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contractliabilitystatuteappealwilldiscriminationcomplianceregulation

liabilityappealwill

Related Cases

U.S. ex rel. Willard v. Humana Health Plan of Texas Inc., 336 F.3d 375, 56 Fed.R.Serv.3d 458

Facts

Irvin Willard, a former sales representative for Humana, claimed that the company discouraged less healthy individuals and those from rural areas from enrolling in its Medicare HMO plans. He alleged that Humana adopted various techniques to prevent eligible participants from learning about their enrollment options and that he was warned against enrolling individuals from outlying counties. Willard filed a qui tam complaint under the FCA after the government declined to intervene.

Irvin Willard, a former sales representative for Humana, claimed that the company discouraged less healthy individuals and those from rural areas from enrolling in its Medicare HMO plans.

Issue

Did Humana Health Plan's alleged 'cherrypicking' scheme constitute a violation of the False Claims Act, and did the district court err in dismissing the complaint and denying leave to amend?

Rule

The False Claims Act imposes liability on any person who knowingly presents a false claim for payment to the government. Liability can arise from either express or implied certification of compliance with applicable statutes and regulations, but a claim must be based on a false or fraudulent claim presented to the government.

The False Claims Act imposes liability on any person who knowingly presents a false claim for payment to the government.

Analysis

The court determined that Willard's allegations did not demonstrate that Humana presented any false claims to the government. The court noted that the capitation rates were set on a county-by-county basis, and Willard failed to allege discrimination based on health status within any specific county. Additionally, the court found that the implied certification theory did not apply because compliance with the alleged anti-discrimination regulations was not a condition for payment under Humana's contract with the government.

The court determined that Willard's allegations did not demonstrate that Humana presented any false claims to the government.

Conclusion

The Court of Appeals affirmed the district court's dismissal of Willard's complaint, concluding that he failed to state a valid claim under the FCA and that the district court did not abuse its discretion in denying leave to amend.

The Court of Appeals affirmed the district court's dismissal of Willard's complaint, concluding that he failed to state a valid claim under the FCA.

Who won?

Humana Health Plan prevailed in the case because the court found that Willard's allegations did not constitute a violation of the FCA, as he failed to identify any false claims or demonstrate that Humana engaged in discriminatory practices.

Humana Health Plan prevailed in the case because the court found that Willard's allegations did not constitute a violation of the FCA.

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