 0 8 (1 1 th C ir. 2 0 0 5 ), in w h ich w e r ec en tl y a ff irm ed th e d istrict co u rt’s di s m i s s a l on the gr ound tha tthe r e l a t or ’ s c om pl a i ntw a s de f i c i e ntunde rR ul e 9( b) b e c a u s e it “f

a ile d to e x p la in w h y h e b e lie v e [ d ] f r a u d u le n t c la im s w e r e u ltim a te ly s u b m itte d .” 4 2 8 F .3 d a t 1 0 1 4 . W al ker’ s c om pl ai nti dent i fi es her a s anu rs e pra ct i t i on erw ho w as em pl oyed atL F M . A m ended C om pl ai nt¶7 . W al ker a l l eges that , du ri ng her e m pl oym entat L F M , she neverhad h erow n U P IN and t hatshe w as i nstruct ed ea ch day “ w hi ch do ct or she w ou l d b e bi l l i ng un der. ” A m ended C om pl ai nt¶¶ 11 , 15 . T he A m ended C o m p la in t a ls o a lle g e s th a t W a lk e rh a d a t le a s t o n e p e r s o n a l d is c u s s io n w ith L F M ’ s of

f i c e a dm i ni s tr a t or( i de nt i f i e d i n the c om pl a i ntby na m e ) dur i ng w hi c h the tw o w om en di sc usse d thatW al ker di d n othave her ow n U P IN , w hether W al ker a n d th e o th e rn u r s e p r a c t i t i o n e r s a n d p h y s i c i a n a s s i s t a n t s s h o u l d h a v e th e i ro wn U P IN s, th at(acco rd i n g t o th e o ffi ce ad m i n i strat o r) L F M b i l l ed al l n u rse pr a c t i t i one ra nd phy s i c i a n a s s i s t a nts e r vi c e s a s r e nde r e d “ i nc i de ntt o the s e r vi c e of a physi ci an, ” that(a l so ac cordi ng t o the offi ce adm i ni stra t or) L F M had “ never”23

bi l l e d nur s e pr a c t i t i one rorphy s i c i a n a s s i s t a nts e r vi c e s i n a nothe rm a nne r , a nd the pr opr i e ty of

the bi l l i ng m e thod. A m e nde d C om pl a i nt¶¶ 10-12. T he s e a l l e ga t i ons a r e s uf f i c i e ntt o e xpl a i n w hy W a l ke rbe l i e ve d L F M s ubm i tt e d f a l s e orf r a udul e nt c la im s f o rs e r v ic e s r e n d e r e d b y n u r s e p r a c titio n e r s a n d p h y s ic ia n a s s is ta n ts “i n cid en t t o th e s er v ice o f a p h ys ician .” T h er ef o re , w e a ff

irm th e d istrict co u rt’s o r d e rd e n y in g L F M ’s m o tio n to d is m is s W a lk e r ’s c o m p la in t. VI . C ON C L US I ON F o rth e r e a s o n s s ta te d ab o v e , w e r e v e r s e th e g r a n t o f s u m m a ry ju d g m e n t in f a v o ro f R & F P r o p e r tie s o f

L a k e C o u n ty , I n c ., f

o r m e r ly k n o w n a s L e e s b u r g F a m ily M e di c i ne . W e f

i nd no e rr ori n the di s tr i c tc our t ’ s de ni a l of R & F P r ope r t i e s of

L a ke C ounty , I nc . ’ s m ot i on t o di s m i s s the A m e nde d C om pl a i nt . F i na l l y , w e c onc l ude tha tthe di s tr i c tc our te rr e d i n l i m i t i ng the t e m por a l s c ope of di s c ove ry a nd r e m a nd f orf ur the rpr oc e e di ngs c ons i s t e ntw i th thi s opi ni on. R E VE R S E D A ND R E MAND E D.