Opinion ID: 2722147
Heading Depth: 3
Heading Rank: 2

Heading: Upcoding

Text: The complaint alleges that Planned Parenthood scheduled large numbers of clients for visits during the short windows of time in which physicians would be available at the clinics. Thayer contends that Planned Parenthood then violated the FCA by “bill[ing] visits . . . as problem visits, using CPT codes 99212-99215 (for existing patients) and 99201-99205 (for new patients) for services performed during this window of time even though the physician would usually only briefly look into -9- the room from the hallway at the client or not even see the client[.]” In addition, Thayer alleges that Planned Parenthood used problem codes in billing even “where the client had no medical problem and was only seeking family planning services[.]” These allegations also fail to satisfy Rule 9(b). Although Thayer is not required to plead representative examples of the false claims, she still is required to plead the particular details of the scheme to submit false claims. Thayer’s conclusory and generalized allegations that Planned Parenthood violated the FCA by engaging in upcoding do not meet this requirement. For example, Thayer failed to allege when or how often upcoding took place at the various clinics, who or how many physicians engaged in upcoding, or what types of services were involved in the upcoding scheme. Moreover, instead of alleging what monies were fraudulently obtained as a result of the alleged upcoding, Thayer merely contends that “the United States and Iowa have been damaged in an amount to be proven at trial.” We thus affirm the dismissal of Thayer’s upcoding allegations.3