Court Opinion

ID: 9385642
Source: CourtListenerOpinion
Date Created: 2023-04-07 18:00:55.216029+00
Date Added: 2024-06-11T17:18:03.491082
License: Public Domain

Case: 21-20620       Document: 00516704506             Page: 1      Date Filed: 04/07/2023

              United States Court of Appeals
                   for the Fifth Circuit
                                                                                    United States Court of Appeals
                                                                                             Fifth Circuit

                                    ____________                                           FILED
                                                                                        April 7, 2023
                                     No. 21-20620                                     Lyle W. Cayce
                                    ____________                                           Clerk

   United States of America, ex rel, Clarisse Christine
   Toledo,

                                                                   Plaintiff—Appellant,

                                           versus

   HCA Holdings, Incorporated; Pasadena Bayshore
   Hospital, Incorporated; Bayshore Medical Center,
   Incorporated,

                                             Defendants—Appellees.
                    ______________________________

                    Appeal from the United States District Court
                        for the Southern District of Texas
                             USDC No. 4:19-CV-3683
                    ______________________________

   Before King, Jones, and Duncan, Circuit Judges.
   Per Curiam: *
          Appellant Clarisse Christine Toledo brought retaliation claims under
   the False Claims Act and the 2013 National Defense Authorization Act

          _____________________
          *
              Pursuant to 5th Circuit Rule 47.5, the court has determined that this opinion
   should not be published and is not precedent except under the limited circumstances set
   forth in 5th Circuit Rule 47.5.4.
Case: 21-20620          Document: 00516704506               Page: 2       Date Filed: 04/07/2023

                                           No. 21-20620

   against her former employer and its corporate affiliate. 1 She appeals the
   district court’s order granting Appellees’ motion for summary judgment and
   denying her motion for partial summary judgment. We AFFIRM.
                                     BACKGROUND
           Pasadena Bayshore Hospital is an inpatient hospital. 2 It is affiliated
   with HCA Healthcare, Inc., a nationwide network of healthcare providers.
   Toledo served as Bayshore’s full time Prospective Payment System
   Coordinator for a few months beginning in February 2017. In that role, she
   was responsible for gathering information regarding patients’ rehabilitation
   stays and reporting that information to the Center for Medicare and
   Medicaid Services (“CMS”) via Inpatient Rehabilitation Facility Patient
   Assessment Instruments (“IRF-PAIs”). She reported temporarily to Ohme
   Entin, Bayshore’s Chief Operations Officer, and informally to Mark Rozell,
   HCA’s Director of Operations for the Gulf Coast Division, until March 2017.
   When Entin went on maternity leave, Toledo began reporting to Kathyrn
   Simmons, Bayshore’s newly hired Inpatient Rehab Director. Carrie Capps,
   the Chief Nursing Officer, became Simmons’s supervisor.
           Rozell discovered in May 2017 that Toledo had made etiological and
   impairment group code (“IGC”) errors on six out of ten audited IRF-PAIs.
   Importantly, CMS uses the IGCs reported on the IRF-PAIs to assess
   Bayshore’s compliance with the “60/40 rule,” which requires that sixty
   percent of patients Bayshore admits fall within one of thirteen “compliant”
   diagnoses.       Rozell, in response, conducted a one-on-one training with
           _____________________
           1
            Toledo originally brought this action as a qui tam suit against Bayshore, its affiliate
   HCA Healthcare, Inc., and seventy-one other HCA-affiliated hospitals. The Government
   declined to intervene, Toledo’s qui tam claims were dismissed, and the case was transferred
   to the Southern District of Texas.
           2
               “Bayshore Medical Center, Inc.” is a non-existent entity.

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                                    No. 21-20620

   Toledo, provided her access to webinar trainings on the topic, and sent her
   to a three-day training and certification course.
          Bayshore slipped below the sixty percent compliance ratio in May
   2017. Rozell consequently informed Bayshore that ninety percent of its new
   admissions had to be compliant in order to recover lost ground. When
   Bayshore’s numbers did not improve despite a month-long implementation
   of the change, Simmons audited Toledo’s IRF-PAIs and discovered that
   Toledo had again entered non-compliant codes for compliant patients. At
   least one of these codes was entered after she returned from her certification
   course.
          Simmons raised the issue with her direct supervisor, Carrie Capps.
   Capps then called Rozell, and the two decided to terminate Toledo. As
   Rozell explained, “[I]t did not seem that [Toledo] was developing based on
   all that training and education we had gotten her, and I did not think that she
   was going to be successful in this role if we went forward.”
          The following day, Toledo called an ethics hotline, asserting Bayshore
   was engaging in fraudulent practices and insisting she was wrongfully
   terminated.   An internal investigation concluded Toledo’s claims were
   unsubstantiated.
          Toledo subsequently brought this action. She moved for partial
   summary judgment, and Appellees moved for summary judgement. The
   district court denied Toledo’s motion, granted Appellees’ motion, and
   dismissed Toledo’s claims. Toledo appeals that judgment.
                                 DISCUSSION
          The False Claims Act (“FCA”) prohibits an employer from
   retaliating against an employee for actions taken “in furtherance” of a qui
   tam suit or for “other efforts to stop 1 or more violations” of the FCA.

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                                    No. 21-20620

   31 U.S.C. § 3730(h). Where an employee alleges such retaliation, this court
   applies the McDonnell Douglas burden shifting framework. Diaz v. Kaplan
   Higher Educ., LLC, 820 F.3d 172, 175 n.3 (5th Cir. 2016). “Under this
   framework, the employee must first establish a prima facie case of retaliation
   by showing: (1) that he engaged in protected activity; (2) that the employer
   knew about the protected activity; and (3) retaliation because of the
   protected activity.” Garcia v. Pro. Cont. Servs., Inc., 938 F.3d 236, 241 (5th
   Cir. 2019). The burden then “shifts to the employer to state a legitimate,
   non-retaliatory reason for its decision.” Diaz, 820 F.3d at 176 (quotation
   marks and citation omitted). Once articulated, the burden “shifts back to the
   employee to demonstrate that the employer’s reason is actually a pretext for
   retaliation.” Id. (quotation marks and citation omitted).
          The 2013 National Defense Authorization Act (“NDAA”) similarly
   prohibits retaliation against an employee who discloses to an appropriate
   party “information that the employee reasonably believes is evidence of . . .
   a violation of law, rule, or regulation related to a Federal contract.”
   41 U.S.C. § 4712(a)(1) (amended Dec. 2016). An appropriate party includes
   a “management official or other employee of the [employer] who has the
   responsibility to investigate, discover, or address misconduct.” 41 U.S.C.
   § 4712(a)(2)(G) (amended Dec. 2016). As with an FCA retaliation claim, an
   employer must know of the protected activity. Armstrong v. Arcanum Grp.,
   897 F.3d 1283, 1287 (10th Cir. 2018).
          Toledo argues she engaged in numerous instances of protected
   conduct when she complained to various Bayshore and HCA employees
   about what she now characterizes as fraud. Assuming arguendo that she did
   engage in some protected conduct, a de novo review of the record reveals that

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                                         No. 21-20620

   Capps and Rozell, the relevant decisionmakers, 3 were unaware of such
   conduct, and such conduct did not contribute to her termination. 4 Toledo’s
   retaliation claims under both statutes consequently fail.
           It is undisputed that Capps had no knowledge of Toledo’s allegedly
   protected activity. And Toledo admits that she never used words like fraud
   or illegal when raising concerns to Rozell. See Robertson v. Bell Helicopter
   Textron, Inc., 32 F.3d 948, 951 (5th Cir. 1994) (no protected activity where
   plaintiff failed to use words such as illegal, unlawful, or qui tam in
   characterizing concerns). Even so, Toledo asserts Rozell knew of her
   allegedly protected activity through their communications regarding
   (1) therapists’ inaccurate documentation of CMS-required therapy minutes,
   (2) nurses’ and therapists’ late submission of patient discharge paperwork,
   and (3) missing admission orders. 5
           As to the first issue, communications between Toledo and Rozell
   demonstrate Toledo at most characterized discrepancies in therapy minutes
   as mistakes or possible computer glitches, not fraud. Her communications
   were therefore insufficient to alert Rozell to allegedly protected activity,
   especially considering the accurate documentation of therapy minutes was
   part of her job. See id. at 952 (absent use of terms such as illegal, unlawful, or
           _____________________
           3
            Undisputed testimony demonstrates Capps and Rozell did not consult Simmons
   regarding Toledo’s termination, and Simmons did not volunteer her opinion.
           4
             At the pretext stage, the FCA “requires a showing of but-for causation.” Garcia,
   938 F.3d at 243–44. This court has yet to address the causation standard for NDAA
   retaliation claims. But Appellees concede the “contributing factor” standard applies. See
   Armstrong, 897 F.3d at 1287. We consequently apply that standard for the purposes of this
   appeal.
           5
            Toledo also points to Simmons’s request that Toledo “back-date” admission
   orders and change IGCs from non-compliant to compliant. But she never reported either
   issue to Rozell, nor does she provide evidence that he otherwise knew of Toledo’s
   complaints.

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                                          No. 21-20620

   false-claims investigation, actions taken consistent with job duties failed to
   alert employer to protected activity). Toledo’s single email addressing
   therapists’ use of group therapy to satisfy CMS-required therapy minutes
   was likewise insufficient to alert Rozell to allegedly protected activity. Rozell
   in fact testified that use of group therapy does not violate CMS regulations.
           As to the second issue, Toledo once asked Rozell whether data from
   late discharge paperwork could be used on IRF-PAIs. As Toledo’s job
   involved the input of discharge paperwork data into IRF-PAIs, her question
   was insufficient to alert Rozell to allegedly protected activity. See id. Indeed,
   in response to Toledo’s inquiry, Rozell stated that such data could be used if
   properly documented.
           As to the third issue, Toledo told Rozell that “she found 5 patients
   admitted to rehab without a physician admit order.” Again, Toledo’s
   position required her to report patients’ admission dates, which are
   contained in their admission orders. See id. Toledo notes, however, that
   Rozell stated that “it was not her job to look in the charts for the admission
   order.”     And Appellees confirm that CMS requires patients to have
   admission orders on file. Even assuming Toledo’s single report could
   constitute protected conduct sufficient to alert Rozell, Toledo has presented
   no evidence that such conduct—or any of the previously addressed
   conduct—contributed to her termination. 6 Indeed, Toledo testified that

           _____________________
           6
            Toledo contends Capps and Rozell mistakenly believed she made IGC errors that
   affected Bayshore’s compliance ratio. The record does not support that their “beliefs”
   were mistaken. Regardless, evidence that Toledo’s coding errors did not affect Bayshore’s
   compliance ratio “would establish only that the proffered justification was mistaken, not
   dishonest, which is the key to pretext.” Musser v. Paul Quinn Coll., 944 F.3d 557, 564 (5th
   Cir. 2019); see also LeMaire v. La. Dep’t of Transp. & Dev., 480 F.3d 383, 391 (5th Cir. 2007)
   (noting an employer is not required “to make proper decisions, only non-retaliatory
   ones”).

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                                     No. 21-20620

   Rozell responded appropriately to her concerns in every instance and at no
   point did she feel that he mistreated or retaliated against her.           She
   consequently has not shown Bayshore’s legitimate, non-retaliatory reason for
   firing her was pretext for retaliation.
                                 CONCLUSION
          Because Toledo has not presented a genuine dispute of material fact
   as to whether the relevant decisionmakers knew of her allegedly protected
   conduct or whether her allegedly protected conduct contributed to her
   termination, her retaliation claims fail. The judgment of the district court is
   AFFIRMED.

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