Bell v. Cross

Bell v. Cross

Opinion

PER CURIAM:

This is a False Claims Act (FCA) case. Delia Bell, a registered nurse, alleges that her former employer—a skilled nursing facility (SNF) called Cross Garden Care Center (CGCC)—and its owner Karl Cross (together, the Defendants) submitted false claims for reimbursement to the Centers for Medicare and Medicaid Services (CMS). The district court granted the Defendants' motion for summary judgment. Bell argues on appeal that the district court erred by allocating the burden of proof to her, rather than to the Defendants. On a conditional cross-appeal, the Defendants argue that the affidavit Bell attached to her motion for summary judgment was a sham and should have been stricken. We need not reach the Defendants' conditional cross-appeal because the district court correctly found that the Defendants are entitled to summary judgment, even when considering Bell's affidavit.

We begin with some background on Medicare reimbursement at SNFs. ] Medicare is a federal program that funds health insurance for eligible elderly and disabled people. See 42 U.S.C. §§ 1395 et seq. The program will cover at least some of the cost of an eligible patient's first 100 days at an SNF. SNFs can seek [*3]  reimbursement for the services they provide through a per diem payment system. 42 U.S.C. § 1395yy; 42 C.F.R. § 413.335.

The per diem rate at which Medicare reimburses SNFs is related to the patient's Resource Utilization Group (RUG) score, which quantifies the patient's need for therapy. See Ruckh v. Salus Rehab., LLC, 963 F.3d 1089, 1095 (11th Cir. 2020). A higher RUG score equates to higher Medicare reimbursement. RUG scores are derived from periodic assessments conducted by SNFs to evaluate patients' residual functional capacity. Id. at 1094 (citing 42 U.S.C. § 1395i-3(b)(3)(C)). SNFs must submit these assessments, which are called Minimum Data Sets (MDS), in order to receive Medicare reimbursement. Id.

Bell worked as a nursing home administrator at CGCC from November 2014 until she resigned in August 2015. In April 2016, Bell sued CGCC under the FCA. ] The FCA enables private citizens, known as qui tam relators, to sue on behalf of the United States government. 31 U.S.C. § 3730(b). "To establish a cause of action under the [FCA], a relator must prove three elements: (1) a false or fraudulent claim; (2) which was presented, or caused to be presented, by the defendant to the United States for payment or approval; (3) with the knowledge that the claim was false." United States v. R&F Props. of Lake Cty., Inc., 433 F.3d 1349, 1355 (11th Cir. 2005) (citing 31 U.S.C. § 3729(a)).

Full case includes Shepard's, Headnotes, Legal Analytics from Lex Machina, and more.