PHILADELPHIA – A federal judge has denied three companies' motions to dismiss an investigator's lawsuit over allegations he was terminated unfairly after uncovering allegedly fraudulent actions.
Alastair Crosbie filed a complaint in March against Highmark Inc., Highmark Health Options and Gateway Health Plan alleging retaliation and unfair termination.
Judge Michael M. Baylson of the U.S. District Court for the Eastern District of Pennsylvania ruled Dec. 4 to deny the defendants' motions to dismiss, finding that the plaintiff’s allegations merit attention. The plaintiff has met the heightened burden required of his allegations, in addition to his actions constituting protected efforts of a whistleblower, Baylson ruled.
According to the complaint, Crosbie is seeking damages for an incident that took place while the plaintiff was in the employ of the defendants. The motion states that the defendants established a payment integrity department and hired the plaintiff, who was a fraud expert, to look into the company’s third-party medical service providers.
Through the course of the plaintiff’s investigations, he says he discovered defects in Highmark Health Options’ (HHO) provider-credentialing system and found that there was a provider who was receiving reimbursement through the defendants even though he was not an approved provider, the decision says.
The plaintiff alleges he reported the issue to his supervisors and upper management. He alleges his concerns were not heeded and the plaintiff and his team made a mandatory referral about the practices to the Delaware Department of Justice’s Medicaid Fraud Control Unit. The defendants allegedly continued working with the unapproved provider.
The plaintiff redoubled his efforts in September or October 2018 but was terminated soon afterward as another female co-worker accused him of actions that he claims he was innocent of. The plaintiff believes that his termination was for his involvement in uncovering the misconduct of the company, rather than the conduct that a coworker had accused him of.
"The allegedly questionable grounds for plaintiff’s termination provides further grounds for the court to infer causation at this stage. Plaintiff alleges that the sexual harassment complaint was made only hours prior to his termination, and that defendants undertook little-to-no investigation of the complaint even though he consistently received positive performance reviews from his immediate supervisors," Baylson wrote.
"As alleged, the alleged circumstances of plaintiff’s termination support an inference of retaliatory motive and, therefore, causation."
U.S. District Court for the Eastern District of Pennsylvania case number 19-1235