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                                                                                 [PUBLISH]

                  IN THE UNITED STATES COURT OF APPEALS

                            FOR THE ELEVENTH CIRCUIT
                              ________________________

                                    No. 17-13185
                              ________________________

                         D.C. Docket No. 0:14-cv-61301-KMW


JACK CARREL,
MAURICIO FERRER,
SHAWN LOFTIS,
                                                                     Plaintiffs - Appellants,

                                            versus

AIDS HEALTHCARE FOUNDATION, INC.,

                                                                      Defendant - Appellee.

                              ________________________

                      Appeal from the United States District Court
                          for the Southern District of Florida
                            ________________________

                                      (August 7, 2018)

Before WILLIAM PRYOR and MARTIN, Circuit Judges, and HALL, * District
Judge.

WILLIAM PRYOR, Circuit Judge:


*
 Honorable James Randal Hall, United States District Judge for the Southern District of
Georgia, sitting by designation.
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      This appeal requires us to decide whether the employee exemption to the

Anti-Kickback Statute, 42 U.S.C. § § 1320a-7b(b)(3)(B), applies to payments that

AIDS Healthcare Foundation, Inc., made to an employee tasked with referring

HIV-positive patients to healthcare services offered by the Foundation. The

Foundation is a nonprofit group that contracts with the State of Florida to provide

an extensive array of medical services to patients with HIV/AIDS. The contracts

require the Foundation to match patients who test positive for the disease with

suitable providers of care. The Foundation offers financial incentives to some

employees who refer patients to other healthcare services operated by the

Foundation, and it offers incentives to patients who use its services. The costs of

these services often are reimbursed by federal healthcare programs, such as

Medicare, Medicaid, and programs funded by the Ryan White Comprehensive

AIDS Resources Emergency Act. Three former employees sued the Foundation

under the False Claims Act, 31 U.S.C. § 3729 et seq., alleging that the incentives

offered to employees and patients are unlawful kickbacks that render false any

claims for federal reimbursement. The district court dismissed all but two of the

claims for lack of particularity. And it later granted summary judgment in favor of

the Foundation on the remaining claims based on the employee exemption to the

Anti-Kickback Statute. The district court also denied the relators leave to file a

fourth amended complaint. We affirm.

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                                 I.         BACKGROUND

         We divide this section in two parts. First, we describe the facts, as we must,

in the light most favorable to the relators. See Chaparro v. Carnival Corp., 693

F.3d 1333, 1335 (11th Cir. 2012); Jones v. UPS Ground Freight, 683 F.3d 1283,

1291–92 (11th Cir. 2012). Second, we describe the proceedings in the district

court.

                                       A.     The Facts

         AIDS Healthcare Foundation, Inc., is a national nonprofit that provides a

variety of medical services to individuals with HIV/AIDS. It has contracts with the

State of Florida that require it to conduct HIV testing and to match clients with

positive test results to healthcare providers. To promote this goal, the Foundation

offers financial incentives to certain employees who refer individuals who test

positive for HIV/AIDS to other medical offerings provided by the Foundation,

such as its clinic and pharmacy services. For example, the Foundation employs

“Linkage Coordinators” who earn a $100 bonus for every referred patient who

completes certain follow-up procedures at Foundation clinics. It also provides

small incentives, such as nutrient shakes and vitamins, to patients who use its

services. The Foundation receives approximately half of its revenue from federal

healthcare programs, including Medicare, and Medicaid, and programs established

by the Ryan White Comprehensive AIDS Resources Emergency Act.

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      Three former employees of the Foundation, Jack Carrel, Mauricio Ferrer,

and Shawn Loftis, sued the Foundation under the False Claims Act, 31 U.S.C.

§ 3729 et seq. They alleged that the incentives provided to employees and patients

violated the Anti-Kickback Statute, 42 U.S.C. § 1320a-7b, and rendered false any

claims for public reimbursement for the treatment of these patients, see id.

§ 1320a-7b(g). And the relators later filed a third amended complaint that alleged

that the Foundation engaged in a widespread practice of submitting claims for

services tainted by unlawful payments to employees and patients.

      In their effort to satisfy the particularity requirement for allegations of fraud,

see Fed. R. Civ. P. 9(b), the relators identified several pieces of evidence. They

asserted that Foundation policies provide for incentive payments to Linkage

Coordinators and employees who administer HIV tests, that the President of the

Foundation has admitted to offering incentives to patients, and that the Foundation

has aggressive policies for recruiting patients. The relators also pointed to a

spreadsheet created by the Foundation that lists hundreds of patients, employees,

test dates, and potential sources of insurance coverage, including federal healthcare

programs. And they alleged that because public funds account for almost 50

percent of Foundation revenue, mathematical probability suggests that the

Foundation submitted claims for unlawfully referred patients.




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      The relators also highlighted their positions at the Foundation. Carrel was

“the Director of Public Health” for the Southern Bureau of the Foundation between

August 2012 and August 2013, Ferrer was a “Senior Program Manager” from May

2011 to August 2012, and Loftis was a “Grants Manager” from January 2013 to

August 2013. They asserted that their jobs gave them insight into the “standard

operating procedure at [the Foundation]” where “patients . . . were referred to and

received health services from [the Foundation], which included services paid for

by Federal Health Care Programs.” And they described various meetings with

other officials where they observed discussions of financial data and incentives.

      With two exceptions, the relators failed to identify specific claims submitted

to the federal government that involved incentives given to patients or employees.

On the contrary, the complaint conceded that “[t]he precise number of illegally

referred HIV-positive patients cannot be known with certainty at this time,” and it

primarily relied on allegations about “the regular course of business at [the

Foundation].”

      The two exceptions involved “representative false claims” where the

government was actually billed for services provided to referred patients. The first

concerned a patient, John Doe #1, who “tested positive for HIV at [a Foundation]

facility in January 2013” and was “assigned to [a Foundation] Linkage Coordinator

named Julio Rodriguez who referred him to [the Foundation] for clinical services.”

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John Doe #1 completed his follow-up visits at a Foundation clinic, and in February

2013 the Foundation “directed its accounts payable department to pay . . .

Rodriguez a commission for successfully linking [the] patient . . . to treatment with

[the Foundation].” The Foundation then informed John Doe #1 that “it was billing

[the] Ryan White [Program] for his treatment,” and “the Broward County Health

Services Planning Council [told him] that it was paying [the Foundation] for his

treatment with Ryan White funds.” And the relators made parallel allegations

about another patient, John Doe #2, who received health care funded by the Ryan

White Program after he was referred to Foundation services by Rodriguez.

                    B.    The Proceedings in the District Court

      After the United States and Florida declined to intervene, the Foundation

moved to dismiss the complaint. It argued that the complaint failed to plead the

actual submission of false claims with particularity. See Fed. R. Civ. P. 9(b). And it

contended that the referral fees fell within a statutory exemption to the Anti-

Kickback Statute that excludes “any amount paid by an employer to an employee

. . . for employment in the provision of covered items or services.” 42 U.S.C.

§ 1320a-7b(b)(3)(B).

      The district court granted the motion in part and dismissed all claims except

the representative claims about the John Does. It ruled that the combination of

allegations that the Foundation relied on public money, that the “kickback schemes

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were pervasive,” and that the relators had some insider knowledge about

Foundation funding were insufficient to establish that the Foundation “actually

submitted false claims or received payment on such claims.” It also highlighted

that the spreadsheet that listed patient data failed to establish that the Foundation

submitted false claims because this document did “not memorialize any actual

claims [the Foundation] submitted to government programs for services provided

to illegally referred patients.”

      After discovery, the Foundation moved for summary judgment against the

two remaining claims based on the employee exemption to the Anti-Kickback

Statute. See id. The Foundation underscored that this exemption applies to “any

amount paid by an employer to an employee . . . for employment in the provision

of covered items or services,” id., and that the Ryan White Act specifically

provides that “referrals” are covered “services,” id. § 300ff-51(e)(1)–(2); see also

id. §§ 300ff-14(c)(3)(E) & (e)(1), 300ff-22(b)(3)(E) & (d)(1), 300ff-51(c)(3)(e). It

concluded that this exemption applied because Rodriguez was an employee

providing a statutory service when he referred the John Does to other Foundation

offerings. And it highlighted that contracts with Florida required the Foundation to

refer patients to medical care.

      The relators then moved for leave to file a fourth amended complaint. They

stated that the amended complaint had the benefit of new information gleaned from

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discovery and that these new findings warranted “broaden[ing] the scope of th[e]

action.” But the motion failed to state exactly what new information the revised

64-page complaint included or to explain how these facts could satisfy the

particularity requirement.

      The United States filed a statement of interest in support of the Foundation.

It explained that it had “a significant interest in the proper interpretation and

correct application of the False Claims Act . . . and the Anti-Kickback Statute” and

that the Foundation had correctly interpreted the law. It maintained that “the Ryan

White Program . . . explicitly includes referrals to appropriate providers as covered

services,” and that the relevant “statutes and regulations do not restrict grant

recipients . . . from paying employees to refer patients needing medical care to that

same grant recipient if, as here, it is an otherwise appropriate Ryan White

provider.”

      The district court granted summary judgment in favor of the Foundation. It

ruled that the employee exemption applied because Rodriguez was an employee

and the referrals were covered “services.” 42 U.S.C. § 1320a-7b(b)(3)(B). And it

denied the motion to amend as moot.

                         II.    STANDARD OF REVIEW

      Two standards govern our review. We review de novo both the dismissal of

a complaint, Access Now, Inc. v. Sw. Airlines Co., 385 F.3d 1324, 1326 (11th Cir.

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2004), and a summary judgment, Ellis v. England, 432 F.3d 1321, 1325 (11th Cir.

2005). And we review a denial of leave to amend a complaint for abuse of

discretion. Carruthers v. BSA Advertising, Inc., 357 F.3d 1213, 1217 (11th Cir.

2004).

                                III.   DISCUSSION

      We divide our discussion in three parts. First, we explain that the payments

to Rodriguez fell within the employee exemption to the Anti-Kickback Statute.

Second, we explain that the district court correctly dismissed the relators’ other

claims for lack of particularity. Third, we explain that the relators waived their

argument about amendment.

 A.      The Referral Payments to Rodriguez Fell Within the Employee Exemption.

      To determine whether the Foundation was entitled to pay Rodriguez for

referring patients to other Foundation services, we must consider the texts of three

statutes: the False Claims Act, the Anti-Kickback Statute, and the Ryan White Act.

A careful review of their relevant provisions and related regulations establishes

that the Foundation was entitled to pay its employee for referring patients to its

services. And the relators’ arguments about congressional intent fail.

      The False Claims Act, 31 U.S.C. § 3729 et seq., creates liability for

individuals “who present or directly induce the submission of false or fraudulent

claims” to the government, Universal Health Servs., Inc. v. United States ex rel.

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Escobar, 136 S. Ct. 1989, 1996 (2016); see also 31 U.S.C. § 3729(a)(1)(A), (B),

(G) (forbidding specific fraudulent acts). It also “permits, in certain circumstances,

suits by private parties on behalf of the United States against [violators].” Hughes

Aircraft Co. v. Unites States ex rel. Schumer, 520 U.S. 939, 941 (1997) (citing 31

U.S.C. § 3730(b)). Florida has enacted a parallel statutory scheme with similar

provisions. See Fla. Stat. §§ 68.082(2)(a), (b), (g), 68.083(2).

      The Anti-Kickback Statute, which broadly forbids kickbacks, bribes, and

rebates in the administration of government healthcare programs, see 42 U.S.C.

§ 1320a-7b(b), provides that “a claim that includes items or services resulting from

a violation of [the Anti-Kickback Statute] constitutes a false or fraudulent claim for

purposes of [the False Claims Act],” id. § 1320a-7b(g). The Anti-Kickback Statute

creates liability for anyone who “knowingly and willfully offers or pays any

remuneration . . . to any person to induce such person . . . to refer an individual to a

person for the furnishing . . . of any item or service for which payment may be

made in whole or in part under a Federal health care program.” Id. § 1320a-

7b(b)(2) (emphasis added). Notwithstanding its general prohibition on paying for

“refer[rals],” id., the Anti-Kickback Statute exempts “any amount paid by an

employer to an employee (who has a bona fide employment relationship with such

employer) for employment in the provision of covered items or services,” id.

§ 1320a-7b(b)(3)(B) (emphasis added). And the statute exempts “any payment

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practice specified by the Secretary [of the Department of Health and Human

Services] in regulations.” Id. § 1320a-7b(b)(3)(E). A regulation provides a parallel

exemption for “any amount paid by an employer to a[] [bona fide] employee . . .

for employment in the furnishing of any item or service for which payment may be

made in whole or in part under Medicare, Medicaid, or other Federal health care

programs.” 42 C.F.R. § 1001.952(i).

      The Ryan White Act establishes that the referral of patients with HIV/AIDS

is a standalone compensable “service.” The Act permits funding of “core medical

services,” 42 U.S.C. § 300ff-14(a)(2)(A); see also id. § 300ff-22(a)(1), a definition

that includes “[e]arly intervention services,” id. § 300ff-14(c)(3)(E); see also id.

§§ 300ff-14(e)(1), 300ff-22(b)(3)(E) & (d)(1). In turn, the Act explains that these

early intervention services include “referrals of individuals with HIV/AIDS to

appropriate providers of health and support services, including . . . to entities

receiving [funding under the Ryan White Act] for the provision of such services.”

Id. § 300ff-51(e)(2); see also id. § 300ff-51(e)(1)(C).

      The texts of these laws make clear that the Foundation was entitled to pay

Rodriguez for referring the John Doe patients. As the district court ruled and the

relators concede, Rodriguez was an employee of the Foundation. The Anti-

Kickback Statute permits payments to employees for their “employment in the

provision of covered items or services.” Id. § 1320a-7b(b)(3)(B). And the Ryan

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White Act defines “[c]ore medical services,” id. § 300ff-51(c)(3), to include

“referrals of individuals with HIV/AIDS to appropriate providers of health . . .

services,” id. § 300ff-51(e)(2); see also id. §§ 300ff-14(c)(3)(E) & (e)(1), 300ff-

22(b)(3)(E) & (d)(1), 300ff-51(c)(3)(e). The relators do not dispute that the

Foundation is an “appropriate provider.” And they admit that contracts between the

Foundation and Florida “required [the Foundation] to refer HIV [positive] patients

into medical care.” Because referrals are compensable medical services under the

Ryan White Act, the Foundation was entitled to pay Rodriguez for referring the

John Does.

      Despite the plain text of the statutes and regulation, the relators contend that

Congress and the agency did not really mean what they wrote. Instead, they assert

that drafting history, policy concerns, and tangentially related regulations and

caselaw implicitly bar the Foundation from “buying” referrals on a per-capita

basis. They also suggest that, even if certain kinds of referral arrangements are

covered by the exemption, the exemption implicitly excludes the “purchase” of

referrals that direct patients to a particular provider instead of to any provider in a

nondiscriminatory fashion. And they colorfully argue that there is a “yawning

difference between the appropriate provision of referral services to people with

HIV/AIDS and the corrupt purchase of patient referrals.”




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      The relators cite the drafting history and general purpose of the Anti-

Kickback Statute and its regulatory exceptions for the proposition that “buy[ing]”

referrals categorically violates the principle of honesty in medical services. They

assert that Congress intended for the statute to prohibit “financial incentives to

induce referrals of program business” and the “steering of patients to particular

providers, thus violating the policy of freedom of choice.” The relators also

underscore that the statute requires the agency to consider factors such as “patient

freedom” and “competition among health care providers” when it promulgates safe

harbors, id. § 1320a-7d(a)(2), and that the agency consequently stated in a

proposed rule that safe harbors should “encourage competition, innovation[,] and

economy.” The relators maintain that these general principles of freedom and

neutrality establish that referral programs—particularly those that pay on a per-

capita basis and those that pay employees only when they refer patients to a

medical program run by the payor—are unlawful.

      We lack the authority to ignore the texts of these laws in the service of

general purposes and selective legislative history. Although the relators complain

that paid referrals threaten “freedom of choice” and introduce market

inefficiencies, the employee exemption plainly covers the payments to Rodriguez.

And the relevant statutes say nothing to forbid payment on a per-capita basis or to

require nondiscriminatory referrals to any available healthcare provider. Indeed,

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the employee exemption covers “any amount paid by an employer to an employee”

without specifying the terms, method, or frequency of payment, id. § 1320a-

7b(b)(3)(B) (emphasis added), and the Ryan White Act requires only that referrals

be made to an “appropriate provider[],” id. § 300ff-51(e)(2). And that another

regulatory exemption to the Anti-Kickback Statute specifically excludes the kind

of “volume”-based compensation that the relators complain about, 42 C.F.R.

§ 100.952(f)(2), implies the lack of similar language in the regulation about the

employee exemption permits payment on a per-capita basis, see id. § 100.952(i).

      The relators cannot complain that this interpretation of the exemption is

absurd. On the contrary, incentive-based referral arrangements are logical in the

light of the urgent need to ensure that people with HIV/AIDS receive prompt care

before their conditions worsen. Congress may well have concluded that it preferred

that patients receive any care—even if not from the optimal provider—as quickly

as possible. And paid incentives logically further this goal. Indeed, the statement of

interest submitted by the government in the district court states “that Congress

embraced the notion of ‘one stop shopping’ for patients with HIV/AIDS.”

      The relators next cite a variety of unrelated regulatory exemptions to the

Anti-Kickback Statute for the same proposition that pay-per-referral arrangements

are inherently abusive and implicitly excluded from the employee exemption. For

example, they point out that different exemptions for referral arrangements may

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not apply if compensation is “based . . . on the volume or value of any referrals . . .

or [the] business otherwise generated,” 42 C.F.R. § 1001.952(f)(2) (emphasis

added), or if the referrals are not accompanied by disclosures, see id.

§ 1001.952(f)(4); see also generally id. § 1001.952 (outlining other regulatory

exemptions). The relators conclude that because these other safe harbors were

promulgated “after enactment of the Ryan White Program,” their principles of

fairness and disclosure somehow implicitly limit the scope of the employee

exemption.

      We disagree. That other exemptions to the Anti-Kickback Statute may not

apply to the payments that the Foundation made to Rodriguez is irrelevant to

whether the John Doe referrals were statutorily exempted “covered items or

services,” 42 U.S.C. § 1320a-7b(b)(3)(B), under the plain terms of the Ryan White

Act, see id. § 300ff-51(e). Indeed, many of the other regulatory exemptions cited

by the relators apply to business relationships that are completely different from an

employee-employer relationship. See, e.g., 42 C.F.R. § 1001.952(b) (concerning

“payment[s] made by a lessee to a lessor”); id. § 1001.952(c) (concerning

“[e]quipment rental”); id. § 1001.952(d) (concerning “[p]ersonal services and

management contracts”). In short, unrelated regulatory provisions cannot

eviscerate a distinct statutory exemption that plainly applies to the actions of the

Foundation.

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      The relators also cherry-pick statements from caselaw to suggest that paid

referrals are inherently unlawful. For example, they cite United States v. Starks,

where we held that the Anti-Kickback Statute reached a scheme where a publicly-

funded drug-treatment program paid unaffiliated public-health workers tasked with

“advis[ing] pregnant women about possible treatment for drug abuse” to refer these

women to the drug-treatment program. 157 F.3d 833, 836 (11th Cir. 1998); see

also id. at 835–36. In upholding the convictions against a void-for-vagueness

challenge to the statute, we explained that “even if [the defendants] believed that

[the workers] were bona fide employees [of the program], they were not providing

‘covered items or services.’” We explained that one of the workers “received

payment . . . only for referrals and not for any legitimate service for which the

Hospital received any Medicare reimbursement.” Id. at 839. And we pointed out

that the program “did not at any time pay [the workers] for any of their time, effort,

or business expenses, or for any covered Medicare service.” Id. at 836. The relators

contend that the employee exemption categorically “does not protect payments

made only for referrals.”

      The relators’ argument misses the mark. Unlike the payments in Starks that

were made to non-employees in exchange for referrals not contemplated by a

healthcare program, the payments that the Foundation made to Rodriguez were in

exchange for referrals that were both a standalone compensable service under the

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Ryan White Act and demanded by its contracts with Florida. The relators cannot

avoid the plain text of the statutory exemption.

       B.     The Relators’ Other Allegations Fail for Lack of Particularity.

      Federal Rule of Civil Procedure 9(b) requires a party “alleging fraud or

mistake . . . [to] state with particularity the circumstances constituting fraud or

mistake.” To satisfy this particularity standard in a qui tam action, a relator must

allege the actual “submission of a [false] claim” because “[t]he False Claims Act

does not create liability merely for a health care provider’s disregard of

[g]overnment regulations or improper internal policies unless . . . the provider . . .

asks the [g]overnment to pay amounts it does not owe.” United States ex rel.

Clausen v. Lab. Corp. of Am., 290 F.3d 1301, 1311 (11th Cir. 2002). The

complaint also must offer “some indicia of reliability . . . to support the allegation

of an actual false claim for payment being made to the [g]overnment.” Id. It is not

enough that a relator “merely . . . describe[s] a private scheme in detail [and] then

. . . allege[s] simply and without any stated reason . . . his belief that claims

requesting illegal payments must have been submitted, were likely submitted[,] or

should have been submitted.” Id. Nor may he point to “improper practices of the

defendant[]” to support “the inference that fraudulent claims were submitted”

because “submission . . . [can]not [be] inferred from the circumstances.” Corsello

v. Lincare, Inc., 428 F.3d 1008, 1013 (11th Cir. 2005). Indeed, even if the relator is

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an insider who alleges awareness of general billing practices, an accusation of

“[u]nderlying improper practices alone [is] insufficient . . . absent allegations that a

specific fraudulent claim was in fact submitted to the government.” Id. at 1014

(emphasis added); see also United States ex rel. Sanchez v. Lymphatx, Inc., 596

F.3d 1300, 1302 (11th Cir. 2010). In short, he must “allege the ‘who,’ ‘what,’

‘where,’ ‘when,’ and ‘how’ of fraudulent submissions.” Corsello, 428 F.3d at

1014.

        For example, in Clausen we held that the relator’s “descri[ptions of] the

various schemes [the defendant company] allegedly implemented to generate

unneeded or duplicative medical tests on unsuspecting . . . patients” were

insufficient because he “merely offer[ed] conclusory statements . . . and d[id] not

adequately allege when—or even if—the schemes were brought to fruition” by the

actual submission of false claims. 290 F.3d at 1312. Although the relator generally

alleged that false bills were submitted for unnecessary tests, “[n]o amounts of

charges were identified,” “[n]o actual dates were alleged,” “[almost no] policies

about billing or even second-hand information about billing practices were

described,” and “[n]o copy of a single bill or payment was provided.” Id. And in

United States ex rel. Atkins v. McInteer, we held that “detail[ed]” allegations of “an

elaborate scheme for defrauding the government by submitting false claims” were

insufficient when the relator failed to “show[] that the defendants actually

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submitted reimbursement claims for the services he describe[d].” 470 F.3d 1350,

1359 (11th Cir. 2006). Although the relator was an insider “psychiatrist responsible

for the provision of medical care,” we explained that he lacked “firsthand

knowledge of the defendants’ submission of false claims” because he was “not a

billing and coding administrator responsible for filing and submitting the . . .

claims” and relied instead on “rumors from staff and observ[ations of] records of

what he believed to be the shoddy medical and business practices of two other

psychiatrists.” Id.; see also Sanchez, 596 F.3d at 1302.

      To be sure, “we are more tolerant toward complaints that leave out some

particularities of the submissions of a false claim if the complaint also alleges

personal knowledge or participation in the fraudulent conduct.” United States ex

rel. Matheny v. Medco Health Solutions, Inc., 671 F.3d 1217, 1230 (11th Cir.

2012). For example, in Matheny we held sufficient allegations that the defendant

had submitted false “[d]iscovery [s]amples” when the relator “allege[d] personal

involvement in . . . the creation of [an] actual [d]iscovery [s]ample,” alleged when

the discovery sample was submitted, id. at 1230, and “allege[d] in detail who made

the [d]iscovery [s]amples . . ., who approved and directed the process . . ., and how

various employees, including [the] [r]elator . . ., altered the patient accounts to

produce a false [d]iscovery [s]ample,” id. at 1229. And in United States ex rel.

Walker v. R&F Properties of Lake County, Inc., we held sufficient allegations of

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fraudulent billing when the realtor was a nurse practitioner who had personally

used incorrect billing codes on a consistent basis and had been told by the “office

administrator” that the defendant healthcare provider “‘never’ billed [these

fraudulent services] in another manner.” 433 F.3d 1349, 1360 (11th Cir. 2005)

(emphasis added). Although the relator failed to specify when the defendant

actually submitted the false claims that were based on the fraudulent billing

methods, we held that her pertinent insider information was “sufficient to explain

why [she] believed [that the defendant] submitted false or fraudulent claims.” Id. at

1360. Nonetheless, we have made clear that even if a relator “assert[s] . . . direct

knowledge of [a] defendant[’s] billing and patient records,” she still must allege

“specific details” about false claims to establish “the indicia of reliability necessary

under Rule 9(b).” Sanchez, 596 F.3d at 1302 (internal quotation marks omitted).

      The relators contend that the district court erred when it dismissed their

broad allegations of widespread misconduct. They maintain that they pleaded with

sufficient particularity their sweeping claims that the Foundation sought

reimbursement after it paid employees for unlawful referrals and enticed patients

with free food, gift cards, cash, and other perks. Although they admit ignorance of

“the exact number of illegally referred patients for whom [the Foundation]

submitted claims for payment with government funds,” they assert “direct

knowledge that [the Foundation] does so.” We disagree.

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       The complaint failed to allege fraud with particularity. Most importantly, the

relators failed to offer sufficient “indicia of reliability . . . to support the allegation

[that] actual false claim[s] for payment [were] made to the [g]overnment.”

Clausen, 290 F.3d at 1311. Although the relators allege a mosaic of circumstances

that are perhaps consistent with their accusations that the Foundation made false

claims—such as that the Foundation provided incentives to certain patients and

employees, that the Foundation frequently requested reimbursement from federal

healthcare programs, and that Foundation policies focused on aggressive patient

recruitment—the relators fail to allege with particularity that these background

factors ever converged and produced an actual false claim where the Foundation

both violated the Anti-Kickback Statute when it unlawfully recruited a patient and

then billed the government for the services provided to that patient. Indeed, the

relators conceded in their complaint that “[t]he precise number of illegally referred

HIV-positive patients cannot be known with certainty at this time.”

       To be sure, the relators made particular allegations about the John Doe

representative claims, but these claims cannot help the relators because they

involved no fraud. As explained above, the payments to Rodriguez fell squarely

within the employee exemption, so these defective allegations hardly suggest other

instances of actual fraud. Indeed, that the referrals cited by the relators were

covered “services” under the Ryan White Act only undercuts the notion that the

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Foundation was engaged in rampant illegal conduct in other transactions that the

relators failed to identify with specificity. We will not infer fraud from instances of

perfectly lawful conduct.

      Nor can the relators rely on mathematical probability to conclude that the

Foundation surely must have submitted a false claim at some point. Again, a

relator must allege an “actual false claim for payment” that was presented to the

government. Id. Speculation that false claims “must have been submitted” is

insufficient. Id. If anything, the relators’ mathematical guesswork cuts the other

way. They concede that less than 50 percent of Foundation funding comes from

public coffers, so it is entirely possible that even if certain patients and employees

received incentives, the ensuing treatment was untethered from government

funding. Cf. Matheny, 671 F.3d at 1227 (explaining that “the [r]elators . . . alleged

the existence of federal funds with particularity” when the “[c]omplaint specifie[d]

the Medicare or Medicaid invoice number or reimbursement check and the

[billing] code for accounts alleged to contain [o]verpayments” and included

exhibits that “identif[ied] the Medicare or Medicaid claim invoice number . . . or

the government reimbursement check number” (internal quotation marks omitted)).

The relators failed to establish that the Foundation ever submitted a claim for an

unlawfully referred patient.




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      The relators also cannot rely on their “personal knowledge or participation”

in the alleged fraud. Id. at 1230. Carrel pointed to his position as a “Director of

Public Health” and his attendance at “monthly financial review meetings with the

. . . Finance Manager.” And Ferrer and Loftis highlighted their managerial

positions and possession of nondescript information that “patients who were

illegally referred . . . would, as a matter of course, receive various [reimbursed]

health services from the [F]oundation” and that public “funding was used in

[Foundation] operations.” But the relators failed to explain how their access to

possibly relevant information translated to knowledge of actual tainted claims

presented to the government. Indeed, that the relators supposedly had access to

pertinent data and still were unable to pinpoint specific false claims other than

meritless accusations about the John Does suggests that they lack any meaningful

“personal knowledge or participation in the fraudulent conduct.” Id. To be sure,

Ferrer asserted that he personally saw Foundation workers offer gift cards to

“employees who secured and referred clients” and that he knew that the

Foundation gave incentives like “milkshakes and vitamins” to patients. But these

allegations about exchanges at unspecified times are untethered to any particular

transaction or claim that actually involved government funding. In short, the

relators’ general allegations of “standard operating procedure[s],” “standard

business practice[s],” and the “course of . . . operations” at the Foundation hardly

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establish that the Foundation ever “ask[ed] the [g]overnment to pay amounts it

[did] not owe.” Clausen, 290 F.3d at 1311.

      The relators also unpersuasively point to a Foundation spreadsheet that lists

various patients, employees, test dates, and other medical and referral information,

and they highlight that this sheet identifies public healthcare programs—such as

Medicaid and the Ryan White program—as funding sources for some of these

patients. According to the relators, this document suggests that the Foundation

unlawfully claimed government funding for these patients. But the notations on the

spreadsheet about possible sources of funding fail to establish that the relevant

claims “actual[ly] . . . [were] made to the [g]overnment.” Id. Indeed, the relators

admit that the spreadsheet reflects “what potential governmental sources of

funding were available for medical care.” As the district court explained, the

“[s]preadsheet is neither a billing form nor a record of actual reimbursements” and

it “does not memorialize any actual claims [the Foundation] submitted to

government programs for services provided to illegally referred patients.” And

again, that the Foundation was entitled to pay for at least some referrals covered by

the Ryan White Act dilutes any inference of fraud from this record.

      The relators also cite statements made by Foundation executives and

excerpts of company documents that suggest that the Foundation took an

aggressive approach to patient recruitment, but this evidence fails to identify actual

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false claims. For example, the president of the Foundation allegedly has admitted

to “[t]he provision of small incentives to patients” and the payment of referral fees

to employees. But that the Foundation supposedly made such expenditures at

unknown times and places again fails to establish specific instances where the

Foundation wrongfully demanded payment from the government. The relators also

point to an internal financial presentation where the Foundation listed referral

figures, which they conclude “evidences [the Foundation’s] intense interest in

tracking its success in channeling patient referrals.” But this information again fails

to tie the referral program to specific, fraudulent claims submitted to the

government.

      In sum, the general allegations that the Foundation sometimes claimed

public reimbursement for services, sometimes offered incentives to employees and

patients, and sometimes served patients eligible for government programs is not a

specific allegation of the “presentment of [a false] claim.” Id. Absent more exact

allegations that these factors converged into actual false claims, even accusations

that “the practices of [the Foundation were] unwise or improper . . . [do not

establish] actionable damage to the public fisc as required under the False Claims

Act.” Id. The relators cannot rely on their sweeping accusations that lack the

“‘who,’ ‘what,’ ‘where,’ ‘when,’ and ‘how’” of the supposedly fraudulent

submissions. Corsello, 428 F.3d at 1014.

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          C.      The Relators Waived Their Argument About Amendment.

      The relators briefly argue that the district court abused its discretion when it

denied as moot their motion to file a fourth amended complaint. They allege that

the new complaint contained unspecified “additional details of the organization-

wide kickback scheme,” and they argue that the employee exemption does not bar

amendment because Medicare and Medicaid, unlike the Ryan White Act, “do not

reimburse for referral services.” We are unpersuaded.

      The relators’ opening brief contains only a single paragraph of abstract

arguments about why they should be permitted to amend, and we have consistently

explained that “argument[s] . . . briefed in the most cursory fashion . . . [are]

waived.” In re Globe Mfg. Corp., 567 F.3d 1291, 1297 n.3 (11th Cir. 2009). This

failure to clearly identify relevant arguments and supporting factual allegations is

particularly significant in the light of the heightened pleading requirement of Rule

9(b). More specifically, the relators are demanding that we comb through the 64-

page fourth amended complaint, identify new allegations, and determine sua

sponte whether these accusations are sufficiently particular. We reject this

invitation to do the relators’ work for them.

                                 IV.    CONCLUSION

      We AFFIRM.




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