Court Opinion

ID: 9380011
Source: CourtListenerOpinion
Date Created: 2023-03-16 21:01:22.416229+00
Date Added: 2024-06-11T17:17:06.349003
License: Public Domain

USCA4 Appeal: 21-1765     Doc: 32         Filed: 03/15/2023       Pg: 1 of 21

                                                PUBLISHED

                                 UNITED STATES COURT OF APPEALS
                                     FOR THE FOURTH CIRCUIT

                                                    No. 21-1753

        CHANDRA BALDERSON, on behalf of herself and a class of others similarly situated,

                            Plaintiff - Appellee,

                     v.

        LINCARE INC.,

                            Defendant - Appellant.

                                                    No. 21-1765

        CHANDRA BALDERSON, on behalf of herself and a class of others similarly situated,

                            Plaintiff - Appellant,

                     v.

        LINCARE INC.,

                            Defendant - Appellee.

        Appeals from the United States District Court for the Southern District of West Virginia,
        at Charleston. Thomas E. Johnston, Chief District Judge. (2:19-cv-00666)

        Argued: October 27, 2022                                         Decided: March 15, 2023
USCA4 Appeal: 21-1765     Doc: 32        Filed: 03/15/2023   Pg: 2 of 21

        Before NIEMEYER and RICHARDSON, Circuit Judges, and Michael S.
        NACHMANOFF, United States District Judge for the Eastern District of Virginia, sitting
        by designation.

        Reversed by published opinion. Judge Niemeyer wrote the opinion, in which Judge
        Richardson and Judge Nachmanoff joined.

        ARGUED: David B. Goroff, FOLEY & LARDNER, LLP, Chicago, Illinois, for
        Appellant/Cross-Appellee. Andrew Carver Robey, HISSAM FORMAN DONOVAN
        RITCHIE PLLC, Charleston, West Virginia, for Appellee/Cross-Appellant. ON BRIEF:
        Andrew Gresik, Chicago, Illinois, Lawrence Kraus, FOLEY & LARDNER LLP, Boston,
        Massachusetts, for Appellant/Cross-Appellee. J. Zak Ritchie, Ryan McCune Donovan,
        HISSAM FORMAN DONOVAN RITCHIE PLLC, Charleston, West Virginia, for
        Appellee/Cross-Appellant.

                                                  2
USCA4 Appeal: 21-1765      Doc: 32          Filed: 03/15/2023     Pg: 3 of 21

        NIEMEYER, Circuit Judge:

               Lincare, Inc., a supplier of respiratory-therapy products and services, terminated the

        employment of one of its most productive sales representatives, Chandra Balderson,

        concluding that she had violated Lincare’s “Corporate Health Care Law Compliance

        Program” and “Code of Conduct.” While Balderson does not dispute her conduct, she

        contends that Lincare discriminated against her on the basis of sex because it gave a fellow

        male employee, who had engaged in similar conduct, only a “final written warning.” Based

        on this, she commenced this action against Lincare, alleging that it violated the West

        Virginia Human Rights Act, W. Va. Code § 5-11-9, which is enforced with the

        jurisprudence developed under Title VII of the federal Civil Rights Act of 1964.

               Following a bench trial, the district court found Lincare liable to Balderson and

        awarded her $30,141 in compensatory damages and $120,000 in punitive damages. In its

        opinion, the court concluded that the male employee was indeed an appropriate comparator

        and that Lincare’s proffered explanation for its decision to terminate Balderson’s

        employment was not credible. And to find Lincare liable on the ultimate issue of

        discriminatory intent, the court reasoned that because “the only difference” between the

        comparator’s situation and Balderson’s was that “[the comparator] is male and that Ms.

        Balderson is female,” it followed that “the disparate treatment between [them] was a result

        of discriminatory animus.” The court pointed to no other evidence to support a finding of

        discriminatory animus based on sex.

               On appeal, Lincare contends that there was no evidence of discrimination on the

        basis of sex and that therefore the district court’s finding that it violated the Human Rights
                                                      3
USCA4 Appeal: 21-1765       Doc: 32         Filed: 03/15/2023      Pg: 4 of 21

        Act was clearly erroneous as a matter of fact and erroneous as a matter of law. Balderson

        cross-appealed, contending that the district court erred in determining her compensatory

        damages award.

               While the district court’s findings are entitled to substantial deference, in this case

        the core evidence showed that Balderson was fired by a woman and replaced by a woman

        and that, during the entire process, there was no indication that gender was even remotely

        a factor in Lincare’s decision. Balderson herself acknowledged in her trial testimony that

        during her employment with Lincare, “[n]o one ever made any gender-related comments

        directed at [her]” and that during the entire termination process, there was nothing “about

        [Lincare’s] conduct that led [her] to believe that they were treating [her] differently because

        of [her] gender.” The only explanation Balderson offered to substantiate the claim that

        Lincare had discriminated against her on the basis of sex was her “belie[f]” that she and

        her comparator “were doing the same thing” and the fact that “he’s a man; [she’s] a

        woman.” And the district court relied on this reasoning.

               On this record, while we conclude that Balderson made a persuasive case that firing

        her was probably an unfair business decision, she nonetheless failed to present evidence

        sufficient for a factfinder to conclude that it was the product of discrimination based on

        sex. Accordingly, we reverse. And because of this conclusion, we find Balderson’s cross-

        appeal moot.

                                                      4
USCA4 Appeal: 21-1765      Doc: 32          Filed: 03/15/2023     Pg: 5 of 21

                                                      I

               Lincare is a Florida corporation based in Clearwater, Florida, which does business

        through facilities across the country, including, as relevant here, a facility in Parkersburg,

        West Virginia. The company is a supplier of respiratory-therapy products and services,

        selling, among other things, non-invasive mechanical ventilators to in-home patients on

        their physicians’ orders. In providing ventilators, Lincare’s sales representatives work with

        physicians by, among other things, providing them with guidance as to the information

        necessary for their patients to obtain coverage for the devices from their insurance

        companies or from federal programs such as Medicare.

               Lincare required all employees to be familiar with and to act in compliance with its

        Corporate Health Care Law Compliance Program and Code of Conduct, which include

        specific requirements for ethical employee conduct. The Code of Conduct states that it

        was “designed to aid all Company employees . . . in complying with the increasingly

        complex Health Care Laws” — including the rules and regulations pertaining to Medicare,

        Medicaid, and other government-funded health care programs — “by referencing specific

        written policies and procedures,” compliance with which is “mandatory for Company

        employees.” To serve this purpose, the Code provides a number of examples of prohibited

        conduct, including “[m]isrepresenting a diagnosis for the patient to justify the services or

        equipment furnished” and “[o]ffering or giving valuable property, equipment, services,

        gifts or other benefits to a person in exchange for the referral of patients to the Company.”

        Lincare’s compliance program was overseen by Jennifer Pedersen, who had been Lincare’s

        Chief Compliance Officer since 2000. She oversaw a department with 46 employees, and
                                                      5
USCA4 Appeal: 21-1765      Doc: 32         Filed: 03/15/2023     Pg: 6 of 21

        she and her team conducted approximately 100 compliance investigations each year,

        “investigat[ing] anything that’s reported to [them] that is an actual or perceived violation

        of the healthcare [compliance] program.”

               In November 2015, Chandra Balderson began working as the sales representative

        for Lincare in the Parkersburg market area. Prior to her employment with Lincare, she had

        worked as a respiratory therapist, and she was licensed as a respiratory care therapist in

        West Virginia and Ohio. At Lincare, she became a top-10 performer out of Lincare’s

        approximately 1,800 sales representatives. Consistent with that success, her compensation

        was “heavily weighted towards commission[s]” — in 2018, for example, she earned over

        $80,000 for the year in commissions, in addition to her base salary of around $25,000. As

        the sales representative for the Parkersburg area, Balderson reported to Chad Brady, the

        manager of the Parkersburg center, and she worked closely with him. Her responsibilities

        included, as relevant here, reviewing sales orders for accuracy and completeness. As she

        testified, she would “look at the progress notes to make sure that [the] piece of equipment

        [being ordered] would be covered [by insurance] based on what the physician had

        documented in their progress note” before submitting the order for approval. If the

        progress note did not “contain all the information that would be needed for approval by

        Lincare,” Balderson was trained to “educate the physician on what was missing and what

        was needed to get [the] order completed.” When Balderson was out of the office, Brady

        sometimes filled in and performed this review process, although that task was not part of

        his normal duties. Brady did not have sales responsibility and, accordingly, did not earn

        commissions.
                                                     6
USCA4 Appeal: 21-1765      Doc: 32         Filed: 03/15/2023      Pg: 7 of 21

               In furtherance of its corporate compliance program, Lincare conducted a voluntary

        internal audit of the Parkersburg center in May 2019. That audit revealed, among other

        things, that the files for 19 patients for whom ventilators had been ordered contained a

        handwritten progress note, signed and dated by a physician, with a nearly identical

        statement of why the ventilator was medically necessary. Specifically, while the top

        portion of each progress note had a different patient’s name and identifying information,

        the body of each note appeared to be “cloned” or a “template,” stating exactly or nearly

        exactly:

               Patient is diagnosed with chronic respiratory failure consequent to COPD.
               BIPAP was tried and failed. The ventilator is required to decrease work of
               breathing, improve pulmonary status and interruption of respiratory support
               could lead to serious harm, decline in health status, worsening of condition,
               increase risk of increasing CO2 retention, untimely readmissions, or death.

               The results of this audit were reported to Pedersen, who, as Lincare’s Chief

        Compliance Officer, undertook an investigation to discover the source of the “handwritten

        cloned notes found in patient records that had been submitted to Lincare” for the purchase

        of ventilators. One patient’s file, in particular, led to the answer. It showed that after

        receiving a ventilator order from the physician for that patient, Balderson concluded that

        the order did not have the required documentation needed for approval. In response, she

        sent a fax to the physician’s office on May 2, 2019, with a cover sheet that stated:

               – I need face to face notes within the last 6 months that mention [the
                 patient’s] COPD [diagnosis] and chronic respiratory failure [diagnosis]

               – I need the attached statement added or the progress note signed, dated,
                 and timed with patient’s name and [date of birth] added also

                                                     7
USCA4 Appeal: 21-1765      Doc: 32          Filed: 03/15/2023      Pg: 8 of 21

               – The Trilogy [ventilator] order was missing a few things. I added. Just
                 need [the doctor] to sign [and] date.

        Attached to that fax was (1) an unsigned, handwritten progress note on which the patient-

        information section was blank, and (2) a typewritten statement with a caption stating,

        “Sample documentation for Trilogy/Astral.”          Both of these documents contained

        essentially the same boilerplate language as the other progress notes identified by the audit.

        The patient’s file showed that later on that same day — May 2, 2019 — the physician

        signed and dated the handwritten template progress note that Balderson had sent and added

        the patient’s identifying information. The physician also signed the revised order form and

        had these documents, as well as records from the patient’s recent office visits, faxed back

        to Balderson. Moreover, while the diagnostic codes that the physician included on the

        original order form were codes for COPD and chronic respiratory failure, the patient’s

        office-visit records did not clearly reflect those diagnoses. Instead, they indicated a

        “[p]rimary diagnosis” of “[r]estrictive ventilatory defect,” as well as a diagnosis for

        obstructive sleep apnea. On reviewing these documents, Pedersen concluded that the

        template progress note that the doctor had signed at Balderson’s suggestion was not

        supported by, and indeed was “contradict[ed]” by, the patient’s medical records. Pedersen

        therefore concluded that Balderson had “violated the [company’s compliance] program by

        sending these documents to the physician.”

               Continuing the investigation, Pederson — together with Sandra Moreau, Lincare’s

        Healthcare Services Manager, and Sheila Kalteux, Lincare’s Senior Corporation Counsel

        — traveled from Florida to the Parkersburg center on June 3, 2019. There, they met with

                                                      8
USCA4 Appeal: 21-1765       Doc: 32         Filed: 03/15/2023      Pg: 9 of 21

        Balderson and Brady, as well as other local Lincare employees. When Balderson met with

        the three senior Lincare officials, she acknowledged using the handwritten template

        progress notes to make it easier for the physicians she worked with to order ventilators for

        their patients, and she provided Pedersen with 17 such notes that had been in her sales

        binder. Each note had a header for one of two physician offices with which Balderson

        worked. The patient-information section on each of these forms was blank, but each

        contained the same generic statement of medical necessity that was included in the 19

        completed notes uncovered earlier during the audit. Balderson later acknowledged that she

        had “instructed each physician to include” the language “so that their [ventilator] orders

        would get approved.”

               During the course of the Parkersburg investigation, Pederson also learned that Brady

        had provided “coaching” or “leading” information to physicians by sending physicians a

        document entitled “Good Chart Notes Examples.” That document provided three examples

        of statements sufficient to support a ventilator order:

               Patient evaluated for COPD. Cough has been getting worse over the past 5
               years. Patient has established diagnosis of COPD & Chronic Respiratory
               Failure. Patient requires home ventilator 24/7 to sustain life.

               Patient presents with a history of COPD. This has been a problem for some
               time. It is associated with dyspnea on exertion. Nothing seems to improve
               his/her cough. His/her medication history is remarkable for COPD &
               Chronic Respiratory Failure. Patient requires home ventilator therapy to
               sustain life.

               Patient has a long-standing history of COPD resulting in Chronic Respiratory
               Failure. He/She has chronic elevations of his/her CO2 levels. CPAP/BIPAP
               has been tried but does not lower the CO2 levels in his/her blood. Because
               of his/her condition, I feel that home ventilator therapy is required for his/her
               condition to sustain life.

                                                      9
USCA4 Appeal: 21-1765       Doc: 32          Filed: 03/15/2023      Pg: 10 of 21

        Pederson further learned that some physicians had used the language suggested by Brady

        in substantially similar form.      Finally, she learned that Brady had provided “free

        equipment” to a patient because he failed to “follow the standard protocol for replacing

        equipment [lost in a fire] so that it could be billed to the patient’s payor.”

               At the end of the June 3 investigatory visit, Pedersen made the decision to terminate

        Balderson’s employment for violating Lincare’s corporate compliance program based on

        her use of the template progress notes. At a meeting with Balderson, Brady, Moreau, and

        Kalteux, Pederson informed Balderson that her employment was being terminated for

        “leading” physicians. Pederson later testified that use of such template notes had “always

        resulted in termination” in the past. Indeed, she said specifically that she had “discharged

        a male [employee] . . . pretty close . . . in time to when Ms. Balderson was discharged”

        based on his use of template notes. Pederson also explained why the conduct represented

        such a serious infraction, testifying that because “Medicare administrative contractors

        really caution physicians . . . about not having these templates, [particularly] if the

        documentation is only there to support reimbursement,” the use of the template progress

        notes can “put a physician’s practice at risk” and can also result in “contradictory

        information” being introduced into a patient’s medical record.

               By contrast, Pedersen decided not to terminate Brady’s employment. Instead, she

        gave him a “final written warning,” which stated, “This final written warning is being

        issued to you because you violated Lincare’s policies as they pertain to the Healthcare laws

        and regulations. You wrote information on a fax to a physician that could be considered

        coaching or leading information.        It was also determined that you provided free
                                                      10
USCA4 Appeal: 21-1765      Doc: 32          Filed: 03/15/2023       Pg: 11 of 21

        equipment.” In explaining why she punished Balderson and Brady differently, Pederson

        stated that she determined that Brady’s violation “did not rise to the magnitude” of

        Balderson’s. As she explained:

               The difference between the example notes and the cloned progress notes is
               that the cloned notes were . . . used for a physician to add to a . . . specific
               patient’s record. The [good] chart note examples provide information to a
               physician about the type of information that should be included in a progress
               note if most payers are going to reimburse for that service. . . . [T]hese chart
               note examples are just information to provide to the physician of things that
               could be included if applicable to that patient. That’s not to say that this was
               right. We have educational brochures that could have been used instead of
               this.

               After terminating Balderson’s employment, Lincare hired a woman to serve as the

        new sales representative for the Parkersburg market area.

               Balderson commenced this action against Lincare in West Virginia state court in

        August 2019, on her own behalf and on behalf of others similarly situated, alleging that

        Lincare had violated the West Virginia Patient Safety Act and the West Virginia Wage

        Payment and Collection Act. After Lincare removed the action to federal court on the basis

        of diversity jurisdiction, Balderson added a claim under the West Virginia Human Rights

        Act for discrimination on the basis of sex and dropped her class allegations.

               The district court granted Lincare’s motion for summary judgment on all claims

        except for the discrimination claim, and with respect to that claim, it conducted a bench

        trial in October 2020. By a memorandum opinion dated June 7, 2021, the court granted

        judgment to Balderson and awarded her $30,141 in compensatory damages and $120,000

        in punitive damages, as well as attorneys fees and costs.

                                                     11
USCA4 Appeal: 21-1765      Doc: 32          Filed: 03/15/2023      Pg: 12 of 21

               In conducting its analysis under the West Virginia Human Rights Act, the court

        employed the burden-shifting analysis used in federal Title VII cases, as required by West

        Virginia law. See, e.g., Barefoot v. Sundale Nursing Home, 457 S.E.2d 152, 159–60 (W.

        Va. 1995). The district court held that Balderson had established a prima facie case, finding

        (1) that, as a female, she was a member of a protected group; (2) that she was discharged

        from her employment; and (3) that a male employee — Brady — was disciplined less

        severely than her, even though “both engaged in similar conduct.” The court recognized

        that Balderson had to support the inference of discrimination by showing that Brady was

        similarly situated to her in all relevant respects, and it found that Brady was indeed “an

        appropriate comparator,” as “[t]heir relevant conduct [was] nearly indistinguishable.” It

        observed that “Lincare’s attempt to distinguish the two by characterizing Mr. Brady’s

        conduct as providing [only] ‘examples’ [was] merely semantics.”              The court thus

        concluded that Balderson had “proved her prima facie case of gender discrimination based

        on disparate treatment.”

               Next, the court found that even though Lincare had “articulated a legitimate, non-

        discriminatory reason for Ms. Balderson’s discharge from employment” — namely, that

        she violated the company’s compliance program — that reason was pretextual because

        “Lincare’s explanation [was] simply not credible.” To reach that conclusion, the court

        gave three reasons. First, it observed that Lincare had “shifted its justification” for firing

        Balderson over the course of the litigation, stating first that it had fired Balderson because

        she was “leading” physicians and then stating later that it fired her for “[m]isrepresenting

        a diagnosis or falsifying documents” based on the fax cover sheet she had sent to a
                                                     12
USCA4 Appeal: 21-1765      Doc: 32         Filed: 03/15/2023      Pg: 13 of 21

        physician’s office. Second, the court found that Lincare’s argument that Balderson’s

        conduct “could have violated or actually did violate various healthcare laws” was belied

        by the fact that Lincare had failed to report her conduct to the U.S. Department of Health

        and Human Services, as it was required to do under a Corporate Integrity Agreement with

        the agency. Finally, and most “critical” according to the court, it found that pretext was

        demonstrated by the difference in Lincare’s discipline of Brady and Balderson, despite the

        fact that Brady’s conduct was “at least comparable.”

               Having concluded that Balderson had established a prima facie case and that

        Lincare’s response was “merely pretextual,” the court found by a preponderance of the

        evidence that Lincare’s “disparate treatment between Ms. Balderson and Mr. Brady was a

        result of discriminatory animus.” In reaching this conclusion, it stated that it was entitled

        to “infer the ultimate fact of sex discrimination” simply upon finding that Balderson had

        established a prima facie case and that Lincare’s proffered reason for her termination was

        pretextual, citing St. Mary’s Honor Center v. Hicks, 509 U.S. 502, 510–11 (1993), and

        Jiminez v. Mary Washington College, 57 F.3d 369, 378 (4th Cir. 1995). The court stated

        that “the only difference between Mr. Brady’s situation and Ms. Balderson’s is that Mr.

        Brady is male and that Ms. Balderson is female” and therefore, it reasoned, their different

        punishments could only be explained by the difference in their sex.

               From the district court’s judgment, Lincare filed this appeal. Balderson filed a

        cross-appeal, challenging the amount that the district court awarded her in compensatory

        damages.

                                                     13
USCA4 Appeal: 21-1765        Doc: 32          Filed: 03/15/2023       Pg: 14 of 21

                                                        II

               Lincare contends that the district court clearly erred (1) in concluding that a

        “similarly-situated male” was treated differently than Balderson and, in any event, (2) in

        disregarding evidence that Balderson’s termination “had nothing to do with gender

        discrimination” but instead was a business judgment made to enforce its compliance

        program. In essence, these challenges focus on (1) the requirement that, as an element of

        the prima facie case for discriminatory treatment, Balderson show that Brady was a

        comparator similarly situated to her “in all relevant respects” and (2) the ultimate

        requirement that to prove her claim, Balderson show, at least by inference, “discriminatory

        animus” — that is, the intent to discriminate because of sex.

               The West Virginia Human Rights Act makes it unlawful “[f]or any employer to

        discriminate against an individual with respect to . . . tenure . . . if the individual is able and

        competent to perform the services required.”           W. Va. Code § 5-11-9(1).         The term

        “discriminate” is defined by the Act to mean “to exclude from, or fail or refuse to extend

        to, a person equal opportunities because of . . . sex,” or another prohibited ground. Id. § 5-

        11-3(h). The Supreme Court of Appeals of West Virginia has held that cases brought under

        the Act are “governed by the same analytical framework and structures developed under

        Title VII” of the Civil Rights Act of 1964, including the same “burden-shifting . . .

        framework for analyzing pretext claims.” Barefoot, 457 S.E.2d at 159–60 (citing St.

        Mary’s Honor Ctr., 509 U.S. 502, and others). As the Barefoot court outlined, following

        the Supreme Court’s Title VII cases, the “plaintiff must first create an inference of

        discrimination by establishing a prima facie case.” Id. at 160. “The burden of production
                                                        14
USCA4 Appeal: 21-1765      Doc: 32          Filed: 03/15/2023      Pg: 15 of 21

        then shifts to the defendant to proffer a legitimate, nondiscriminatory reason for the

        challenged employment action.” Id. “Finally, the plaintiff then is accorded an opportunity

        to demonstrate that either age, gender, or ancestry was a determinative factor in the

        defendant’s employment decision or the defendant’s articulated rationale was merely a

        pretext for discrimination.” Id.

               The U.S. Supreme Court in Reeves v. Sanderson Plumbing Products, Inc., 530 U.S.

        133 (2000), explained the holding of St. Mary’s Honor Center in more detail:

               There [in St. Mary’s Honor Center] we held that the factfinder’s rejection of
               the employer’s legitimate, nondiscriminatory reason for its action does not
               compel judgment for the plaintiff. The ultimate question is whether the
               employer intentionally discriminated, and proof that “the employer’s
               proffered reason is unpersuasive, or even obviously contrived, does not
               necessarily establish that the plaintiff’s proffered reason is correct.” In other
               words, “it is not enough to disbelieve the employer; the factfinder must
               believe the plaintiff’s explanation of intentional discrimination.”

        Id. at 146–47 (cleaned up) (quoting St. Mary’s Honor Ctr., 509 U.S. at 524, 519).

               The district court purported to follow this structure but, we conclude, erred both

        factually and legally. First, it clearly erred in concluding that the conduct of Balderson and

        Brady was “nearly indistinguishable.” Second, it erred in concluding that because it had

        found that at least some of Lincare’s proffered reasons for firing Balderson were false,

        those reasons were necessarily a pretext for the real reason of discriminating on the basis

        of sex. And finally, it erred in concluding that Balderson had carried the burden of

        demonstrating intentional discrimination, especially because Balderson herself denied that

        anything was ever said or done to make her think at the time that her gender had played

        any role in her employment or in the termination of her employment. On this last point,

                                                      15
USCA4 Appeal: 21-1765      Doc: 32          Filed: 03/15/2023      Pg: 16 of 21

        the court proceeded from the premise that if Balderson proved both a prima facie case and

        that the reasons given by Lincare were pretextual, then unlawful discrimination must

        automatically follow. Reeves, however, specifically rejected that reasoning.

               Without the need to address whether the district court clearly erred in finding that

        Balderson had established a prima facie case and that Lincare’s proffered reasons were

        false, we conclude that the Reeves error is dispositive. Specifically, the district court

        assumed that because it had found (1) that Balderson had proved a prima facie case of

        disparate treatment and (2) that Lincare’s explanation was not credible, it necessarily

        followed that it was permitted, without more, to “infer the ultimate fact of sex

        discrimination.”   This legal analysis failed to faithfully apply the Supreme Court’s

        prescriptions, as incorporated into West Virginia law.

               In Reeves, the Supreme Court specifically addressed the question of “whether a

        plaintiff’s prima facie case of discrimination . . . , combined with sufficient evidence for a

        reasonable factfinder to reject the employer’s nondiscriminatory explanation for its

        decision, is adequate to sustain a finding of liability for intentional discrimination.” 530

        U.S. at 140. The Court’s conclusion was that such a showing may be sufficient but that it

        is not necessarily so — it depends on the circumstances. The Court thus recognized that

        while there will be cases in which the “trier of fact [can] infer the ultimate fact of

        discrimination” from the combination of the plaintiff’s prima facie case and “the

        factfinder’s disbelief of the reasons put forward by the defendant,” id. at 147 (cleaned up),

        it does not follow that “such a showing by the plaintiff will always be adequate to sustain

        a [factfinder’s] finding of liability,” id. at 148. Instead, the Court observed, there will
                                                     16
USCA4 Appeal: 21-1765       Doc: 32          Filed: 03/15/2023      Pg: 17 of 21

        “[c]ertainly . . . be instances where, although the plaintiff has established a prima facie case

        and set forth sufficient evidence to reject the defendant’s explanation, no rational factfinder

        could conclude that the action was discriminatory.” Id. (emphasis added).

               The district court failed to recognize this possibility and to address it in light of the

        circumstances presented. Had it done so, it would have been compelled to conclude that

        Balderson’s case was one of the type recognized in Reeves, in which a prima facie showing

        of a similar comparator, combined with reasons to doubt the employer’s explanations, is

        not sufficient to support a finding on the “ultimate” issue — the employer’s discriminatory

        intent. Here, while Balderson had presented sufficient evidence to prove that Lincare’s

        decision to terminate her employment was unwise and even unfair, she failed at any stage

        to provide a basis for inferring that her discharge had anything to do with her sex. In

        nonetheless holding Lincare liable, the court summarily concluded that Balderson had

        proved “discriminatory animus” because she and Brady were disciplined differently and

        “Mr. Brady is male [while] Ms. Balderson is female.” This truncated reasoning was not

        sufficient to support a conclusion that Lincare intentionally discriminated against

        Balderson because of her sex.

               Balderson presented no evidence, explicit or implied, that would allow a factfinder

        to find that sex played any role in Lincare’s decision to terminate her employment. In her

        trial testimony, Balderson herself agreed that in her experience at Lincare before her

        termination, sex was never an issue — that “[n]o one ever made any gender-related

        comments directed at [her].” She also testified that during the termination process, which

        involved Pederson’s interview of her and a meeting with Brady, Pederson, and two other
                                                      17
USCA4 Appeal: 21-1765      Doc: 32          Filed: 03/15/2023      Pg: 18 of 21

        senior Lincare officers, there was nothing “about [their] conduct that led [her] to believe

        that they were treating [her] differently because of [her] gender.” Moreover, Pederson and

        her two colleagues who conducted the investigation leading to Balderson’s termination

        were all female, and Lincare hired a female to replace Balderson. In short, there was no

        evidence that would permit the inference that gender was at play at any point during

        Balderson’s employment and the process of her termination. Yet, as Reeves makes clear,

        “although intermediate evidentiary burdens shift back and forth,” Balderson retained “the

        ultimate burden” to establish that Lincare intentionally discriminated against her on the

        basis of sex. Reeves, 530 U.S. at 143 (cleaned up). “In other words, it is not enough to

        disbelieve the employer; the factfinder must believe the plaintiff’s explanation of

        intentional discrimination” — in this case, that Lincare fired Balderson because of her sex.

        Id. at 147 (cleaned up).

               Not only was the record bare of evidence that Balderson’s sex played a role in her

        termination, the district court clearly erred in finding, as the core of its cursory analysis,

        that the two employees’ circumstances were “nearly indistinguishable.” Based on that

        finding, the court essentially reasoned that the disparity of their punishments could only be

        explained as sex discrimination. That finding, however, does not fit the facts.

               While Brady and Balderson engaged in similar conduct in providing “leading”

        information to physicians, it is just not the case that the “only difference” between them

        was sex. Balderson was a sales representative who, because she earned the majority of her

        compensation from commissions, had a direct financial incentive to increase her sales as

        much as possible, including by reducing any friction in a sale’s being completed.
                                                     18
USCA4 Appeal: 21-1765      Doc: 32         Filed: 03/15/2023     Pg: 19 of 21

        Moreover, under the agreement between Balderson and Lincare governing her receipt of

        commissions, she could only receive such payments if she “personally obtain[ed] all . . .

        billing pre-requisites” necessary for Lincare to receive payment from the patient’s

        insurance provider, including a statement from the doctor explaining why the product was

        medically necessary. And, as a normal part of her job duties, when the Parkersburg center

        received a ventilator order from a physician’s office, Balderson was charged with

        “review[ing] [the] order for accuracy and completeness” and “look[ing] at the progress

        notes to make sure that [the] piece of equipment would be covered [by insurance] based on

        what the physician had documented in their progress note” before submitting the order for

        approval. If a progress note did not “contain all the information that would be needed for

        approval by Lincare,” Balderson had been trained to “educate the physician on what was

        missing and what was needed to get [the] order completed.”

               By contrast, Brady’s job description made clear that, as the Parkersburg center’s

        manager, he did not have “sales responsibility” and, consistent with that, he did not earn

        commissions. Moreover, while Brady would sometimes review ventilator orders for

        completeness if Balderson was out of the office, that only happened “one or two times

        every [two or] three months,” and conducting such a review was not “part of [his] normal

        job duties.”

               In addition to this major difference with respect to their respective job

        responsibilities and the nature of their positions, the conduct for which they were

        disciplined also differed. During Pedersen’s investigation of the origin of the cloned notes

        found in 19 patient files, Balderson admitted that she had regularly been using the
                                                    19
USCA4 Appeal: 21-1765      Doc: 32          Filed: 03/15/2023     Pg: 20 of 21

        handwritten template progress notes for some one-and-a-half to two years prior to her

        termination, knowing that the template notes would be added directly to patient files once

        they were signed by the physician. Pederson later testified that by sending such notes to

        physicians, Balderson had “significantly . . . put [the] physician[s’] practice at risk.” In

        addition, she indicated that the use of such notes also increased the risk of inaccurate

        information being introduced into the documentation used to justify payments from

        insurance companies and the government. Brady, on the other hand, was found to have

        sent physicians a page with three different “Good Chart Notes Examples.” (Emphasis

        added). While Brady likely should have foreseen that some physicians would use the

        language from those examples “in a substantially similar form,” as the investigation indeed

        revealed had been done, Brady, as the district court noted, “never intended physicians to

        use his example language as a ‘word-for-word copy/paste’ template.”              Yet, it was

        undisputed that Balderson had that exact intent, and she actually kept copies of blank

        template notes in her possession with the intent to facilitate physicians’ use of them.

               Thus, although the district court concluded that Brady’s and Balderson’s relevant

        conduct was not just similar but “nearly indistinguishable” and even “the same,” the record

        and the court’s own underlying findings do not support that conclusion. As such, that

        finding, which lay at the heart of the district court’s analysis, was clearly erroneous. Under

        the facts as proved, Lincare could have reasonably concluded — as Pedersen testified that

        she had concluded — that the difference between the two practices was material.

        Moreover, even if the district court was convinced that Balderson’s and Brady’s conduct

        was so similar that fairness required them to receive the same discipline, the question for
                                                     20
USCA4 Appeal: 21-1765      Doc: 32          Filed: 03/15/2023     Pg: 21 of 21

        the court was not whether Lincare had made a good, equitable, or even fair decision. It

        was instead whether the actual reason for their disparate discipline was that Balderson was

        a woman and Brady was a man.

               While Balderson may have made a case that Lincare’s decision to fire her was a

        poor one and not in the best interests of the company — a proposition with which we might

        agree, especially in view of the fact that Balderson was such a valuable producer for the

        company and the incident in this case was her first infraction — that does not lead to the

        conclusion that Balderson was discharged because of her sex. Because there is no evidence

        to support that finding, we reverse the judgment of the district court.

                                                                                     REVERSED

                                                     21