Opinion ID: 772535
Heading Depth: 2
Heading Rank: 1

Heading: Falsity of Claim

Text: 15 The parties do not dispute that a claim for Medicare payment is a claim under the FCA. See United States ex rel. Aflatooni v. Kitsap Physicians Servs., 163 F.3d 516 (9th Cir. 1999). The FCA does not define what types of claims are false. However, a claim may be false even if the services billed were actually provided, if the purported provider did not actually render or supervise the service. See Peterson v. Weinberger, 508 F.2d 45, 52 (5th Cir. 1975) (holding that a defendant was liable under the FCA although services billed to Medicare were performed by qualified people, where the claim forms falsely certified that the defendant was the provider); S. Rep. No. 99-345, at 9 (1986), reprinted in 1986 U.S.C.C.A.N. 5266, 5274 (citing Peterson to support the proposition that a false claim for Medicare reimbursement is actionable). 16 According to the Medicare fiscal intermediary's bulletins, and as found by the district court, box 24k on the HCFA-1500 form is to be filled in with the assigned PIN for the performing physician or supplier. Medicare Special Notice (Medicare Publications, San Francisco, CA), Aug. 1995, at 5; Medicare Bulletin (Chico, CA), Mar. 1993, at 18. Box 33 is for the PIN of the billing entity, which can be either an individual or group, and is labeled Physician's, Supplier's Billing Name, Address, ZIP Code & Phone #; PIN #, GRP #. Medicare Special Notice (Medicare Publications, San Francisco, CA), Aug. 1995, at 6; Medicare Bulletin (Chico, CA), Mar. 1993, at 19-20; HCFA-1500 (Dec. 1990). The district court found, and the parties do not dispute, that Dr. Mackby's PIN was inserted in boxes 24k and 33 on the Asher Clinic forms. 17 While the purpose of box 24k is not specified on the form itself, Medicare bulletins sent to Asher Clinic state that the box is to be used for the PIN of the performing physician or supplier. Placing Dr. Mackby's PIN in box 24k indicated that Dr. Mackby was the performing physician or supplier and therefore constituted a false statement. Box 33 is clearly labeled as requiring the PIN or group number of the physician or supplier providing the treatment, and Dr. Mackby was neither of these. Therefore, placing his PIN number in this box was a false statement as well. 18 Mackby argues that the falsity of the claims submitted by Asher Clinic depends solely upon the technical interpretation of the instructions for the claims because the claims accurately describe physical therapy services that were actually rendered. However, the fact that physical therapy services were actually rendered does not negate Asher Clinic's false representation that Dr. Mackby performed the services described on the claim forms or that those services were rendered incident to Dr. Mackby's supervision. It is the representation of Dr. Mackby's involvement that is false, and that falsity is sufficient to satisfy the first element of an FCA claim. See Peterson, 508 F.2d at 52 (a Medicare claim may be false even if services were provided). 19 Mackby also argues that to sustain an FCA action, a claim must be found to be false under any plausible interpretation, citing United States v. Race, 632 F.2d 1114, 1120 (4th Cir. 1980) and United States v. Anderson, 579 F.2d 455, 460 (8th Cir. 1978). These cases state that in a criminal FCA proceeding, when there are ambiguities as to the falseness of a claim, the government must negative any reasonable interpretation that would make the defendant's statement factually correct. Anderson, 579 F.2d at 460. The Race and Anderson cases are distinguishable from the present case in that they are criminal cases. In those cases, the government had to prove falsity beyond a reasonable doubt. In contrast, the burden of proof in the present case is a preponderance of the evidence. 20 Furthermore, Anderson specifically noted that its standard applied in light of ambiguities in the language of the defendant's certifications to the government. 579 F.2d at 459-60. And, in Race, the court held that the government in effect had conceded that the defendant's construction of the contract language was reasonable; as a result, the government could not negate any reasonable interpretation that would make the defendant's statement factually correct. Race, 632 F.2d at 1120 (quoting Anderson, 579 F.2d at 460). In the present case, the government did not concede that Mackby's interpretation was reasonable, and the district court did not find any ambiguity as to what Mackby claimed. The district court found that the instructions for box 24k required the PIN of the performing physician or supplier, that those for box 33 required the PIN of the billing entity and the identifying information for the physician or supplier, and that Dr. Mackby's PIN did not satisfy either requirement. These findings by the district court are not clearly erroneous.