{"id":5616,"date":"2020-03-31T19:54:00","date_gmt":"2020-03-31T19:54:00","guid":{"rendered":"https:\/\/www.dinsmore.com\/?post_type=publications&p=5616"},"modified":"2025-10-01T19:55:47","modified_gmt":"2025-10-01T19:55:47","slug":"two-circuits-hold-the-fca-does-not-require-objective-falsity-creating-confusion-on-the-appropriate-standard","status":"publish","type":"publications","link":"https:\/\/www.dinsmore.com\/publications\/two-circuits-hold-the-fca-does-not-require-objective-falsity-creating-confusion-on-the-appropriate-standard\/","title":{"rendered":"Two Circuits Hold the FCA Does Not Require \u201cObjective Falsity,\u201d Creating\u00a0Confusion on the Appropriate Standard"},"content":{"rendered":"\n

<\/a>Analysis:<\/strong>
United States ex rel. Druding v. Care Alternatives, Inc. <\/em>(3rd Circuit) \u2022 Winter ex rel. United States v. Gardens Reg\u2019l Hosp. & Med. Ctr., Inc. <\/em>(9th Circuit)<\/strong><\/p>\n\n\n\n

\"Curley<\/figure>\n\n\n\n

In recent decisions this month, the Third and Ninth Circuits reversed defense victories predicated on the \u201cobjective falsity\u201d standard under the False Claims Act (FCA). See<\/em> United States ex rel. Druding v. Care Alternatives, Inc.<\/em>, No. 18-3298, 2020 U.S. App. LEXIS 6795 (3d Cir. Mar. 4, 2020); Winter ex rel. United States v. Gardens Reg\u2019l Hosp. & Med. Ctr., Inc., <\/em>No. 18-55020, 2020 U.S. App. LEXIS 8986 (9th Cir. Mar. 23, 2020). Both cases involve disputes between relators and defendants about whether a physician\u2019s medical opinion is \u201cfalse\u201d within the meaning of the FCA. Although the relators prevailed on appeal in both cases, the Ninth Circuit\u2019s opinion in Winter<\/em> is far less problematic for FCA defendants. The Winter<\/em> panel\u2019s analysis makes clear that its holding does not represent a massive shift in approach and instead rejects only a label that some courts have used in analyzing disputes about medical opinions. Unfortunately, the Druding<\/em> panel\u2019s analysis creates the potential for significant confusion among lower courts bound by its holding and increases the risk that courts will allow meritless cases to proceed to discovery or trial.<\/p>\n\n\n\n

Winter<\/em> Background<\/a><\/strong>  |  Druding<\/em> Background<\/a><\/strong>  |  Analysis<\/strong><\/a><\/p>\n\n\n\n

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<\/a>  <\/p>\n\n\n\n

Winter <\/em><\/strong>Background<\/strong><\/h3>\n\n\n\n

In Winter<\/em>, the relator alleged that the defendants falsely certified that inpatient hospitalizations were medically necessary. 2020 U.S. App. LEXIS 8986 at *_. In relevant part, Medicare reimburses providers for inpatient hospitalization only if a physician certifies that admitting the patient to a hospital is reasonable and necessary for the patient\u2019s treatment and documents the factors supporting that certification in the patient\u2019s medical record. Id. <\/em>at *_ (reviewing relevant Medicare statutes). The regulation acknowledges that the factors relevant to such a determination are \u201ccomplex.\u201d Id.<\/em> (quoting 42 C.F.R. \u00a7 412.3). The relator alleged that the defendant hospital\u2019s inpatient admissions increased significantly after a new management company began jointly managing operations and identified sixty-five patients whose medical records allegedly did not support the need for inpatient treatment. Id.<\/em> at *_.<\/p>\n\n\n\n

The district court granted the defendants\u2019 motion to dismiss, holding that the relator had failed to allege \u201c\u2018an objectively false representation\u2019 . . . because \u2018subjective medical opinions . . . cannot be proven to be objectively false.\u2019\u201d Id.<\/em> at *_ (quoting United States v. Gardens Reg\u2019l Hosp. & Med. Ctr., Inc.<\/em>, No. CV 14-08850-JFW, 2017 U.S. Dist. LEXIS 221356, at *20 (C.D. Cal. Dec. 29, 2017)). The Ninth Circuit reversed, holding that \u201ca false certification of medical necessity can give rise to FCA liability.\u201d Id.<\/em> at *_. The court explained that a medical certification can be false \u201cfor the same reasons any opinion can be false or fraudulent,\u201d including \u201cif the opinion is not honestly held, or if it implies the existence of facts . . . that do not exist.\u201d Id.<\/em> at *_.<\/p>\n\n\n\n

<\/a>  <\/p>\n\n\n\n

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Druding <\/em>Background<\/strong><\/h3>\n\n\n\n

In Druding<\/em>, the relators alleged that the defendant falsely certified that patients were terminally ill and eligible for hospice care. Medicare reimburses hospice care for otherwise eligible patients when (1) one or more physicians certifies that the patient is \u201cterminally ill,\u201d meaning the patient has a life expectancy of six months or less, and (2) \u201c[c]linical information and other documentation that supports the medical prognosis\u201d is included in the patient\u2019s medical record. 2020 U.S. App. LEXIS 6795, at *4-6. Relevant guidance from the Medicare and Medicaid Services (CMS) explains that although \u201cmaking a prognosis [of terminal illness] is not an exact science,\u201d \u201ca medically sound basis that supports the clinical judgment\u201d is necessary for reimbursement. Id.<\/em> at *6-7 (quoting 79 Fed. Reg. at 50,470; 70 Fed. Reg. 70,532, 70,534-35 (Nov. 22, 2005)).<\/p>\n\n\n\n

Discovery produced \u201cdueling expert opinions.\u201d Id.<\/em> at *8. The relators\u2019 expert opined that, based on a review of a sample of patient records, thirty-five percent of the certifications of terminal illness were unsupported by the medical record. Id. <\/em>at *8-9. The defendant\u2019s expert opined that all of the defendant\u2019s certifications and diagnoses were appropriate. Id.<\/em> at *9.<\/p>\n\n\n\n

After discovery, the defendant moved for summary judgment and argued that the relators failed to establish each of the required elements:  falsity, scienter, and materiality. Id. <\/em>The district court granted summary judgment based exclusively on falsity. In reviewing the factual record, the district court concluded that there was no evidence that the defendant pressured physicians to admit ineligible patients and no evidence that any medical records at issue were falsified. Druding v. Care Alternatives, Inc.<\/em>, 346 F. Supp. 3d 669, 687-88 (D.N.J. 2018). Instead, the only evidence supporting the relators\u2019 case was the testimony of their expert, which the defendant\u2019s expert disputed. Citing the Third Circuit\u2019s prior statement that \u201cexpressions of opinion, scientific judgments or statements as to conclusions which reasonable minds may differ cannot be false,\u201d id.<\/em> at 688 (quoting United States ex rel. Hill v. Univ. of Med. & Dentistry of N.J.<\/em>, 448 F. App’x 314, 316 (3d Cir. 2011)), the district court held that a \u201cmere difference of opinion between physicians, without more<\/em>, is not enough to show falsity,\u201d 2020 U.S. App. LEXIS 6795, at *9 (quoting 346 F. Supp. 3d at 685 (emphasis added in 3d Cir. opinion)).<\/p>\n\n\n\n

The Third Circuit reversed, holding that \u201cexpert testimony that opines that accompanying patient certifications did not support patients’ prognoses of terminal illness\u201d was sufficient to establish a triable issue on the falsity element. Id.<\/em> at *11. It remanded the case to the district court with specific instructions that the elements of \u201cfalsity and scienter must be [analyzed] independent from one another.\u201d Id.<\/em> at *25.<\/p>\n\n\n\n

<\/a>  <\/p>\n\n\n\n

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Analysis<\/strong><\/h3>\n\n\n\n

Although the holdings in Druding <\/em>and Winter<\/em> are superficially similar, the depth of analysis and potential breadth of the holdings are quite different. In Winter<\/em>, the Ninth Circuit took care to tie its holding closely to existing FCA precedent addressing medical necessity certifications and to precedent addressing the falsity of opinions. By contrast, the Third Circuit\u2019s sweeping language and imprecise analysis in Druding<\/em> could create significant confusion in the lower courts.<\/p>\n\n\n\n

Both decisions start with the language of the FCA and conclude that, because Congress did not define the meaning of \u201cfalse or fraudulent,\u201d courts presume that Congress intended to incorporate the common law definitions. Winter<\/em>, 2020 U.S. App. LEXIS 8986 at *_; Druding<\/em>, 2020 U.S. App. LEXIS 6795, at *12. Both rely on the Supreme Court\u2019s holding in Omnicare, Inc. v. Laborers Dist. Council Constr. Indus. Pension Fund<\/em>, 575 U.S. 175 (2015) that opinions can be false under the securities laws. Winter<\/em>, 2020 U.S. App. LEXIS 8986 at *_; Druding<\/em>, 2020 U.S. App. LEXIS 6795, at *12. And both note that other circuits have held that medical opinions can be \u201cfalse or fraudulent\u201d within the meaning of the FCA. Druding<\/em>, 2020 U.S. App. LEXIS 6795, at *17-18 (citing United States ex rel. Polukoff v. St. Mark’s Hospital<\/em>, 895 F.3d 730, 742-46 (10th Cir. 2018)) and *19 (citing United States v. Paulus<\/em>, 894 F.3d 267, 275 (6th Cir. 2018)); Winter<\/em>, 2020 U.S. App. LEXIS 8986 at *_ (citing Paulus<\/em> and Polukoff<\/em>).<\/p>\n\n\n\n

The opinions diverge, however, in how they characterize the broader legal framework. The Winter<\/em> panel explains that its opinion is not a sea change in the law. The panel cites the Ninth Circuit\u2019s prior holding in Hooper v. Lockheed Martin Corp.<\/em>, 688 F.3d 1037 (9th Cir. 2012) that false estimates\u2014essentially opinions\u2014\u201ccan be a source of liability under the FCA.\u201d Id.<\/em> at *_; see also Hooper<\/em>, 688 F.3d at 1049 (explaining that a bid can be false when it \u201cis not what the defendant actually intends to charge\u201d). It also explains that the breadth of its holding should be limited by \u201cstrict enforcement of the [FCA\u2019s] materiality and scienter requirements,\u201d Winter<\/em>, 2020 U.S. App. LEXIS 8986 at *_ (quoting United Health Servs., Inc. v. United States ex rel. Escobar<\/em>, 136 S. Ct. 1989, 2002 (2016)), and by the traditional requirements imposed by common law to limit claims of fraud based on subjective opinions, id.<\/em> at *_ (explaining that an opinion is actionable if it \u201cimplies the existence of facts that do not exist, or if it is not honestly held,\u201d or if the speaker lacks sufficient facts to justify it).<\/p>\n\n\n\n

The Winter <\/em>panel also notes that its holding is \u201cnot directly . . . contrary\u201d to the Eleventh Circuit’s recent decision in United States v. AseraCare, Inc.<\/em>, 938 F.3d 1278 (11th Cir. 2019). \u201cIn AseraCare<\/em>, the Eleventh Circuit held that \u2018a clinical judgment of terminal illness warranting hospice benefits under Medicare cannot be deemed false, for purposes of the False Claims Act, when there is only<\/em> a reasonable disagreement between medical experts as to the accuracy of that conclusion, with no other evidence<\/em> to prove the falsity of the assessment.\u2019\u201d Winter<\/em>, 2020 U.S. App. LEXIS 8986 at *_ (quoting AseraCare<\/em>, 938 F.3d at 1281 (emphases added in Winter<\/em>)). The Winter<\/em> panel explains that its holding is consistent with AseraCare <\/em>for two reasons:  (1) AseraCare <\/em>recognized that medical opinions can be false under certain circumstances but not when the only evidence of falsity is disputed expert testimony, and (2) AseraCare<\/em> recognized that applicable regulations provided for a more deferential standard of review for certifications of terminal illness\u2014the issue in AseraCare <\/em>and in Druding<\/em>\u2014than the medical necessity standard at issue in Winter<\/em>. Id.<\/em> at *_. The Winter<\/em> panel also notes that, unlike AseraCare<\/em>, it was considering a motion to dismiss that required acceptance of the relator\u2019s allegations, which went well beyond \u201cjust a reasonable difference of opinion.\u201d Id.<\/em> at *_.<\/p>\n\n\n\n

When compared to the careful analysis in Winter<\/em>, the analysis in Druding<\/em> suffers because the panel creates a strawman rather than engaging with the opinion below and supporting authorities. In the Third Circuit\u2019s view, the district court improperly immunized all medical opinions from liability and botched its analysis of the falsity element in multiple ways. But a careful reading of the district court\u2019s opinion and supporting authorities reveals that neither of these premises are accurate.<\/p>\n\n\n\n

First, the Druding<\/em> panel mistakenly asserts that the district court established a \u201cbright-line rule that a doctor\u2019s clinical judgment cannot be \u2018false,\u2019\u201d id.<\/em> at *18, and indicates its intent to \u201cdepart\u201d from the Eleventh Circuit\u2019s holding in AseraCare<\/em> that \u201cclinical judgments cannot be untrue,\u201d id.<\/em> at *23-24. But the district court held, consistent with the reasoning in AseraCare<\/em>,that a dispute between the parties\u2019 experts\u2014without more\u2014was insufficient to establish a triable issue. Druding<\/em>, 346 F. Supp. 3d at 688; see also AseraCare<\/em>, 938 F.3d at 1281. The AseraCare <\/em>court found for the defendant not only because the government\u2019s expert failed to testify that \u201cno reasonable doctor could have concluded that the identified patients were terminally ill at the time of certification,\u201d but also because he reversed his own opinion on several patients over the course of the litigation while continuing to assert \u201cthat both sets of contradictory opinions remained \u2018accurate to a reasonable degree of certainty.\u2019\u201d Id.<\/em> at 1287-88.<\/p>\n\n\n\n

The Druding <\/em>panel\u2019s outright rejection of the holding in AseraCare<\/em> creates unnecessary confusion. It is possible that the two courts actually reached the same conclusion\u2014that an expert\u2019s opinion asserting that no reasonable physician could have reached the conclusions at issue creates a triable issue of fact on falsity. See<\/em> AseraCare<\/em>, 938 F.3d at 1305 n.18 (explaining that \u201cthe Government could meet its burden under the falsity standard . . . if it could establish through expert testimony that no reasonable physician<\/em> reviewing the medical records at issue could have concluded that a particular patient was terminally ill\u201d) (emphasis added)). Because the Druding <\/em>panel chose to distinguish AseraCare <\/em>legally rather than engaging factually, it leaves significant questions about what expert testimony is required to create a triable issue of fact, as the Third Circuit and district court offer divergent characterizations of the record. Compare <\/em>2020 U.S. App. LEXIS 6795, at *8-9 (asserting\u2014without citation to the record\u2014that the relators\u2019 expert opined that no reasonable physician would have certified the patients at issue as terminally ill) with <\/em>346 F. Supp. 3d at 688 (noting that the relators\u2019 expert testified \u201cthat 12 of the 15 patients identified in the Amended Complaint were actually appropriate for hospice for at least part of their stay and . . . that reasonable physicians could differ with his assessment\u201d (record citations omitted)).<\/p>\n\n\n\n

Second, the Druding <\/em>panel unnecessarily criticized the district court for the process it used to analyze the falsity element. Although the panel chastises the district court for improperly \u201climit[ing] its analysis to factual falsity,\u201d Druding<\/em>, 2020 U.S. App. LEXIS 6795, at *16, the district court\u2019s opinion makes clear that it analyzed the relators\u2019 claims under a legal falsity framework,1<\/a><\/sup> see<\/em> Druding<\/em>, 346 F. Supp. 3d at 682-83 (explaining that the relators \u201cinvoke\u201d the \u201cimplied false certification theory,\u201d which is a form of legal falsity and citing Escobar<\/em>, 136 S. Ct. at 2001, for the necessary requirements); id. <\/em>at 687-88 (reviewing evidence in the record and concluding that the only evidence supporting a false certification is the testimony of the relators\u2019 expert). Similarly, the panel\u2019s criticism of the district court\u2019s \u201cimproper[] conflat[ion] [of] the elements of falsity and scienter\u201d in its analysis, 2020 U.S. App. LEXIS 6795, at *11 is also unfounded and is directly contradicted by the authorities the panel cites in support of its holding, see, e.g.<\/em>, id.<\/em> at *12 (citing Omnicare<\/em>, 575 U.S. at 183-86). In Omnicare<\/em>, the Supreme Court explained that a determination of whether an opinion is true or false necessitated consideration of the speaker\u2019s \u201cown state of mind,\u201d Omnicare<\/em>, 575 U.S. at 184, even though the statute at issue in that case did not require proof of intent to deceive or defraud, id.<\/em> at 175. And, to the extent a challenge to the opinion concerns the factual basis for it\u2014either the absence of supporting facts or the presence of contradictory facts\u2014that \u201cinquiry . . . is objective.\u201d Omnicare<\/em>, 575 U.S. at 186-87 (explaining that whether a statement is \u201cmisleading\u201d under the securities laws \u201cdepends on the perspective of a reasonable investor\u201d). Similarly, in Paulus<\/em>, the Sixth Circuit explained that, to be actionably false, a statement must be \u201ccapable of confirmation or contradiction\u201d\u2014a seemingly objective inquiry. 894 F.3d at 275 (quoting United States v. Kurlemann<\/em>, 736 F.3d 439, 445 (6th Cir. 2013)).<\/p>\n\n\n\n

As a result, it is unclear what the Druding <\/em>panel expects of lower courts. It is likely that Druding <\/em>requires a plaintiff\u2019s expert to opine that no reasonable physician could have reached the conclusion at issue\u2014the standard in AseraCare <\/em>and Paulus<\/em>\u2014but it is possible given the district court\u2019s description of the record that an individual expert\u2019s personal disagreement with the treating physician is sufficient to create a triable issue of fact. Moreover, because the Druding <\/em>panel repeatedly \u201creject[s] the objective falsehood standard\u201d without providing clear guidance on alternative standards for pleading and proof, there is an increased risk that district courts will let meritless cases go to discovery or trial.<\/p>\n\n\n\n

Given the Ninth Circuit\u2019s more careful analysis in Winter<\/em> and its explanation of why its holding does not conflict directly with AseraCare<\/em>, it is unlikely that the Supreme Court will address whether the FCA requires \u201cobjective falsity.\u201d Defendants that are forced to address Druding<\/em> should carefully direct the court to the standards articulated in Omnicare<\/em>. As the Ninth Circuit has explained in applying Omnicare<\/em>, an opinion can be false only if (1) \u201c\u2018the speaker did not hold the belief she professed\u2019 and . . . the belief is objectively untrue\u201d; (2) \u201ca statement of fact contained within an opinion statement is materially misleading\u201d because it is untrue; or (3) the opinion statement is objectively misleading due to the omission of a material fact. City of Dearborn Heights Act 345 Police & Fire Ret. Sys. v. Align Tech., Inc.<\/em>, 856 F.3d 605, 615 (9th Cir. 2017) (quoting Omnicare<\/em>, 575 U.S. at 185\u201386). When pleading the falsity of a medical opinion, a plaintiff should, at a minimum, be required to identify specific facts that allegedly make the opinion false rather than simply pleading a conclusory disagreement on the ultimate issue. And at the summary judgment stage, an FCA plaintiff should be required to offer at least an expert opinion of objective unreasonableness and not just the expert\u2019s subjective disagreement with the treating physician.<\/p>\n\n\n\n

BACK TO TOP<\/a><\/p>\n\n\n\n

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1<\/a><\/sup> Many courts have identified two \u201ckinds\u201d of falsity under the FCA:  factual falsity, which occurs \u201cwhen the facts contained within the claim are untrue,\u201d and legal falsity, which occurs “when the claimant . . . falsely certifies that it has complied with a statute or regulation.\u201d Druding<\/em>, 2020 U.S. App. LEXIS 6795, at *15 (emphasis removed).<\/p>\n","protected":false},"excerpt":{"rendered":"

Analysis:United States ex rel. Druding v. Care Alternatives, Inc. (3rd Circuit) \u2022 Winter ex rel. United States v. Gardens Reg\u2019l Hosp. & Med. Ctr., Inc. (9th Circuit) In recent decisions this month, the Third and Ninth Circuits reversed defense victories predicated on the \u201cobjective falsity\u201d standard under the False Claims Act (FCA). See United States ex\u2026<\/p>\n","protected":false},"author":8,"featured_media":0,"menu_order":0,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"tags":[],"publication-type":[],"class_list":["post-5616","publications","type-publications","status-publish","format-standard","hentry"],"acf":[],"yoast_head":"\nTwo Circuits Hold the FCA Does Not Require \u201cObjective Falsity,\u201d Creating\u00a0Confusion on the Appropriate Standard - Dinsmore & Shohl<\/title>\n<meta name=\"description\" content=\"Two Circuits Hold the FCA Does Not Require \u201cObjective Falsity,\u201d Creating\u00a0Confusion on the Appropriate Standard Read insights and legal analysis from attorneys at Dinsmore & Shohl LLP.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.dinsmore.com\/publications\/two-circuits-hold-the-fca-does-not-require-objective-falsity-creating-confusion-on-the-appropriate-standard\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Two Circuits Hold the FCA Does Not Require \u201cObjective Falsity,\u201d Creating\u00a0Confusion on the Appropriate Standard\" \/>\n<meta property=\"og:description\" content=\"Two Circuits Hold the FCA Does Not Require \u201cObjective Falsity,\u201d Creating\u00a0Confusion on the Appropriate Standard Read insights and legal analysis from attorneys at Dinsmore & Shohl LLP.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.dinsmore.com\/publications\/two-circuits-hold-the-fca-does-not-require-objective-falsity-creating-confusion-on-the-appropriate-standard\/\" \/>\n<meta property=\"og:site_name\" content=\"Dinsmore & Shohl\" \/>\n<meta property=\"article:modified_time\" content=\"2025-10-01T19:55:47+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.dinsmore.com\/wp-content\/uploads\/2020\/03\/the-long-way-HERO.jpg\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"14 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/www.dinsmore.com\/publications\/two-circuits-hold-the-fca-does-not-require-objective-falsity-creating-confusion-on-the-appropriate-standard\/\",\"url\":\"https:\/\/www.dinsmore.com\/publications\/two-circuits-hold-the-fca-does-not-require-objective-falsity-creating-confusion-on-the-appropriate-standard\/\",\"name\":\"Two Circuits Hold the FCA Does Not Require \u201cObjective Falsity,\u201d Creating\u00a0Confusion on the Appropriate Standard - 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