United States ex rel. Silingo v. WellPoint, Inc.

The Ninth Circuit affirmed in part and reversed in part the dismissal of an action against Medicare Advantage organizations under the False Claims Act (FCA). Relator alleged that Medicare Advantage organizations retained MedXM to fraudulently increase, or at least maintain, their capitation payments for enrollees whose risk scores were set to expire and revert to the unadjusted Medicare beneficiary average. The panel held that relator has pleaded a wheel conspiracy-like fraud in which MedXM was the hub and defendants were the spokes. Therefore, the panel held that relator's charges of factually false claims, express false certifications, and false records should not have been dismissed due to her use of group allegations. The panel rejected defendants' contentions that the complaint failed to allege a sufficient factual basis to link MedXM's misconduct to defendants' actual submissions of claims or certifications to the Centers for Medicare and Medicaid Services, or that the complaint's allegations about the Medicare Advantage organizations' knowledge of the alleged fraud did not satisfy Rule 8. Finally, the panel affirmed the dismissal of a reverse false claim count, reversed dismissal on the pleadings of other counts, and remanded for further proceedings. View "United States ex rel. Silingo v. WellPoint, Inc." on Justia Law