Justia Health Law Opinion Summaries

Steven M. Camburn, a former sales specialist for Novartis Pharmaceuticals Corporation, filed a qui tam action under the False Claims Act (FCA) and equivalent state and municipal laws. Camburn alleged that Novartis violated the Anti-Kickback Statute (AKS) by offering remuneration to physicians to induce them to prescribe its drug Gilenya, which treats multiple sclerosis. He claimed that Novartis used its peer-to-peer speaker program and other forms of illicit remuneration to influence physicians' prescribing practices.The United States District Court for the Southern District of New York dismissed Camburn's Third Amended Complaint (TAC) with prejudice, concluding that he had not pleaded his allegations with the particularity required under Rule 9(b) to support a strong inference of an AKS-based FCA violation. The court found that Camburn's allegations did not adequately demonstrate the existence of a kickback scheme.The United States Court of Appeals for the Second Circuit reviewed the case and held that a plaintiff states an AKS violation if they allege with particularity that at least one purpose of the purported scheme was to induce fraudulent conduct. The court found that Camburn had adequately pleaded certain categories of factual allegations that gave rise to a strong inference of an AKS violation. Specifically, Camburn sufficiently alleged that Novartis held sham speaker events with no legitimate attendees, excessively compensated physician speakers for canceled events, and selected and retained speakers to incentivize prescription-writing.The Second Circuit affirmed the district court's dismissal in part but vacated the judgment and remanded the case in part. The court instructed the district court to evaluate whether Camburn had stated all the elements of an FCA claim with respect to the adequately pleaded AKS violations and to assess the adequacy of Camburn's claims under state and municipal law. View "Camburn v. Novartis Pharmaceuticals Corporation" on Justia Law

Dr. Judith Robinson, a former employee of HealthNet, a federally qualified health center in Indiana, brought a qui tam action against HealthNet, alleging fraudulent billing practices, including improper Medicaid billing for ultrasound readings. She claimed that HealthNet billed Medicaid for face-to-face encounters that did not occur. Dr. Robinson initially filed a suit in 2013 (Robinson I), which was settled in 2017, excluding the wrap-around claims. These claims were dismissed without prejudice, allowing for future litigation.In 2019, Dr. Robinson filed a new suit (Robinson II) to address the wrap-around claims. The United States declined to intervene, but Indiana did. Indiana moved to dismiss all claims except for the wrap-around claims from October 18, 2013, to February 28, 2015, as the rest were time-barred. The district court dismissed Count III of Dr. Robinson's complaint, which sought to enforce an alleged oral settlement agreement, due to lack of standing, as Dr. Robinson failed to provide competent proof of the agreement's existence.The United States Court of Appeals for the Seventh Circuit reviewed the case. The court affirmed the district court's dismissal of Count III, agreeing that Dr. Robinson lacked standing because she did not demonstrate any breach of the alleged oral agreement by HealthNet. The court also upheld the district court's approval of the settlement between Indiana and HealthNet, finding it fair, adequate, and reasonable. The court noted that the reduction in the relator’s share was due to Dr. Robinson's own actions, including the failure to obtain a tolling agreement, which led to many claims being time-barred. The court also agreed with the application of the Federal Medical Assistance Percentage (FMAP) in calculating the settlement amount. View "Robinson v. Healthnet, Inc." on Justia Law

The case involves Taylor Capito, who filed a class action lawsuit against San Jose Healthcare System, LP, also known as Regional Medical Center San Jose, challenging the assessment of Evaluation and Management Services (EMS) fees for two emergency room visits. Capito argued that Regional had a duty to notify emergency room patients about EMS fees beyond listing them in the chargemaster, such as through posted signage or during the patient registration process. She claimed that Regional's failure to do so constituted an unlawful, unfair, or fraudulent business practice under the Unfair Competition Law (UCL) and violated the Consumers Legal Remedies Act (CLRA).The trial court sustained Regional's demurrer without leave to amend, and the Court of Appeal affirmed. The appellate court reasoned that hospitals do not have a duty to disclose EMS fees beyond what is required by the relevant statutory and regulatory framework, following the reasoning in similar cases like Gray v. Dignity Health and Saini v. Sutter Health. The Court of Appeal also affirmed the trial court's order striking the class allegations in Capito's first amended complaint.The Supreme Court of California reviewed the case and affirmed the Court of Appeal's judgment. The court held that hospitals do not have a duty under the UCL or CLRA, beyond their obligations under the relevant statutory and regulatory scheme, to disclose EMS fees prior to treating emergency room patients. The court emphasized that requiring such disclosure would alter the balance of competing interests, including price transparency and the provision of emergency care without regard to cost, as reflected in the multifaceted scheme developed by state and federal authorities. The court also dismissed Capito's appeal from the trial court's order striking her class allegations as moot. View "Capito v. San Jose Healthcare System, LP" on Justia Law

Henry Jones, a prisoner, filed a lawsuit against nurse Amanda Lamb, alleging that she refused to provide him medical treatment for a broken hand and later denied him pain medication. Jones claimed he could not exhaust administrative remedies because prison officials did not deliver responses to his grievances. Lamb raised the affirmative defense of failure to exhaust administrative remedies under the Prison Litigation Reform Act (PLRA).The United States District Court for the Central District of Illinois granted summary judgment in favor of Lamb, concluding that Jones had unexhausted administrative remedies available for both claims. The court found Jones's assertion that he did not receive the grievance responses not credible, particularly because he had attached his counselor's response to his complaint.The United States Court of Appeals for the Seventh Circuit reviewed the case. The court held that there was a genuine dispute of material fact regarding whether administrative remedies were available to Jones for his medical treatment claim. Specifically, the court found that Jones's declaration that he did not receive the warden's decisions created a genuine issue of fact that should have precluded summary judgment. Therefore, the court reversed the district court's decision on this claim and remanded for an evidentiary hearing to resolve the exhaustion dispute.However, the court affirmed the district court's decision regarding Jones's pain medication claim. Jones did not contest that he received a response directing him to resubmit his grievance and failed to do so. Thus, the court concluded that Jones had unexhausted administrative remedies available for this claim.The Seventh Circuit affirmed in part, reversed in part, and remanded the case for further proceedings consistent with its opinion. View "Jones v. Lamb" on Justia Law

Troy Olhausen, a former Senior Vice President of Business Development and Marketing at Arriva Medical, LLC, filed a qui tam action under the False Claims Act against his former employers, Arriva, Alere, Inc., and Abbott Laboratories, Inc. He alleged that the defendants submitted fraudulent claims to the Center for Medicare and Medicaid Services (CMS) for reimbursement. Specifically, Olhausen claimed that Arriva submitted claims without obtaining required assignment-of-benefits signatures and failed to disclose or accredit certain call-center locations that processed claims.The United States District Court for the Southern District of Florida dismissed Olhausen’s third amended complaint, holding that he failed to plead with the particularity required under Federal Rule of Civil Procedure 9(b) that any fraudulent claims were actually submitted to the government. The district court found that Olhausen did not provide sufficient details to establish that false claims had been submitted, as he did not work in the billing department and lacked firsthand knowledge of the claim submissions.On appeal, the United States Court of Appeals for the Eleventh Circuit reviewed the case. The court concluded that Olhausen adequately pled with particularity that allegedly false claims were submitted under Count II, which involved claims for heating pads that lacked assignment-of-benefits signatures. The court found that the internal audit allegations provided sufficient indicia of reliability to satisfy Rule 9(b). However, the court upheld the dismissal of Count IV, which alleged that Arriva failed to disclose or accredit certain call-center locations, as Olhausen did not adequately allege that any claims involving these locations were actually submitted. Consequently, the court vacated the dismissal of Counts II and VI (conspiracy) and remanded them for further proceedings, while affirming the dismissal of Count IV. View "Olhausen v. Arriva Medical, LLC" on Justia Law

Plaintiff John Doe filed a class action lawsuit against Integris Health, Inc., alleging that Integris collected confidential health information from its website visitors and unlawfully shared it with third parties like Google and Facebook. Doe's complaint, filed in Oklahoma state court, asserted state law claims including negligence, invasion of privacy, and breach of fiduciary duty. Integris removed the case to federal court under the federal officer removal statute, claiming it was acting under the direction of a federal officer by helping the federal government achieve its objective of ensuring patient access to electronic health records (EHR).The United States District Court for the Western District of Oklahoma remanded the case to state court, concluding that Integris had not demonstrated it was "acting under" the direction of a federal officer. The court found that Integris was merely complying with federal regulations, which is insufficient to establish federal officer jurisdiction.The United States Court of Appeals for the Tenth Circuit reviewed the case and affirmed the district court's decision. The Tenth Circuit held that Integris was not "acting under" a federal officer because it was only complying with federal regulations and not fulfilling a basic government task. The court emphasized that compliance with federal law, even if highly detailed and supervised, does not equate to acting under a federal officer. The court also noted that Integris's use of tracking technology on its website was not required by the federal government and was not part of any federal directive. Therefore, the court concluded that removal under the federal officer removal statute was improper. View "Doe v. Integris Health" on Justia Law

A man named Johnathon Lerke, who was under a Murphy conservatorship, challenged his confinement in a county jail while awaiting transfer to a state hospital. Murphy conservatorships are for individuals found incompetent to stand trial and deemed a danger to others. Despite being ordered to a state hospital, Lerke was held in county jail for months due to a lack of space at the hospital. He argued that his confinement in jail was unauthorized and violated his rights.The Superior Court initially found Lerke incompetent to stand trial and ordered him to a state hospital for competency restoration. After nearly two years, the hospital reported that Lerke had not regained competence. Subsequently, a Murphy conservatorship was established, requiring his placement in a state hospital. However, due to the unavailability of space, he remained in county jail. Lerke's counsel requested his release or transfer to a local psychiatric hospital, but the court denied the request, stating that he would remain in jail until a state hospital bed became available.The California Court of Appeal, Fourth Appellate District, reviewed the case. The court concluded that no legal authority permitted Lerke’s indefinite detention in county jail pending his transfer to the state hospital. The statutory framework requires conservatees to be placed in treatment facilities that promote their treatment and protect the public, and county jails do not meet these requirements. Although the court found Lerke’s confinement in jail unlawful, it denied habeas relief because he had already been transferred to an authorized treatment facility during the proceedings. The petition for writ of habeas corpus was denied as moot. View "In re Lerke" on Justia Law

The case involves five severely developmentally disabled men who require intensive care in a residential treatment setting and receive services through New Hampshire’s developmental services system. These services were provided by the Judge Rotenberg Educational Center, Inc. (JRC) in Massachusetts, funded by federal Medicaid home and community-based services (HCBS) waiver funding. In 2022, the federal Centers for Medicare and Medicaid Services (CMS) informed the New Hampshire Department of Health and Human Services (DHHS) that JRC was not an approved HCBS provider, and funding for services at JRC would cease. DHHS committed to funding the services with state funds temporarily, but this was not extended beyond September 2, 2022.The petitioners appealed to the DHHS Administrative Appeals Unit (AAU), arguing that the termination of funding without an alternative placement amounted to a termination of their services. The Commissioner initially ordered DHHS to continue funding during the appeals. However, in March 2023, the Commissioner granted summary judgment to DHHS, ruling that the services were not terminated but required to be provided in a qualified facility. The Commissioner also ruled that RSA chapter 171-A prohibits DHHS from using state funds for services that do not comply with the federal Settings Rule.The Supreme Court of New Hampshire reviewed the case and concluded that the petitioners had a right to appeal the termination and non-renewal of their service contracts with JRC. However, the court affirmed the Commissioner’s decision, holding that RSA chapter 171-A prohibits DHHS from using state funds for services provided by a provider that does not comply with the federal Settings Rule. Thus, the court affirmed the summary judgment in favor of DHHS. View "Petition of Mason" on Justia Law

Jerry L. Blankenship applied for living miner benefits under the Black Lung Benefits Act, claiming he suffered from coal dust-induced pneumoconiosis and was totally disabled. An Administrative Law Judge (ALJ) found Blankenship entitled to a rebuttable presumption of total disability due to pneumoconiosis under 30 U.S.C. § 921(c)(4) and determined that his former employer, Island Creek Coal Company, failed to rebut this presumption. Consequently, Blankenship was awarded benefits. The Benefits Review Board affirmed the ALJ’s decision.Island Creek petitioned for review, arguing that the ALJ improperly conflated the presence of pneumoconiosis and disability causation with the separate total disability analysis. Additionally, Island Creek contended that the ALJ failed to adequately explain his decision to credit the opinions of Blankenship’s medical experts over those of Island Creek’s experts.The United States Court of Appeals for the Fourth Circuit reviewed the case and agreed with Island Creek. The court found that the ALJ improperly relied on the presence of pneumoconiosis and the causation of Blankenship’s impairment in concluding that he was totally disabled. The court also determined that the ALJ failed to provide a sufficient explanation for crediting the medical opinions of Drs. Nader and Green over those of Drs. McSharry and Sargent, violating the duty of explanation under the Administrative Procedure Act.The Fourth Circuit granted Island Creek’s petition for review, vacated the decision of the Benefits Review Board, and remanded the case with instructions for the Board to return Blankenship’s case to the ALJ for reconsideration consistent with the court’s opinion. View "Island Creek Coal Co. v. Blankenship" on Justia Law

The case involves the interpretation of Administrative Code of the City of New York § 12-126, which mandates that New York City pay the full cost of health insurance coverage for active employees, retirees, and their dependents, up to a specified cap. The dispute centers on whether the City is required to pay up to the statutory cap for any health insurance plan it offers or just one plan. Petitioners argue that the City must pay for any plan offered, while the City contends it only needs to pay for one plan and any additional plans are subject to collective bargaining agreements.The Supreme Court of New York County granted a preliminary injunction preventing the City from enforcing an opt-out date for a new Medicare Advantage plan and later permanently enjoined the City from passing any costs of the current plan to retirees, except where costs exceed the statutory cap. The court did not determine the exact statutory cap but suggested that the cost of the Senior Care plan did not exceed it. The Appellate Division affirmed the Supreme Court's decision, agreeing that the City must pay the full cost, up to the statutory cap, for any health insurance plan it offers to retirees.The Court of Appeals of New York affirmed the Appellate Division's decision, holding that § 12-126 requires the City to pay up to the statutory cap for each health insurance plan it offers to employees and retirees. The court did not address the issue of how the statutory cap should be determined for Medicare-eligible retirees, as the City had not preserved this question for review. The court concluded that the legislative history supported the interpretation that the City must pay for any plan it offers, aligning with the intent to provide a choice of health insurance plans to employees and retirees. View "Matter of NYC Org. of Pub. Serv. Retirees, Inc. v Campion" on Justia Law