![]() ![]() (SAC ¶ 29.) 2 capitation rate (a fixed amount per member). (Id.) 2 Traditional Medicare operates on a “fee-for-service” basis where providers are directly paid for their services. (SAC ¶ 21.) AIM determines health insurance coverage in areas of radiology, cardiology, oncology, specialty drugs, and sleep medicine for over 48 health plans with approximately 38 million covered members. ¶ 30.) Under this model, Medicare pays private MA plans a monthly 1 AIM is a specialty health benefits management corporation. ¶¶ 27, 28.) As relevant here, Medicare Part C provides the same benefits as traditional Medicare 2 but operates under a managed care model. ¶ 27.) The program has four parts, and the Department of Health and Human Services, Centers for Medicare and Medicaid Services (“CMS”) administers it. Medicare Medicare is a federally-funded health insurance program that covers medical expenses for individuals over the age of 65, those who are disabled, or those who suffer from End Stage Renal Disease. Priority Health Providence Health Plan Providence Health Assurance Regence BlueCross BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield Regence Blue Shield of Idaho Asuris Northwest Health and PacificSource Community Health Plans. Blue Cross Blue Shield of Michigan Mutual Insurance Company Blue Cross and Blue Shield of North Carolina Moda Health Plan, Inc. ![]() Blue Cross and Blue Shield Healthcare Plan of Georgia Community Insurance Co. Blue Cross of California Blue Cross and Blue Shield of Georgia, Inc. Anthem Health Plans of New Hampshire, Inc. (“Anthem”), and numerous Medicare Advantage (“MA”) insurance plans that allegedly contracted with AIM for its Utilization Management (“UM”) review process, including Anthem Health Plans of Kentucky, Inc. (Id.) The federal government administers the Medicare program through United States Department of Health and Human Services (“HHS”). (SAC ¶ 16.) In this role, she worked on, among other things, compliance with Medicare policies and regulations. (“AIM”) and was a member of AIM’s executive team from July 2012 to January 2015. Susan Nedza served as the Chief Medical Officer for American Imaging Management, Inc. For the reasons set forth below, the Court grants the motions, ,, ,. Before the Court are defendants’ motions to dismiss Relator’s second amended complaint (“SAC”) pursuant to Federal Rules of Civil Procedure 12(b)(6) and 9(b). Susan Nedza (“Relator”), on behalf of the United States, has brought this qui tam action against defendants for their alleged violations of the federal False Claims Act (“FCA”), 31 U.S.C. Alonso MEMORANDUM OPINION AND ORDER Plaintiff-Relator Dr. ) ) AMERICAN IMAGING MANAGEMENT, INC., ) et al., ) ) Defendants. 216 IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION UNITED STATES, ex rel. ![]()
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