Qui Tam Claim – Medical Billing

Listen to this article

7^th Circuit Court of Appeals

Case Name: Rose Presser v. Acacia Mental Health Clinic, LLC

Case No.: 14-2804

Officials: FLAUM, RIPPLE, and HAMILTON, Circuit Judges

Focus: Qui Tam Claim – Medical Billing

Appellants fail to properly put forth allegations of fraud, however provide sufficient allegations for use of improper medical billing codes.

Relator and plaintiff Rose Presser filed a qui tam action under the False Claims Act, 31 U.S.C.

• 3729 et seq. (“FCA”), and its Wisconsin analog, the Wiscon‐ sin False Claims Act, Wis. Stat. § 20.931 et seq. (“WFCA”),1 on behalf of the United States and the State of Wisconsin against defendants Acacia Mental Health Clinic, LLC (“Acacia”) and Abe Freund, the principal owner of Acacia. Ms. Presser alleges that Acacia and Mr. Freund engaged in “upcoding,” provided unnecessary medical procedures, and then charged the federal and state governments for those expenses. The district court granted the defendants’ motion to dismiss the complaint for failure to state a claim of fraud with particularity as required by Federal Rule of Civil Procedure 9(b). We affirm that judgment except as it relates to the claims against both defendants regarding the use of an improper billing code. We hold that Ms. Presser has stated those allegations with sufficient particularity and therefore reverse the district court’s judgment on those claims and remand for further proceedings.

Affirmed in part

Reversed and remanded in part

Full Text

Attorney Derek A. Hawkins is the managing partner at Hawkins Law Offices LLC, where he heads up the firm’s startup law practice. He specializes in business formation, corporate governance, intellectual property protection, private equity and venture capital funding and mergers & acquisitions. Check out the website at www.hawkins-lawoffices.com or contact them at 262-737-8825.