United States Ex Rel. El-Amin v. George Washington University
2008 U.S. Dist. LEXIS 7651, 533 F. Supp. 2d 12, 2008 WL 287983 (2008)
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Rule of Law:
In a False Claims Act case, evidence is only admissible if it is relevant to the specific elements of the claim, such as the falsity of a particular claim submitted to the government and the defendant's knowledge, and its probative value is not substantially outweighed by the danger of unfair prejudice or jury confusion.
Facts:
- Four certified registered nurse anesthetists (CRNAs), referred to as Relators, were formerly employed by the George Washington University Hospital.
- From 1989 to 1995, George Washington University (GWU) provided anesthesia services to Medicare patients, often using residents or CRNAs under the supervision of a licensed anesthesiologist.
- GWU submitted claims for these anesthesia services to Medicare for reimbursement.
- The Relators alleged that GWU's claims falsely represented that a licensed anesthesiologist had personally performed all required steps for each procedure, which would qualify for the highest reimbursement rate.
- Specifically, the Relators claimed that anesthesiologists often failed to perform all of the seven specific tasks required by Medicare regulations (the 'seven steps' regulation) to justify the higher billing rate.
- The Relators believed this practice resulted in GWU receiving thousands, if not millions, of dollars in improper reimbursements from the federal treasury.
Procedural Posture:
- Four CRNAs ('Relators') filed a qui tam lawsuit on behalf of the United States against George Washington University ('GWU') in the U.S. District Court for the District of Columbia.
- The complaint was filed under seal as required by the False Claims Act.
- The United States government investigated the allegations but ultimately declined to intervene in the action, allowing the Relators to proceed with the case on their own.
- The parties engaged in extensive discovery over several years.
- Prior to trial, both the Relators and GWU filed multiple motions in limine, asking the court to preclude or limit certain categories of evidence and testimony from being presented to the jury.
- The District Court is now ruling on these pre-trial evidentiary motions.
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Issue:
Under the Federal Rules of Evidence, is evidence of a defendant's general practices, the government's decision not to intervene in the case, or conduct related to non-disputed claims admissible in a False Claims Act lawsuit alleging fraudulent Medicare billing?
Opinions:
Majority - Judge Kollar-Kotelly
No. In a False Claims Act case, evidence that does not directly pertain to the specific, allegedly fraudulent claims at issue is not admissible. To be admissible, evidence must be relevant under FRE 401, meaning it must tend to prove or disprove a material fact of the claim, such as the falsity of a specific bill or the defendant's knowledge. The court ruled on several categories of evidence: 1) Government's non-intervention: This is inadmissible because the government's reasons for not joining a qui tam suit are varied and speculative; its decision is not probative of the case's merits. 2) Generally accepted medical practices: This evidence is inadmissible because the case concerns compliance with federal reimbursement standards (the 'seven steps'), not the medical standard of care, and introducing the latter would confuse the jury. 3) Habit/Routine Practice: Evidence of anesthesiologists' alleged habits under FRE 406 is inadmissible because the Relators failed to meet their burden to establish that the conduct was a semi-automatic, invariable response to a specific situation. They did not adequately identify the specific habit or show a sufficient sampling and uniformity of response, especially given that medical procedures are complex and volitional. 4) The Locke Reports: These internal consulting reports on GWU's billing practices are inadmissible because they analyzed billing process errors (like overpayments and coding issues) but did not examine whether the anesthesiologists actually performed the work required by the seven steps regulation, making them irrelevant to the core issue. Furthermore, their admission would be unfairly prejudicial and confusing under FRE 403.
Analysis:
This memorandum opinion serves as a strong gatekeeping decision, clarifying the strict evidentiary standards in False Claims Act litigation. By precluding evidence of general practices, government inaction, and tangentially related reports, the court mandates that plaintiffs connect their proof directly to the specific elements of the alleged fraud for each claim. This precedent forces litigants to focus on the granular details of the disputed claims rather than relying on broader, more prejudicial narratives about the defendant's character or general business operations. The ruling significantly narrows the scope of admissible evidence at trial, reinforcing the idea that FCA cases must be proven claim-by-claim and not through generalized allegations of misconduct.
