United States ex rel. Jones v. Concerted Care Grp., Civil Action RDB-16-3056

CourtUnited States District Courts. 4th Circuit. United States District Court (Maryland)
Writing for the CourtRichard D. Bennett United States Senior District Judge
Docket NumberCivil Action RDB-16-3056
PartiesUNITED STATES OF AMERICA ex rel. LASHAWN JONES, et al., Plaintiffs, v. CONCERTED CARE GROUP, et al., Defendants.
Decision Date23 March 2022


CONCERTED CARE GROUP, et al., Defendants.

Civil Action No. RDB-16-3056

United States District Court, D. Maryland

March 23, 2022


Richard D. Bennett United States Senior District Judge

Relators Lashawn Jones and Latoya Godette filed this qui tam action on behalf of the United States and the State of Maryland under the False Claims Act (“FCA”), 31 U.S.C. §§ 3729 et seq., and the Maryland False Claims Act (“MDFCA”), Md. Code, Gen. Provision § 8-101 et seq.[1] Through the operative qui tam, Complaint Jones and Godette allege that Defendants Concerted Care Group, Noah Nordheimer, Alvin Nichols, and Barbara Wahl defrauded the United States Government by requesting Medicaid reimbursements for healthcare services they never provided. (Compl. ¶¶ 4, 177, 182, ECF No. 1.) Now pending is Defendants' Partial Motion to Dismiss Relator's Complaint pursuant to Fed.R.Civ.P. Rules 12(b)(6) and 9(b). (ECF No. 48.) The parties' submissions have been reviewed and no hearing is necessary. See Local Rule 105.6 (D. Md. 2021).


For the reasons set forth below, Defendants' Motion to Dismiss (ECF No. 48) is DENIED IN PART and GRANTED IN PART. Specifically, this Motion is GRANTED with respect to Noah Nordheimer and Alvin Nichols, and those individual defendants are dismissed from this action on all counts without prejudice. With respect to Concerted Care Group and Barbara Wahl, Defendants' Motion is GRANTED as to Counts I(a), I(c), I(d), I(e), and II(a), as Relators CONSENT to the dismissal of those counts. This Motion is DENIED with respect to Counts I(b) and II(b), the only counts which remain in dispute. These counts allege that Defendants knowingly “entered false information related to client services into its electronic medical records system to make it appear as if it had provided services when in fact it had not, ” (Compl. ¶ 186(b)), and “submitted claims for payment to Maryland Medicaid for services that were never provided, ” (id. ¶ 172(b)).


A court ruling on a motion to dismiss “accept[s] as true all well-pleaded facts in a complaint and construe[s] them in the light most favorable to the plaintiff.” Wikimedia Found. v. Nat'l Sec. Agency, 857 F.3d 193, 208 (4th Cir. 2017) (citing SD3, LLC v. Black & Decker (U.S.) Inc., 801 F.3d 412, 422 (4th Cir. 2015)). The following facts are derived from Relators' qui tam Complaint and accepted as true for the purpose of Defendants' motion to dismiss.

I. The Parties

Defendant Concerted Care Group (“CCG”) is a drug addiction treatment and mental health services provider with core facilities located in Baltimore, Maryland. (Compl. ¶¶ 2, 25.) Defendants Noah Nordheimer, Alvin Nichols, and Barbara Wahl (collectively, the “Individual Defendants”) were officers of CCG at all relevant times. (Id. ¶¶ 32, 38-39, 43.) Specifically,


Noah Nordheimer is the CEO and President of CCG, (id. ¶ 32), Alvin Nichols is the Executive Vice President of CCG, (id. ¶ 38), and Barbara Wahl is CCG's Business Operations Director, (id. ¶ 43). Nordheimer and Nichols “maintain[] significant, direct control over many of CCG's systems and processes, including matters related to Medicaid billing.” (Id. ¶¶ 37, 40.) Moreover, Nichols and Wahl supervised Relator Jones directly and indirectly during various periods of her employment at CCG. (Id. ¶¶ 41, 47.)

Relators are two former employees of CCG. Lashawn Jones was a designated Health Home nurse for CCG between July 8, 2015, and October 23, 2015. (Id. ¶¶ 13-14.) Latoya Godette worked as a systems administrator for CCG between March 16, 2015, and November 3, 2015, and was responsible for designing the workflow CCG used to handle its patients' electronic medical records. (Id. ¶¶ 20-23.) Pursuant to the False Claims Act (“FCA”), Jones and Godette bring suit on behalf of the United States Government and the State of Maryland, [2]alleging that CCG and its officers defrauded the United States and the State of Maryland by falsifying patient records to obtain Maryland Medicaid reimbursement for services that they never provided. (Id. ¶¶ 4-5.)

II. Concerted Care's Participation in Health Home

In March 2015, CCG became a service provider for Maryland Medicaid's “Health Home” program, authorized by the Affordable Care Act and administered by the Maryland Department of Health and Mental Hygiene.[3] (Id. ¶¶ 3, 71.) Health Home provides support for


individuals with chronic conditions-such as “mental health, substance abuse, asthma, diabetes, heart disease and being overweight.” (Id. ¶¶ 54-55.) To qualify for coverage under Health Home, individuals must have (i) two or more chronic conditions; (ii) one chronic condition and a risk of a second; or (iii) one serious and persistent mental health condition. (Id. ¶ 54.) To partake in Health Home and receive reimbursements, a provider must enroll as an accredited Medicaid provider in the State of Maryland, satisfy a mandatory service delivery threshold, and comply with certain statutory duties, such as minimum staffing levels and reporting requirements. (Id. ¶ 57, 60.)

In accordance with Health Home regulations, Health Home providers receive $ 98.87 from Medicaid for each client enrollment, and the same amount for each month of services provided to each client. (Id. ¶¶ 65-66.) To enroll a client in Health Home, a provider must provide an “initial assessment, ” requiring the provider to evaluate the participant's health and medical needs, and to request records from the participant's primary care physician and other providers. (Id. ¶ 64 (citing COMAR Once the client has been enrolled in the Health Home program, their provider must provide at least two health services per month, and document those services in eMedicaid. (Id. ¶ 68 (citing COMAR Eligible services include, inter alia, health care management, coordination with medical services, transitional care, patient and family support, referral to support services, status checks, education, health literacy, and addiction treatment. (Id. ¶¶ 56, 70, 120.); COMAR (detailing all covered services).

Health Home providers are encouraged “to follow up with clients and their caregivers and to track the patients' broader health statistics.” (Compl. ¶ 3.) For this purpose, CCG uses


an electronic notification system called Chesapeake Regional Information System for Our Patients (“CRISP”) to maintain and track participant hospital encounter data. (Id. ¶ 61.) Additionally, patient data is entered into the eMedicaid health information system. (Id. ¶ 62.) According to an email incorporated into the Complaint, CCG clients are ordinarily enrolled in the Health Home program and entered into the patient databases for billing following their first day of service. (Id. ¶ 125.)

III. Discovery of Alleged Fraud

Relator Lashawn Jones began working for CCG as a Health Home nurse in July 2015. (Id. ¶¶ 13-14.) Lashawn Jones and Sade Oyekanmi were the only two CCG nurses assigned to Health Home. (Id. ¶ 73.) At the time Jones was hired, approximately 160 to 170 CCG clients were enrolled in Health Home. (Id. ¶¶ 74-75.) This number increased to 289 clients by the time Jones resigned. (Id. ¶ 99.) These clients were allegedly provided services by a single nurse in a single day: CCG's records indicate that all 170 clients were assisted by Oyekanmi on April 30, 2015. (Id. ¶¶ 77-78.) Oyekanmi reported that she was providing services for approximately 160 clients per month. (Id. ¶ 105-11.) However, Jones alleges that she witnessed Oyekanmi visit no more than 30 clients by the end of the third week. (Id. ¶ 112.)

Relators allege that CCG was attempting to maximize its Health Home enrollments, (id. ¶ 72), but was struggling to provide consistent services to its clients, who suffer from “drug addictions, behavioral health problems, and serious psychiatric disorders, ” and regularly fail to make appointments. (Id. ¶ 81.) Accordingly, the Individual Defendants pressured Jones to enroll additional clients in Health Home to obtain additional reimbursements. (Id. ¶¶ 89-90.) On August 31, 2015, Nordheimer sent an email to Nichols, Wahl, and Godette discussing the


importance of Health Home enrollments, and proposing that CCG offer $ 10.00 McDonalds gift cards in exchange for enrolling. (Id. ¶ 90.) On September 11, 2015, Nichols emailed Relator Godette and other employees, directing them to ensure that “all of these unpaid claims are cleaned up, processed, and remitted, ” and to discuss any “revenue impairments” that were “blocking or diminishing the billing process[]” for Health Home. (Id. ¶ 151-52.) In addition, Nordheimer and Wahl circulated spreadsheets of clients who were not enrolled in the program “as a way to push staff to enroll clients in the Health Home program.” (Id. ¶¶ 92-93.)

Jones alleges that Wahl, who was responsible for day-to-day operations at the CCG offices in Baltimore, took aggressive steps to maximize Health Home enrollment and billing. (Id. ¶¶ 44-45, 107-16.) According to the Complaint, Wahl pressured Jones and Oyekanmi to falsify patient data in order to maximize client enrollments. (E.g., id. ¶¶ 108, 114-17, 126-28.) Among other allegations, Jones claims that Wahl: (1) directed Jones to enroll five new clients per day and insisted that she could enroll clients without an in-person examination, (id. ¶¶ 94- 95); (2) instructed both nurses to bill a Health Home service every time they reviewed a client's chart, (id. ¶ 107); (3) ordered both nurses to fill in missing services in the electronic medical records systems with “placeholders” in the patients' charts, (id. ¶¶ 108, 114-17, 157-61); and (4) instructed Jones to fill in missing data in the CRISP system during October 2015 to prepare for a Health Home audit, (id. ¶¶ 126-28).

Both nurses resigned in frustration: Oyekanmi resigned...

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