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NICA Class-Action Lawsuit
NICA Class-Action Lawsuit
NICA Class-Action Lawsuit
AMENDED COMPLAINT
Relators Veronica ("Roni") N. Arven and the Estate of Theodore Arven, III, by and
through undersigned counsel, bring this Amended Complaint on their own behalf as well as on
behalf of the United States pursuant to the qui tam provisions of the federal False Claims Act (31
U.S.C. § 3729 et seq.) against the Florida Birth-Related Neurological Injury Compensation
Association ("the Florida Association") and the Florida Birth-Related Neurological Injury
Compensation Plan ("the Florida Plan") (collectively, "NICA") and in support thereof state as
follows:
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I. OVERVIEW
1. Relators bring this qui tam action on their own behalf as well as on behalf of the
United States to recover treble damages, civil penalties, attorneys' fees and costs for damages to
2. In the late 1980's, Virginia was the first state in the United States to develop a
neurological birth injury compensation fund completely removed from the common law tort
system. Florida developed its own neurological birth injury compensation fund shortly thereafter.
These funds remove the most complex medical malpractice claims from the tort system, providing
an alternative means for compensating the participant for his or her birth-related neurological
injuries. Florida and Virginia are the only two states in the United States to enact statutes creating
3. Roni Arven and Theodore ("Ted") Arven, Ill (deceased) (collectively, ''the
Arvens") are the parents of Cody Arven, a minor child. At all times relevant to this Amended
Complaint, Cody Arven was ~ participant in the Virginia Birth-Related Neurological Injury
Compensation Program (''the Virginia Program"). Cody also became a Medicaid participant in
2014.
Medicaid and the Virginia Program, they learned that the Virgini& Program was knowingly causing
them and numerous other Virginia Program participants to submit false claims to Medicaid. By
federal law, Medicaid is the "payer of last resort" for any and all health care claims for a covered
beneficiary. The Virginia Program nevertheless required its participants to submit health care
claims to Medicaid prior to submitting health care claims to the Program, in effect making the
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5. On July 7, 2015, the Arvens filed under seal a federal False Claims Act complaint
against the Virginia Program in the Eastern District of Virginia, styled United States ex rel.
Theodore Arven, III and Veronica N. Arven v. The Virginia Birth-Related Neurological Injury
Compensation Program, I: 15-cv-870 ("the Virginia Case"). The sealed complaint was
accompanied by a Material Disclosure Memorandum along with substantially all material evidence
and information in the Arvens' possession. This material evidence referenced NICA (the Florida
Association and Plan) and its nearly identical operation. Early on in the case, the Arvens, through
counsel, alerted the Department of Justice to the likelihood that, as with the Virginia Program,
NICA was causing Florida participants to submit false claims for payment to Medicaid.
6. Over the past 30 years, NICA has also declared itself the "payer of last resort" and
shifted much of the costs of care for NICA participants onto the Medicaid program-just like the
Virginia Program did (at least until the Arvens' Virginia Case). Therefore, like the Virginia
.
Program, NICA has knowingly caused numerous NICA participants to submit false claims for
7. NICA has also instructed participants that Medicaid's lien is waived upon award of
NICA benefits, and that neither NICA nor its participants must repay Medicaid for what Medicaid
paid on claims prior to the participants' entry into the Florida Plan. Therefore, NICA has
knowingly concealed or knowingly and improperly avoided or decreased NICA and/or NICA
II. PARTIES
8. At all times relevant hereto, Cody Arven was a participant in the Virginia Program
and was also eligible for Medicaid. Since Cody is a minor child, the Arvens were and are
responsible for his care and upkeep, including managing his health care needs, which includes
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interacting with the Virginia Program as well as with Medicaid. Through those interactions, and
information received and reviewed in connection with the investigation of the Arvens' Virginia
Case, the Arvens learned that Florida operated a neurological birth injury fund- NICA- very
similar to the Virginia Program and that NICA caused participants to submit false claims to
Medicaid.
9. Relater Veronica ("Roni") N. Arven is the mother of Cody Arven, a minor child.
10. Roni Arven's sex-husband, Theodore ("Ted") Arven, III, resided at 721 Governor
Morrison Street #645, Charlotte (Mecklenburg County), North Carolina 28211, at the time of his
sudden passing on March 17, 2019. Ted was Cody's father. Ted Arven's mother, Mary Pearson
Arven, 3076 Streamhaven Drive, Indian Land, South Carolina 29707, is named in Ted's Will as
the Executor of his Estate. On August 12, 2019, Mary Pearson Arven qualified in Mecklenburg
County (NC) Superior Court as Executor of the Estate of Theodore Arven, III. By and through
Mary Pearson Arven as Executor, the Estate ofThedore Arven, III, is a Relator in this action.
11. The Florida Association and Plan have their headquarters and principal place of
12. The Florida Association and Plan each qualify as a ''person" as that term is defined
by the federal False Claims Act. Pursuant to §§ 766.303(3) and 766.31, Fla. Stat., the Florida
Association and Plan are properly subject to a federal False Claims Act lawsuit for causing
participants to submit false claims for payment to Medicaid for care and services covered and
payable by NICA.
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13. This Court has jurisdiction over the subject matter of this action pursuant to 28
14. At all times relevant to the Complaint and Amended Complaint, NICA was
administered to participants throughout the State of Florida, including participants within this
15. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b)(2) and 31 U.S.C.
§ 3732(a).
17. Relators state that to the best of their knowledge none of the allegations against
NICA contained in the Complaint or this Amended Complaint have been publicly disclosed;
however to the extent any of these allegations have been disclosed, the Arvens are the "original
IV. MEDICAID
19. Medicaid was created in 1965 in Title XIX of the Social Security Act. Medicaid is
a joint state and federal assistance program that pays medical expenses for low-income patients.
20. Funding for Medicaid is shared between the Federal Government and those states
participating in the program. The Federal Government pays state agencies the Federal Medical
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21. Many Medicaid recipients have additional sources of health care insurance
coverage, such as Medicare, TRICARE, or a private insurance company. Such "third parties"
include "any individual, entity or program that is or may be liable to pay all or part of the
expenditures for medical assistance furnished under a State plan." 42 C.F.R. § 433.136 (emphases
added); see also 41 U.S.C. § 1396a(25)(A) (defining "third parties" as "parties that are, by statute,
contract, or agreement, legally responsible for payment of a claim for a health care item or
service").
22. Federal law establishes a priority by which entities are responsible for paying a
23. Medicaid is the "payer of last resort" as a matter of federal law, meaning that all
other third party sources of health insurance coverage must be exhausted before Medicaid pays a
claim.
24. State Medicaid agencies take measures to determine whether a third party is liable
for some or all of a recipient's claim for a health care item or service. At the time of an individual's
payors that are liable to pay claims for health care items or services. Medicaid recipients are also
required to assign Medicaid all rights to medical support and medical care payments from third
parties.
25. Medicaid does not pay claims that it knows are the actual or probable liability of
third party health insurance coverage or a third party health insurance program.
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26. Medicaid routinely rejects, and refuses to pay, claims for which a third party is
actually or potentially liable. Such claims are returned to the health care provider to determine the
liability of all third parties. Once determined, Medicaid will only pay the amount of the claim that
exceeds the total liability of all third parties, subject to Medicaid's rate schedule.
27. If no third party is responsible for the claim, or third party benefits are not available
at the time the claim is presented, then Medicaid must pay the claim in full (subject to Medicaid's
rate schedule). However, if Medicaid subsequently learns a third party is liable for some or all of
the claim, or that third party benefits have become available, the third party must pay Medicaid for
28. Cody Arven is the child of Ted and Veronica Arven. He was born on May 28,
29. In the months following his birth, Cody was evaluated via ultrasound and Magnetic
Resonance Imaging ("MRI"). The MRI showed large bilateral areas of periventricular cyst
formation in bis brain, along with scattered smaller cysts throughout the remainder of his cortex.
His doctor, Dr. Linda Krell, found that he suffered from severe bilateral cystic periventricular
30. Cody's treating physicians concluded that his condition was "birth-related" as
defined by Va. Code Ann. § 38.2-5001. The Arvens therefore submitted a Petition under the
Virginia Act on Cody's behalf on December 28, 2006. The Virginia Program concluded that Cody
Arven met the requirements for eligibility under the Virginia Birth-Related Neurological Injury
Compensation Act, is codified at Va. Code Ann. § 38.2-5000 et seq. (the "Virginia Act"), and he
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31 . After Cody Arven was admitted to the Virginia Program, George Deebo, Executive
Director of the Virginia Program, directed the Arvens to apply for Medicaid.
32. At that time, the Arven family was not on Medicaid and they told Deebo as much.
33 . Nevertheless, Deebo instructed the Arvens to apply for Medicaid just in case they
might be eligible for some benefits. Deebo further told the Arvens that the Virginia Program
encouraged its families to apply for and if possible receive Medicaid so that the Medicaid program
34. Years later, in 2014, the Arven family did in fact become eligible for Medicaid.
35. At that time, they were again directed to submit claims related to Cody's health care
36. The Arven family did as they were told, and the resulting claims were false. These
false claims were submitted by the Arvens only because Deebo and others at the Virginia Program
37. The Arvens had specific knowledge that this scheme was widespread and that other
Virginia Program participants followed Deebo's instruction to try and obtain Medicaid.
38. As a result, the Arvens brought the Virginia Case against the Virginia Program in
2015. In the course of investigating the Virginia Case and prior to filing suit, the Arv ens learned
that Florida was the only other state in the nation that maintained a neurological birth-injury
compensation fund. The Arvens further learned through investigation that the Florida fund, NICA,
operated in nearly identical fashion to the Virginia Program and likely caused participants to
submit false claims to Medicaid just like Deebo and others at the Virginia Program had caused the
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39. The State of Florida is a participant in the federal Medicaid program. The Florida
Medicaid program is administered by the Florida Agency for Health Care Administration
("ARCA").
40. The Florida Legislature enacted the Medicaid Third-Party Liability Act, which
provides: "Medicaid [is] the payor of last resort for medically necessary goods and services
furnished to Medicaid recipients. All other sources of payment for medical care are primary to
medical assistance provided by Medicaid." Fla. Stat§ 409.910(1); see also Fla. Stat.§ 409.910(2)
("Third-party benefits for medical services shall be primary to medical assistance provided by
Medicaid.").
41 . Florida Medicaid recipients must inform ARCA of third parties that are potentially
42. In the initial application for Florida Medicaid benefits, Floridians must disclose all
43. Third party payer information is documented in the individual's Medicaid file and
added to the Florida Medicaid Management Information System C'FMMIS"). FMMIS is utilized
when processing Medicaid claims to avoid payment of claims for which a third party is liable.
44. When a Medicaid recipient is treated by a health care provider, the provider
presents a claim for payment to AHCA on behalf of the recipient. The claim is routed through
FMMIS, which instructs the provider to bill the identified third parties prior to submitting a claim
to Medicaid. If the provider resubmits the Medicaid claim, AHCA pays the balance, which
represents the difference between the total third party liability and the full amount of the claim,
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45. AHCA Medicaid payments are comprised of federal, state, and local funds. For
example, in 2017, the Florida Medicaid program was funded with approximately 61 % federal
funds and 39% funds from the state and local governments or taxes on health care providers such
as hospitals and nursing homes. Therefore, approximately $0.61 of every dollar paid by AHCA
46. Medicaid recipients' obligation to disclose third party sources of health insurance
coverage or benefits is continuing in nature. Medicaid applicants and recipients must inform
AHCA of any entity that is or may be liable to provide third party benefits.
47. Consistent with federal law, AHCA is required to seek reimbursement from a third
party once it learns of a previously unknown third party benefit, or when third party benefits are
discovered or become available after payment of a Medicaid claim. See Fla. Stat. § 409.910(4).
48. Florida law grants AHCA certain rights to recover third party benefits, including
(i) the right of subrogation against the third party to recover the full amount of the Medicaid claim;
(ii) the assignment of a Medicaid participant's right, title, and interest in any third party benefit;
and (iii) an automatic lien for the full amount of the Medicaid claim. See Fla. Stat. § 409.940(6).
49. Third parties also have certain duties when providing health care benefits to
Medicaid participants-including, but not limited to, the duty to inquire with AHCA when they
have knowledge or are on notice of a person's participation in Medicaid within one year of the
date of the health care giving rise to the claim. See, e.g., Fla. Stat. § 409 .940(6)(c)(7).
50. The foregoing creates an obligation on the part of third parties to repay AHCA for
Medicaid funds that were the third parties' responsibility but were paid by Medicaid.
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51. When ARCA receives reimbursement from a third party for a Medicaid claim,
AHCA has to repay the United States its pro rata share. See 42 C.F.R. § 433.140(c). For example,
in 2017, AHCA must pay the United States 61 % of each third party reimbursement.
VII. NICA
52. The Florida Association is an independent entity created by Florida Statute in 1988
for the purposes of administering the Florida Plan. See Fla. Stat. § 766.303, et seq.
53. The Florida Plan provides compensation for children who sustain mentally and
54. To be awarded compensation, a petition must be filed on behalf of the injured child
with the Florida Division of Administrative Hearings. See Fla. Stat. § 766.305(1). Within ten days
of filing the petition, the Florida Association must be furnished with all available relevant medical
incurred to date which identifies any payment made for such expenses and services and the payor;"
relative to the impairments." Fla. Stat. § 766.305(3). An administrative law judge sets the matter
over for a hearing up to 120 days from the filing of the petition, at which time the judge determines
the compensability of the child's injury and the amount of compensation, if any, awardable under
55. An award under NICA includes (a) the actual expenses for medically necessary and
reasonable treatment related to the injury, as well as certain related expenses; (b) a lump sum or
periodic payments totaling $100,000 as well as a death benefit of $10,000; and (c) expenses in
connection with filing a claim. See Fla. Stat. § 766.31(1). The award requires "the immediate
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payment of expenses previously incurred and shall require that future expenses be paid as
56. NICA will not cover any items or services for which the injured child has received
or is entitled to receive payment or reimbursement Hunder the laws of any state or the Federal
Government, except to the extent such exclusion may be prohibited by federal law." Fla. Stat.
§ 766.31(1)(a)(l, 3).
57. The exclusion of Medicaid eligible items or services from payment by NICA is
A. Even Though, Under Federal Law, Medicaid Is Always the Payer of Last
Resort, NICA Requires Participants to Submit Claims to Medicaid Before
Payment by the Florida Plan.
58. In a 2015 article that she authored, NICA's Executive Director Kenney Shipley
stated how NICA is supposed to function: "Once a clam has been approved, NICA provides
anything that is 'medically necessary and reasonable' for the child for the rest of his or her life."
http://flbog.sip.ufl.edu/risk-rx-article/nica-floridas-innovative-altemative-to-costly-litigation,
accessed July 22, 2019, attached hereto as Exhibit A. NICA actually functions very differently,
instead forcing Plan participants to submit their claims first to Medicaid for payment before NICA
59. NICA's September 3, 2015 statement of plan policy declares that the Florida Plan
"is the payer oflast resort; that is, the Plan pays after available insurance or governmental programs
have paid for such medically necessary and reasonable expenses." See NICA, Benefit Handbook,
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60. The Florida Association provides certain procedures for filing a claim for benefits
under NICA. Those procedures reiterate the Florida "Plan is the payer of last resort. As such, the
Plan must be provided with a copy of the NICA covered individual's health insurance policy, if
there is one, and Medicaid/Medicare eligibility before benefits can be paid from the Plan." See
Exhibit B, at 17.
61. NICA requires the parents or legal guardians of an injured child to "seek benefits
from other sources for which they are eligible" before submitting a claim to the Florida Plan. See
Exhibit B, at 17. Such other sources of benefits include Medicaid., For example, NICA requires
that th.e parent first submit a claim to Medicaid for diapers, and NICA will not pay for those diapers
unless first provided with Medicaid denial information. See Exhibit B, at 14.
62. If a parent does not seek payment of a health care claim from private insurance or
governmental programs (including Medicaid), NICA "may not reimburse or may reimburse at a
lower amount for benefits that the child would be eligible for." See Exhibit B, at 17-18.
63. NICA admitted to its external auditors that Medicaid has been paying for NICA-
covered services. NICA' s audited financial statements for fiscal years 2016 and 2017 report:
"Since the payments made by Medicaid reduce the amounts that would be paid by NICA otherwise,
any change in the portion of benefits covered by Medicaid could impact NICA's loss and loss
adjustment expenses." Florida Birth-Related Neurological Injury Compensation Ass 'n, Financial
Statements, Years Ended June 30, 2017 and 2016, at 6, attached hereto as Exhibit C. Despite this
admission, and an explicit recognition that it could be a "liable third party to Medicaid," Exhibit ,
C, at 6, NICA did not self-report or disclose to the federal government that it has caused
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B. Even Though Federal Law Requires Third Parties to Repay Medicaid Liens,
NICA Does Not Repay Participants' Medicaid Liens.
64. Prior to entry into NICA, neurologically birth-injured children undergo significant
medical care and treatment and incur commensurate medical expenses, which are paid by the
family, private insurance, or federal and/or state medical programs. Often these expenses are paid
by Medicaid. The NICA award includes reimbursement for those medical expenses incurred
before entering the Florida Plan. See Fla. Stat. § 766.31 (1 )-(2).
65. To the extent Medicaid paid claims for health care items or services arising from
the injured child's neurological birth injury, Medicaid has a lien for the amounts it paid (i.e., its
conditional payments). When third party benefits become available-such as a NICA award-
68. Instead, NICA instructs participants that: (i) N1CA is not a third party for purposes
of Medicaid; (ii) it need not repay Medicaid's lien; and (iii) that the Medicaid lien is "withdrawn."
69. N1CA's Executive Director Kenney Shipley made NICA's position clear in 2015
when she wrote: "If there is a Medicaid lien, it is withdrawn," adding, contrary to federal law,
''NICA is not a 'third party' for the purpose of collecting a Medicaid lien." K. Shipley, NICA -
70. Upon information and belief, Medicaid's lien for amounts paid prior to an injured
child's entry into NICA is not waived by the federal Centers for Medicare and Medicaid Services
("CMS") or by ARCA.
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71. Paragraphs 1 through 70 are hereby incorporated as if fully set forth herein.
72. The United States seeks relief against Defendants under the False Claims Act, 31
U.S.C. § 3729(a)(l)(A).
73. From 1989 to the present, Defendants have knowingly caused to be presented to
Medicaid false or fraudulent claims for payment with respect to all NICA participants who are also
Medicaid recipients. Under federal law, Medicaid not NICA is the payer of last resort.
74. These Medicaid claims were false or fraudulent because they were for amounts and
75. The false or fraudulent nature of such claims was material to Medicaid's decision
76. As a result of the false or fraudulent claims, the United States sustained direct and
substantial monetary damages, equal to the amount of Medicaid funds paid to or on behalf of NICA
participants for items and services for which NICA was a liable third party.
77. By reason of the false or fraudulent claims, the United States has sustained
damages in a substantial amount to be determined at trial, and is entitled to treble damages plus a
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78. Paragraph 1 through 70 are hereby incorporated as if fully set forth herein.
79. The United States seeks relief against Defendants under the False Claims Act, 31
U.S.C. § 3729(a)(l)(G).
80. Defendants were and are obligated to repay Medicaid funds whenever a NICA
award is made to a Medicaid recipient. This obligation includes payment of expenses previously
81. Defendants have knowingly made or used, or caused to be made or used, false
Medicaid.
83. Defendants knowingly and improperly avoided that obligation to pay or transmit
money to Medicaid.
84. By reason of Defendants' acts and omissions, the United States has sustained
damages in a substantial amount to be determined at trial, and is entitled to treble damages plus a
WHEREFORE, Relators, on behalf of the United States, pray that judgment be entered in
1. That Defendants cease and desist from violating 31 U.S.C. § 3729, et seq.;
2. That Defendants pay the United States triple the amount of its damages to be
determined, plus the maximum civil penalty for each violation of 31 U.S.C. § 3729;
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3. That Relators be awarded all reasonable expenses, attorneys' fees, and costs
4. That in the event the United States proceeds with this action, Relators, for bringing
this action, be awarded an amount of at least 20 percent of the proceeds of any award or the
awarded an amount that the Court decides is reasonable for collecting the civil penalty and
damages;
§ 3730(d);
8. That the Court award such other and further relief as is just, equitable, and proper.
JURY DEMAND
Pursuant to Rule 38 of the Federal Rules of Civil Procedure, Relators hereby demand trial
by jury.
GENTRY LOCKE
~ 2:1. f ..t-.-•- - -
E. Scott Austin (VSB No. 41260) (admitted pro hac vice)
Evans G. Edwards (VSB No. 79588) (admitted pro hac vice)
10 Franklin Road, SE
Suite 900
Roanoke, Virginia 24011
Phone: (540) 983-9300
Fax: (540) 983-9400
Email: saustin@gentrylocke.com
edwards@gentrylocke.com
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