United States District Court, D. Maryland
UNITED STATES OF AMERICA ex rel. ANTHONY C. CAMPOS
THE JOHNS HOPKINS HEALTH SYSTEM CORPORATION
Catherine Blake United States District Judge
Anthony C. Campos ("Campos") brings this qui
tarn action under the federal False Claims Act
("FCA"), 31 U.S.C. §§ 3729, et
seq., against defendant The Johns Hopkins Health System
Corporation ("Hopkins"). Campos alleges Hopkins
violated 31 U.S.C. § 3729(a)(1)(A) and (B) when it
engaged in a scheme to prioritize out-of-state patients and
then submitted claims to the federal government representing
its compliance with contracts which, according to Campos,
prohibited such a scheme. Now pending is Hopkins's motion
to dismiss. For the reasons set forth below, Campos has
failed to state a claim, and the motion will be granted.
motion to dismiss stage, this court accepts as true the facts
alleged in the complaint. See Aziz v. Alcolac, 658
F.3d 388, 390 (4th Cir. 2001). Hopkins is a corporation
created in 1986 under the laws of Maryland, which has
multiple subsidiaries. ECF No. 10, ¶11. The subsidiaries
relevant to this case are the Johns Hopkins Hospital, the
Johns Hopkins Bayview Medical Center, Howard County General
Hospital, and Suburban Hospital ("Hopkins
Subsidiaries"). Id. Campos was the Director of
Patient Access Operations at Hopkins from December 2011 to
January 2017. Id. at ¶ 6. In that capacity he
oversaw a twenty-five person team of operations analysts,
operations and call center managers, and patient access
managers for approximately eighteen medical departments
within Hopkins. Id. He also oversaw a three hundred
and seventy person Patient Access call center, which was
responsible for scheduling patients for all appointments
throughout the Hopkins medical system. Id. Campos is
the original source of the facts and information set forth in
the complaint concerning Hopkins' activities.
Id. at ¶ 8.
February 11, 2014, the Centers for Medicare and Medicaid
("CMS") and the State of Maryland entered into the
Maryland All-Payer Model Agreement ("Model
Agreement"). ECF No. 10, ¶ 17. The Model Agreement
establishes how regulated Maryland hospitals, including the
Hopkins Subsidiaries, are reimbursed for services by CMS and
the State of Maryland through Medicare and Maryland Medicaid.
Id. Pursuant to the Model Agreement, Maryland's
Health Services Cost Review Commission ("HSCRC"),
the agency authorized to set hospital rates in Maryland,
follows a Global Budget Revenue ("GBR") Model.
Id. at ¶21. Under the GBR Model, an annual
budget cap for each hospital in Maryland is pre-established
so that each hospital's annual revenue from providing
hospital services is known at the beginning of the fiscal
year, regardless of the number of patients actually treated
or the amount of services actually delivered. Id.
The GBR Model was implemented pursuant to a provision of the
Social Security Act which authorizes CMS to "test
innovative payment and service delivery models that have the
potential to reduce Medicare, Medicaid, or Children Health
Insurance Program ("CHIP") expenditures while
maintaining or improving the quality of care for
beneficiaries." ECF No. 10-2, p. 1. .
14, 2014, the HSCRC and Hopkins entered into an agreement
pursuant to the GBR Model (the "Global Budget
Agreement"), which used Hopkins's past history
regarding the volumes, costs, and patterns of its hospital
services to establish Hopkins's annual budget cap.
Id. at ¶ 22. Importantly, during the relevant
time period, Hopkins's annual budget cap applied only to
health care services provided to Maryland residents.
Id. at ¶23, except that at Howard County
General Hospital services provided to out-of-state patients
were also included. ECF No. 10-3, p. 19. Revenue for services
provided to out-of-state residents at any of Hopkins's
other three hospitals was not counted towards the cap.
Id. As a result, any revenue earned by Hopkins for
such services increased Hopkins's overall revenue beyond
the annual budget cap. Id.
provisions of the Global Budget Agreement are relevant for
purposes of this case.
a provision within the "Overview" section:
In accepting this Agreement, each JHHS Hospital agrees to
operate within the GBR's financial constraints and to
comply with the various patient-centered and
population-focused performance standards that have been or
will be established by the HSCRC .... ECF No. 10-3, p. 4.
a provision within a subsection of a section entitled
"Monitoring of GBR Operation and Performance, "
entitled "Case Mix/Severity Levels":
The HSCRC will pay close attention to the overall case mix
and the severity levels within DRGs at each Hospital. If
requested, the Hospital will demonstrate to the HSCRC that
any reductions in its case mix index or its severity levels
are not the result of deliberate efforts by the Hospital to
deny, for inappropriate financial reasons, any services to
particular patients, or treatments for particular conditions
that fall within the scope of the medical capabilities of the
Hospital and its attending medical staff. ECF No. 10-3, p.
a provision within a section entitled "Out-of-Area and
Out-of-State Volumes and Revenues":
Significant changes in out-of-state volume and volumes from
outside an individual Hospital's PSA and SSA have the
potential to positively or negatively affect the success of
the GBR Model. In FY 2013, approximately 17.97 percent of the
Hospital System's total revenue came from non-Maryland
residents. If this percentage changes materially during the
term of this Agreement, the HSCRC staff and the Hospital will
evaluate the causes of the change to ensure that the goals
and objectives of this Agreement, the GBR model and the final
contract between CMMI and the State of Maryland are not being
undermined by such changes. ECF No. 10-3, p. 14.
alleges that Hopkins violated these three provisions of the
Global Budget Agreement when it engaged in a campaign to
recruit out-of-state patients at the expense of instate
patients. This campaign was known as the campaign to
"fill the plane with the right kind of
travelers"-to completely fill Hopkins's hospital
schedule, using as many out-of-state patients as possible.
ECF No. 10, ¶¶ 27-28. Campos offers numerous
details about this scheme. The most relevant are set forth
Hopkins's senior management initiated the campaign for
the explicit purpose of increasing revenue, which Hopkins
could do only by treating out-of-state patients who were not
subject to the annual budget cap. Id. at
¶¶ 27-31, 34, 3 7.
doctors expressed concern about this campaign but were
ignored by senior management. Id. at ¶¶
pursuant to the orders of Hopkins's senior management,
the Department of Patient Access began implementing practices
and procedures that gave out-of-state patients priority
access to appointments. Id. at ¶¶ 35-37.
Specifically, all domestic out-of-state patients were to be
offered an appointment within thirty days, regardless of
clinical urgency or necessity. Id. at ¶ 40. The
Patient Access call center, 'which was responsible for
ensuring this came to pass, was told to focus specifically on
the most profitable departments. Id. at ¶¶
40-41. Campos alleges personal knowledge that one of those
departments, the Department of Otolaryngology, had a policy
that if an out-of-state patient could not initially be
scheduled within thirty days, a supervisor was to get
involved to ensure that the appointment was provided within
that time period. The department had a policy of giving
in-state patients an appointment within forty-two days, and
there was no ...