Court Opinion

ID: 4421675
Source: CourtListenerOpinion
Date Created: 2019-07-31 19:00:42.701105+00
Date Added: 2024-06-11T14:51:35.198749
License: Public Domain

Case: 16-17059       Date Filed: 07/31/2019       Page: 1 of 20

                                                                        [DO NOT PUBLISH]

                  IN THE UNITED STATES COURT OF APPEALS

                            FOR THE ELEVENTH CIRCUIT

                               ________________________

                                     No. 16-17059
                               ________________________

                          D.C. Docket No. 1:13-cv-23671-MGC

THOMAS BINGHAM,

                                                                           Plaintiff-Appellant,

                                             versus

HCA, INC.

                                                                          Defendant-Appellee

                               ________________________

                      Appeal from the United States District Court
                          for the Southern District of Florida
                            ________________________

                                        (July 31, 2019)

Before MARCUS, BLACK, and WALKER,∗ Circuit Judges.

WALKER, Circuit Judge:

       ∗ John M. Walker, Jr., United States Circuit Judge for the Second Circuit, sitting by
designation.
               Case: 16-17059        Date Filed: 07/31/2019   Page: 2 of 20

        This is a qui tam action brought under the False Claims Act by Plaintiff-

Appellant Thomas Bingham (“Relator”) against Defendant-Appellee HCA, Inc.

(“HCA”). HCA is a healthcare services provider that owns and operates hospitals

and surgery centers throughout the United States. Relator’s claims relate to the

Centerpoint Medical Center in Independence, Missouri (the “Centerpoint Claims”)

and the Aventura Hospital in Aventura, Florida (the “Aventura Claims”). On

November 4, 2016, the district court (Cooke, J.) entered judgment in favor of HCA

following its grant of summary judgment on the Centerpoint Claims and dismissal

of the Aventura Claims on the pleadings. Relator appeals, arguing that the district

court erred in granting both motions. For the reasons set forth below, we AFFIRM

the judgment of the district court.

                                I.       BACKGROUND

        We begin with a brief overview of the False Claims Act, then describe the

factual premise of Relator’s claims, and conclude with the procedural history of the

case.

           A. Relator’s Claims Under the False Claims Act

        “The False Claims Act is the primary law on which the federal government

relies to recover losses caused by fraud.” McNutt ex rel. United States v.

Haleyville Med. Supplies, Inc., 423 F.3d 1256, 1259 (11th Cir. 2005). The False

Claims Act “permits private persons to file a form of civil action (known as qui

                                              2
              Case: 16-17059     Date Filed: 07/31/2019     Page: 3 of 20

tam) against, and recover damages on behalf of the United States from, any person

who . . . ‘knowingly presents, or causes to be presented . . . a false or fraudulent

claim for payment or approval . . . [or] knowingly makes, uses, or causes to be

made or used, a false record or statement to get a false or fraudulent claim paid or

approved by the Government.’” United States ex rel. Clausen v. Lab. Corp. of Am.

Inc., 290 F.3d 1301, 1307 (11th Cir. 2002) (quoting 31 U.S.C. § 3729(a)(1)–(2)).

For his services, the relator is entitled to a substantial percentage of the recovery.

31 U.S.C. § 3730(d).

      Relator’s claims under the False Claims Act are for certain allegedly

improper Medicare payments received by HCA. The claims are predicated on his

assertion that HCA violated the Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b)

(“AKS”), and 42 U.S.C. § 1395nn(a) (the “Stark Statute”), by providing sweetheart

deals to certain physicians who leased space in medical office buildings developed

by HCA in exchange for patient referrals from those physicians. Noncompliance

with either statute is a bar to the receipt of Medicare payments, and therefore a

violation of either statute can form the basis of liability under the False Claims Act

for past Medicare payments attributable to the violations. United States ex rel.

Bingham v. HCA, Inc., No. 13-23671-CIV, 2016 WL 344887, at *2 (S.D. Fla. Jan.

28, 2016).

                                           3
             Case: 16-17059     Date Filed: 07/31/2019   Page: 4 of 20

         B. The Centerpoint Claims

      In 2003, HCA began to develop the Centerpoint Medical Center, a new

hospital and medical office building (“MOB”) in Independence, Missouri. HCA

hired Tegra Independence Medical Surgical, L.C. (“Tegra”), a third-party

developer, to develop the MOB. As part of the development project, Tegra leased

out space in the MOB to physicians. In 2012, Tegra sold the MOB for $50 million.

Relator alleges that as part of the development of the MOB, HCA paid Tegra $4

million in allegedly improper subsidies, primarily through an initial lease and an

arrangement involving parking facilities at the MOB, which Tegra passed on to

physician tenants through payments under Cash Flow Participation Agreements

(“CFPAs”) between Tegra and physician tenants, low initial lease rates, restricted

use waivers, and free office improvements. In exchange, Relator alleges, HCA

received $260 million in Medicare and Medicaid payments from patients referred

to HCA’s hospital by the physician tenants.

      Tegra offered CFPAs to any physician tenant who would sign a ten-year

lease. The CFPA entitled the physician tenant to a pro-rata share of the property’s

operating cash flow, including proceeds from any sale of the building. A project

manager for Tegra stated in an affidavit that a “ten-year lease term was longer than

the average lease term in the market at the time the CFPAs were negotiated and

executed.” App’x 117-6 ¶ 21. The formula used to calculate a physician tenant’s

                                          4
             Case: 16-17059     Date Filed: 07/31/2019   Page: 5 of 20

payout under his or her CFPA depended on the amount of space that person leased.

The leases entered into in 2006 and 2007 between Tegra and physician tenants who

also signed on to CFPAs provided for a rental rate of $18.90 per square foot.

      On January 1, 2005, an appraiser engaged by HCA, Holladay Properties

(“Holladay”), performed a market rent study on the rental space in the MOB and

concluded that the fair market rent range was $14.50 to $19.00 per square foot. This

study assumed free parking and did not take into account the CFPAs. In June 2005,

that appraisal was updated to reflect, among other things, Tegra’s use of the CFPAs,

and confirmed that the fair market rent range was still $14.50 to $19.00 per square

foot. In 2007, Holladay certified that the business and lease terms were consistent

with fair market value, signed the study, and provided it to HCA.

      On June 18, 2007, Holladay prepared a Standard Business and Lease Terms

Memorandum. The memorandum noted that the CFPAs were being offered to

physician tenants and concluded that the fair market rent range was $21.50 to

$23.50 per square foot. The memorandum stated that the increase in rental rates

was due to higher construction costs.

      Relator also alleges that HCA gave physician tenants restricted use waivers

and free office improvements. In support, he points to one example in which a

doctor wanted to install a digital rad machine, which, because it was non-standard,

required modifications to his suite as well as the approval of HCA, as the operator

                                         5
              Case: 16-17059    Date Filed: 07/31/2019   Page: 6 of 20

of the hospital. Relator alleges that HCA, rather than physician tenants, made free

improvements to office spaces, based on the fact that the general contractor who

worked with HCA applied for the building permits, and HCA was shown as the

“owner” on the building permits, many of which were filed prior to the start of the

physician tenant’s lease.

         C. The Aventura Claims

      The Aventura Hospital is a hospital complex in Aventura, Florida that is

owned and operated by HCA. In 2002, HCA recruited the Greenfield Group

(“Greenfield”) to develop a MOB adjacent to the Aventura Hospital. The alleged

Aventura arrangement was broadly similar to the alleged Centerpoint arrangement.

Relator alleges that HCA financed and subsidized Greenfield through a ground

lease and development agreement. In 2007, Greenfield sold the MOB, and Relator

alleges that profits were paid to physician tenants who partnered with Greenfield.

Relator also alleges that HCA provided direct remuneration to referring physician

tenants, including free parking rights and benefits, below market rents, subsidized

common area maintenance, and free use permissions. Procedural History

      On August 15, 2014, Relator filed his First Amended Complaint (“FAC”),

and on February 23, 2015, the United States declined to intervene in the suit, as

permitted by the False Claims Act. See 31 U.S.C. § 3730. On July 22, 2015, the

parties jointly moved to stay discovery pending resolution of HCA’s anticipated

                                          6
              Case: 16-17059    Date Filed: 07/31/2019    Page: 7 of 20

motion to dismiss. The district court denied that motion, and discovery began.

HCA then moved to dismiss Relator’s complaint. On January 28, 2016, the district

court dismissed the Aventura Claims without prejudice for failure to comply with

Rule 9(b) of the Federal Rules of Civil Procedure but allowed the Centerpoint

Claims to continue. On March 8, 2016, Relator filed his Second Amended

Complaint (“SAC”), which included additional facts pertaining to the Aventura

Claims. Thereafter, HCA moved for summary judgment on the Centerpoint

Claims. On April 6, 2016, the district court, following a hearing, granted that

motion. Finally, on October 14, 2016, the district court granted HCA’s motion to

strike impermissible facts in Realtor’s SAC and dismissed the repleaded Aventura

Claims. On November 4, 2016, the district court entered a final judgment that

dismissed the Aventura Claims on the pleadings and granted summary judgment to

HCA on the Centerpoint Claims. This appeal followed.

                                II.   DISCUSSION

      On appeal, Relator argues that the district court erred in entering final

judgment in favor of HCA on both the Centerpoint and Aventura Claims. We find

no error and affirm the district court’s judgment.

                                          7
              Case: 16-17059    Date Filed: 07/31/2019   Page: 8 of 20

         A. Centerpoint Claims

                i. Standard of Review

      “We review the district court’s grant of summary judgment de novo,

applying the same legal standards that bound that court and viewing all facts and

reasonable inferences in the light most favorable to the nonmoving party.” United

States ex rel. Walker v. R&F Props. of Lake Cty., Inc., 433 F.3d 1349, 1355 (11th

Cir. 2005) (internal quotation marks omitted). “Summary judgment is appropriate

‘if the movant shows that there is no genuine dispute as to any material fact’ such

that ‘the movant is entitled to judgment as a matter of law.’” United States ex rel.

Phalp v. Lincare Holdings, Inc., 857 F.3d 1148, 1153 (11th Cir. 2017) (quoting

Fed. R. Civ. P. 56(a)). “Genuine disputes are those in which the evidence is such

that a reasonable jury could return a verdict for the non-movant. For factual issues

to be considered genuine, they must have a real basis in the record.” Ellis v.

England, 432 F.3d 1321, 1325–26 (11th Cir. 2005) (internal quotation marks

omitted). The appeals court “will affirm a grant of summary judgment if it is

correct for any reason.” United States v. $121,100.00 in U.S. Currency, 999 F.2d
1503, 1507 (11th Cir. 1993).

                ii. Anti-Kickback Statute Claims

      Relator’s first claim under the False Claims Act is predicated on his

allegation that HCA violated the AKS. See 42 U.S.C. § 1320a-7b(b). The AKS

                                          8
              Case: 16-17059      Date Filed: 07/31/2019    Page: 9 of 20

“broadly forbids kickbacks, bribes, and rebates in the administration of

government healthcare programs.” Carrel v. AIDS Healthcare Found., Inc., 898
F.3d 1267, 1272 (11th Cir. 2018). In relevant part, it provides that “[w]hoever

knowingly and willfully offers or pays any remuneration (including any kickback,

bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any

person to induce such person . . . to refer an individual to a person for the

furnishing or arranging for the furnishing of any item or service for which payment

may be made in whole or in part under a Federal health care program . . . shall be

guilty of a felony.” 42 U.S.C. § 1320a-7b(b)(2)(A).

      An AKS violation thus requires that there be “remuneration” offered or paid

in the transaction at issue. Because “remuneration” is not specifically defined in

the statute, we must turn to “the common usage of words for their meaning.” In re

Walter Energy, Inc., 911 F.3d 1121, 1143 (11th Cir. 2018) (internal quotation

marks omitted). “To determine the ordinary meaning of a term, we often look to

dictionary definitions for guidance.” Id. Black’s Law Dictionary defines

“remuneration” in pertinent part as “[p]ayment; compensation.” Remuneration,

Black’s Law Dictionary (11th ed. 2019). Compensation, in turn, cannot be given

unless some sort of benefit is conferred. See, e.g., Compensation, Black’s Law

Dictionary (11th ed. 2019) (“Remuneration and other benefits received in return

for services rendered”). In a business transaction like those at issue in this case,

                                            9
             Case: 16-17059     Date Filed: 07/31/2019    Page: 10 of 20

the value of a benefit can only be quantified by reference to its fair market value.

See also Klaczak v. Consol. Med. Transp., 458 F. Supp. 2d 622, 679 (N.D. Ill.

2006) (“Relators cannot prove that the Hospital Defendants received

remuneration—something of value—without comparing the contracted rates with

fair market value.”).

      This understanding of “remuneration” is supported by the definition of

“remuneration” in 42 U.S.C. § 1320a-7a(i)(6), which relates to civil monetary

penalties in connection with medical fraud. Although that definition is limited to

that particular section of Title 42, it also defines “remuneration” to include the

“transfer[ ] of items or services for free or for other than fair market value” and

thus is consistent with our view of the correct definition. Id.

      For these reasons, the issue of fair market value is not limited to HCA’s safe

harbor defense, as Relator suggests, but is rather something Relator must address

in order to show that HCA offered or paid remuneration to physician tenants.

Here, Relator argues that HCA passed remuneration to physician tenants through

Tegra, so the critical question we must ask is whether physician tenants received

anything of value from Tegra under or in connection with their leases in excess of

the fair market value of their lease payments.

      Relator first points to the “low-end” rents that physician tenants paid for

space in the MOB. But Relator concedes that the proposed rents were within the

                                          10
             Case: 16-17059     Date Filed: 07/31/2019   Page: 11 of 20

range of “market rates” for new construction. Appellant’s Br. at 20. And although

the fair market rent range increased between the 2005 and 2007 appraisals, the

appraiser determined that the increase was due to higher construction costs.

Moreover, judging from the leases that Relator attached to his FAC, it appears that

many leases were entered into during 2005 and 2006, prior to the 2007 appraisal,

which would make them less “low-end.”

      Relator also points to profits received by physician tenants through the

CFPAs as evidence of unlawful remuneration. But Relator has not shown that

these agreements conferred any benefit in excess of fair market value. CFPAs

were offered only to tenants who would sign a ten-year lease, which was a longer

term than the market average at the time those lease agreements were negotiated.

In addition, Holladay’s two market rent studies conducted during 2005 confirmed

the same fair market rent range before and after taking into account the CFPAs,

thereby demonstrating that these agreements did not confer any additional value to

physician tenants.

      Relator also argues that HCA made free improvements to the offices of

certain physician tenants and gave certain physician tenants restricted use waivers.

But neither of these allegations is supported by sufficient facts. Relator does not

tie the improvements to specific physician tenants who were or could be referral

sources, nor does he present evidence that the use waivers were anything other

                                         11
             Case: 16-17059     Date Filed: 07/31/2019   Page: 12 of 20

than a standard exercise of discretion under the relevant leases or that HCA was

required to ask for something in exchange for the use waivers. “[M]ere

conclusions and unsupported factual allegations are legally insufficient to defeat a

summary judgment motion.” Ellis, 432 F.3d at 1326.

      For these reasons, we conclude that Relator has not shown that HCA

conveyed any remuneration to physician tenants of the Centerpoint MOB, and

therefore that Relator’s AKS claim fails on summary judgment.

               iii. Stark Statute Claim

      Relator’s second claim under the False Claims Act pertaining to Centerpoint

is that HCA violated the Stark Statute. See 42 U.S.C. § 1395nn(a). “In its most

general terms, the Stark statute prohibits doctors from referring Medicare patients to

a hospital if those doctors have certain specified types of ‘financial relationships’

with that hospital.” United States ex rel. Mastej v. Health Mgmt. Assocs., Inc., 591
F. App'x 693, 698 (11th Cir. 2014) (citing 42 U.S.C. § 1395nn(a)(1)(A)). The Stark

Statute also “prohibits that same hospital from presenting claims for payment to

Medicare for any medical services it rendered to such referred patients.” Id. (citing

42 U.S.C. § 1395nn(a)(1)(B)). A prohibited “financial relationship” includes a

“compensation arrangement,” 42 U.S.C. § 1395nn(a)(2)(B), defined as “any

arrangement involving any remuneration between a physician (or an immediate

family member of such physician) and an entity [providing a designated health

                                          12
              Case: 16-17059    Date Filed: 07/31/2019   Page: 13 of 20

service],” subject to certain exceptions,         42 U.S.C. § 1395nn(h)(1)(A).

“Remuneration,” in turn, “includes any remuneration, directly or indirectly, overtly

or covertly, in cash or in kind.” 42 U.S.C. § 1395nn(h)(1)(B). Both direct and

indirect compensation arrangements are therefore prohibited under the Stark Statute.

      In this case, there is no genuine factual dispute over whether a prohibited

indirect compensation arrangement under the Stark Statute exists because it plainly

does not. Regulations promulgated in part under 42 U.S.C. § 1395nn define an

“indirect compensation agreement” as requiring, among other things, that

compensation received by a referring physician “varies with, or takes into account,

the volume or value of referrals or other business generated by the referring

physician.”   42 C.F.R. § 411.354(c)(2)(ii).     HCA has shown that there is no

correlation between the size of physician tenants’ space leases and their referrals to

HCA, Appellee’s Br. at 9, and Relator offers only conclusory statements that HCA

“took into account the value of referrals” in planning the MOB, Appellant’s Br. at

32–33. Even if Relator’s contention is true, it does not show that the rental rates or

other benefits allegedly given by HCA to any specific physician tenant are at all

correlated with the volume or value of referrals from that physician tenant.

Therefore, because there is no real basis in the record from which to conclude that

compensation paid by HCA to physician tenants varies with or takes into account

                                         13
              Case: 16-17059      Date Filed: 07/31/2019    Page: 14 of 20

the volume or value of referrals, there is no genuine factual dispute on this point.

See Ellis, 432 F.3d at 1326.

       Relator argues that the district court erred in considering this definition of an

“indirect compensation arrangement” because it relates to exceptions under the

Stark Statute rather than Relator’s prima facie burden. But Relator waived this

argument by failing to raise it before the district court. See, e.g., Denis v. Liberty

Mut. Ins. Co., 791 F.2d 846, 848–49 (11th Cir. 1986) (“Failure to raise an issue,

objection or theory of relief in the first instance to the trial court generally is

fatal.”). In fact, Relator cited approvingly to 42 C.F.R. § 411.354(c)(2) in his

Opposition to Motion for Partial Summary Judgment. App’x 159 at 9.

      For these reasons, we conclude that Relator has not shown that there is a

financial relationship between HCA and physician tenants that violates the Stark

Statute. We therefore agree with the district court that HCA was entitled to

summary judgment regarding Relator’s Centerpoint Claims.

          B. Aventura Claims

       The district court dismissed Relator’s Aventura Claims because it concluded

that Relator “impermissibly use[d] information learned through discovery to

supplement [these] allegations,” and that without this additional information, the

SAC did not meet the heightened pleading standard of Rule 9(b). Bingham v.

                                            14
             Case: 16-17059    Date Filed: 07/31/2019   Page: 15 of 20

HCA, Inc., No. 13-23671-CIV, 2016 WL 6027115, at *4 (S.D. Fla. Oct. 14, 2016).

On appeal, Relator argues that both conclusions were erroneous. We disagree.

                i. Grant of HCA’s motion to strike information

      On July 22, 2015, the parties jointly moved to stay discovery pending

resolution of HCA’s anticipated motion to dismiss. The district court denied that

motion, and discovery began. HCA then moved to dismiss Relator’s complaint.

On January 28, 2016, the district court granted HCA’s motion to dismiss Relator’s

Aventura Claims but allowed Relator to amend his complaint regarding these

claims. Discovery, however, had proceeded while the district court considered and

decided HCA’s motion to dismiss. On March 8, 2016, Relator filed his SAC,

adding additional facts pertaining to the Aventura Claims, including information

obtained through discovery. Thereafter, HCA filed a second motion to dismiss

Relator’s Aventura Claims and a motion to strike certain alleged facts on the basis

that Relator’s SAC impermissibly used information learned through discovery, and

that, without that information, the SAC did not meet the heightened pleading

standard of Rule 9(b). The district court agreed and granted both motions.

Bingham, 2016 WL 6027115, at *4.

      We review the district court’s grant of HCA’s motion to strike alleged facts

from Relator’s SAC under Federal Rule of Civil Procedure 12(f) for an abuse of

discretion. See Branch Banking & Tr. Co. v. Lichty Bros. Constr., Inc., 488 F.
15
              Case: 16-17059     Date Filed: 07/31/2019    Page: 16 of 20

App’x 430, 434 (11th Cir. 2012); McCorstin v. U.S. Dep't of Labor, 630 F.2d 242,

244 (5th Cir. 1980). “[T]he abuse of discretion standard allows a range of choice

for the district court, so long as that choice does not constitute a clear error of

judgment.” In re Rasbury, 24 F.3d 159, 168 (11th Cir. 1994) (internal quotation

marks omitted).

      Although courts should freely grant leave to amend pleadings, see Fed. R.

Civ. P. 15(a)(2), amendments that include material obtained during discovery,

prior to a final decision on the motion to dismiss, may not be appropriate in cases

to which the heighted pleading standard of Rule 9(b) applies if the amendment

would allow the plaintiff to circumvent the purpose of Rule 9(b), see United States

ex rel. Keeler v. Eisai, Inc., 568 F. App’x 783, 804–05 (11th Cir. 2014). Applying

Rule 9(b) to False Claims Act claims “ensures that the relator’s strong financial

incentive to bring [a False Claims Act] claim—the possibility of recovering

between fifteen and thirty percent of a treble damages award—does not precipitate

the filing of frivolous suits.” United States ex rel. Atkins v. McInteer, 470 F.3d
1350, 1360 (11th Cir. 2006). Indeed, “[t]he particularity requirement of Rule 9 is a

nullity if Plaintiff gets a ticket to the discovery process without identifying a single

claim.” Id. at 1359 (internal quotation marks omitted).

      We agree with the district court that, in this case, the goals of applying Rule

9(b) to False Claims Act cases are advanced by striking information in Relator’s

                                           16
             Case: 16-17059     Date Filed: 07/31/2019    Page: 17 of 20

SAC that was learned through discovery, prior to a final decision on the motion to

dismiss, because, as discussed further below, Relator’s FAC did not satisfy the

heightened pleading standard of Rule 9(b). As the district court noted, it is

important to discourage plaintiffs from being able to “learn the complaint’s bare

essentials through discovery” which could “needlessly harm a defendants’ [sic]

goodwill and reputation by bringing a suit that is, at best, missing some of its core

underpinnings, and, at worst, are baseless allegations used to extract settlements.”

Bingham, 2016 WL 6027115, at *4 (quoting Clausen, 290 F.3d at 1313 n.24).

Similarly, prohibiting a relator “to use discovery to meet the requirements of Rule

9(b) reflects, in part, a concern that a qui tam plaintiff, who has suffered no injury

in fact, may be particularly likely to file suit as a pretext to uncover unknown

wrongs.” Id. at *5 n.4 (internal quotation marks omitted). Finally, allowing a

relator to amend a complaint after discovery would force the government to decide

whether or not to intervene in the case without complete information. Id. at *5.

      For these reasons, we conclude that the district court did not abuse its

discretion in granting HCA’s motion to strike information in Relator’s SAC that

was obtained through discovery.

                ii. Grant of Motion to dismiss

      “We review de novo the district court’s grant of a motion to dismiss under

Fed. R. Civ. P. 12(b)(6) for failure to state a claim, accepting the factual allegations

                                          17
             Case: 16-17059      Date Filed: 07/31/2019    Page: 18 of 20

in the complaint as true and construing them in the light most favorable to the

plaintiff.” Glover v. Liggett Grp., Inc., 459 F.3d 1304, 1308 (11th Cir. 2006) (per

curiam). “A plaintiff must plausibly allege all the elements of the claim for relief.

Conclusory allegations and legal conclusions are not sufficient; the plaintiffs ‘must

state a claim to relief that is plausible on its face.’” Feldman v. Am. Dawn, Inc.,

849 F.3d 1333, 1339–40 (11th Cir. 2017) (citation omitted) (quoting and citing

Bell Atl. Corp. v. Twombly, 550 U.S. 544, 557, 570 (2007)).

      Furthermore, “[a] complaint under the False Claims Act must meet the

heightened pleading standard of Rule 9(b), which states ‘[i]n alleging fraud or

mistake, a party must state with particularity the circumstances constituting fraud

or mistake.’” Hopper v. Solvay Pharm., Inc., 588 F.3d 1318, 1324 (11th Cir. 2009)

(second alteration in original) (quoting Fed. R. Civ. P. 9(b)). “A False Claims Act

complaint satisfies Rule 9(b) if it sets forth facts as to time, place, and substance of

the defendant’s alleged fraud, specifically the details of the defendants’ allegedly

fraudulent acts, when they occurred, and who engaged in them.” Id. (internal

quotation marks omitted).

      Considering Relator’s complaint after excising the additional information

obtained through discovery, we agree with the district court that the remaining

allegations do not satisfy the pleading requirements of Rule 9(b). On appeal,

Relator argues that it was incorrect for the district court to assume that all of the

                                           18
             Case: 16-17059     Date Filed: 07/31/2019    Page: 19 of 20

additional facts in his SAC were learned through discovery. Appellant’s Br. at 38.

But Relator does not point to specific facts in the SAC that he learned prior to

discovery. Instead, he points us back to his FAC, arguing that his FAC pleaded all

of the “essential elements” of the Aventura Claims. Appellant’s Br. at 38. These

elements are stated in the FAC on “information and belief,” however, and Relator

does not state with any particularity how HCA conveyed remuneration directly or

indirectly to specific tenants of the Aventura MOB. App’x 14 ¶ 131, 134–35.

Similarly, Relator’s allegations that leases entered into between HCA and

Greenfield did not reflect fair market value are supported, if at all, only by

Relator’s own calculations regarding the value of the land. App’x 14 ¶ 133, 136.

      On appeal, Relator also points to specific allegations in his SAC that find a

parallel in the FAC. Appellant’s Br. at 39. But these allegations are similarly

devoid of facts regarding the substance of HCA’s alleged misconduct and do not

describe in any detail the alleged misconduct, when it occurred, and who engaged

in it. See Hopper, 588 F.3d at 1324. For example, Relator states in a conclusory

fashion that, based on information and belief, the total amount of the ground lease

payment from HCA to Greenfield was less than fair market value. App’x 14 ¶ 135.

Similarly, although Relator alleged that HCA’s Aventura scheme included

“[v]aluable inducements offered and paid to referring physicians to encourage

them to locate and maintain their offices on HCA hospital campuses” and

                                          19
             Case: 16-17059    Date Filed: 07/31/2019    Page: 20 of 20

“[c]ontrol over third-party medical office building owners’ relationships with their

physician tenants . . . so as to ensure the flow of remuneration to physicians who

referred patients to HCA,” Relator does not provide specific details or evidence to

support his claims that long-term ground leases were “[g]rossly undervalued” or

included “[o]verly generous” terms. Id. ¶ 5–6.

      Therefore, we agree with the district court that Relator’s allegations lack the

“indicia of reliability” to support his Aventura Claims, Bingham, 2016 WL
6027115, at *5 (internal quotation marks omitted), and that Relator has therefore

failed to state a claim under the False Claims Act with respect to his Aventura

Claims.

          C. Conclusion

      For these reasons, we AFFIRM the district court’s grant of judgment in

favor of HCA regarding Relator’s Centerpoint Claims and Aventura Claims.

AFFIRMED.

                                         20