Opinion ID: 220093
Heading Depth: 1
Heading Rank: 1

Heading: introduction

Text: This matter comes on before this Court on an appeal from an order the District Court entered on May 13, 2010, granting the motion of appellees United Health Group, AmeriChoice, and AmeriChoice-New Jersey (collectively appellees) under Federal Rule of Civil Procedure 12(b)(6) to dismiss Charles Wilkins' and Daryl Willis' (collectively appellants) qui tam action [1] based on the False Claims Act (FCA), 31 U.S.C. § 3729, for failure to state a claim on which relief may be granted. Appellants have alleged that appellees, through their participation in federally funded health insurance programs, certified that they were in compliance with all healthcare laws and regulations even though they knowingly violated several Medicare marketing regulations, resulting in their submission of false claims for payment to the federal government. Appellants further alleged that AmeriChoice-NJ violated the FCA by illegally providing kickbacks in violation of the Medicare Anti-Kickback Statute (AKS), 42 U.S.C. § 1320a-7b, to a New Jersey medical clinic to induce the clinic to switch its patients to AmeriChoice-NJ's Medicare and Medicaid programs. Moreover, appellants have alleged that AmeriChoice-NJ agents violated the AKS by enticing doctors to provide the names of patients eligible for Medicare and Medicaid programs. Thus, this action involves two distinct types of claims with which we will deal separately. In addition to involving two distinct types of claims, the action implicates the two medical programs to which we already have referred, Medicare, a federally subsidized health insurance program for the elderly and certain disabled persons, see 42 U.S.C. § 1395c and d, and Medicaid, a cooperative federal-state public assistance program pursuant to which the federal government makes matching funds available to pay for certain medical services furnished to needy individuals, see 42 U.S.C. § 1396. Some elderly poor are dual eligible under both programs. [2] Though appellants mention both programs in their complaint, this case is essentially a Medicare case arising, as the District Court indicated at the outset of its opinion, out of alleged fraudulent claims to Medicare. United States ex rel. Wilkins v. United Health Group, Inc., Civ. No. 08-3425, 2010 WL 1931134, at , 2010 U.S. Dist. LEXIS 47080, at  (D.N.J. May 13, 2010) ( Wilkins ). The District Court held that appellants' allegations failed to state a plausible claim for relief under the FCA for two reasons: (1) appellants failed to identify a single false claim that appellees submitted to the Government, and (2) the marketing regulations that appellants claimed appellees violated were not relevant to the Government's decision to pay appellees' Medicare claims. In addition, the Court dismissed appellants' AKS claims because they did not include an allegation that appellees certified that they were in compliance with the AKS or that such compliance was a relevant consideration when the Government processed their Medicare claims. Inasmuch as we agree with the Court's disposition of appellants' Medicare marketing regulations claims but disagree with its holding with respect to appellants' AKS claims, we partially will affirm and partially will reverse the Court's May 13, 2010 order and we will remand the case to the District Court for further proceedings.