Justia Health Law Opinion Summaries

A group of long-term care providers and their associated management company filed cost reports for 2015 with the Mississippi Division of Medicaid (DOM), reporting dividends received from three insurance companies as “other income” rather than offsetting them against insurance costs. This reporting practice had been consistently followed and accepted by DOM for over two decades. When DOM audited the 2015 cost reports around 2018, it changed its approach by offsetting these dividends against current insurance costs, thereby affecting reimbursement rates for services provided by the providers.After DOM made these adjustments, the providers sought reconsideration, but DOM upheld its decision. The providers then pursued an administrative appeal, where a hearing officer found DOM’s adjustments supported by substantial evidence and not arbitrary or capricious, recommending affirmation of DOM’s actions. DOM’s executive director adopted this recommendation. The providers appealed to the Hinds County Chancery Court, which affirmed DOM’s decision, concluding that the State Plan required reference to the Provider Reimbursement Manual (PRM) for guidance, and that DOM acted within its authority and did not violate any statutory or constitutional rights. The chancellor also found no evidence of a written internal policy regarding the treatment of such dividends.On appeal, the Supreme Court of Mississippi reviewed whether DOM’s actions were arbitrary and capricious, whether public notice of the change was required, and other issues. The Court held that DOM’s abrupt reversal of its long-standing unwritten internal policy, without reasonable explanation or public notice, was arbitrary and capricious. The Court further found that public notice was required under federal regulations for significant policy changes affecting payment rates. Accordingly, the Supreme Court of Mississippi reversed the decisions of DOM and the chancery court and rendered judgment in favor of the providers. View "Hattiesburg Medical Park Management Corp. v. Mississippi Division of Medicaid" on Justia Law

During the COVID-19 pandemic, an employer instituted a company-wide vaccine mandate that applied to all employees, including those working remotely. Two remote employees requested religious exemptions from the vaccine requirement. One objected on the basis of her Christian beliefs regarding the use of fetal cell lines in vaccine development, while the other cited her conscience and faith, referencing Catholic teachings. Both exemption requests were denied, and the employees were subsequently terminated.After their terminations, the two employees initiated a lawsuit in the United States District Court for the District of Maryland. Their claims included religious discrimination under Title VII of the Civil Rights Act and two disability discrimination claims under the Americans with Disabilities Act (ADA): one for unlawful medical inquiry and one for being “regarded as” disabled due to their unvaccinated status. The district court dismissed all claims, concluding that the plaintiffs had not sufficiently pleaded that their objections were based on religious beliefs and finding that neither ADA theory was viable because vaccination status is not equivalent to a disability.On appeal, the United States Court of Appeals for the Fourth Circuit reviewed the district court’s decision de novo. The Fourth Circuit held that the plaintiffs’ complaints plausibly alleged that their opposition to the vaccine mandate was an essential part of their religious faith and that their refusal to be vaccinated was connected to those beliefs. Therefore, the court found that the district court erred in dismissing the Title VII religious discrimination claims at the pleading stage. However, the Fourth Circuit affirmed the dismissal of both ADA claims, holding that an inquiry into vaccination status is not a disability-related inquiry and that being unvaccinated does not constitute a physical or mental impairment under the ADA. The case was affirmed in part, vacated in part, and remanded for further proceedings on the Title VII claims. View "Finn v. Humane Society of the United States" on Justia Law

A provider of air ambulance services transported a patient insured by a health maintenance organization, but the provider was not part of the insurer’s network. After the transport, the provider and insurer could not agree on the payment amount. The dispute was submitted to the Independent Dispute Resolution (IDR) process established by the federal No Surprises Act, which requires each party to submit a payment offer and supporting rationale to an arbitrator. The arbitrator, a certified IDR entity, selected the insurer’s lower payment offer. The provider alleged that the insurer had misrepresented its “Qualifying Payment Amount” (QPA) by submitting a lower QPA to the arbitrator than it had previously provided to the provider, and claimed this constituted fraud.The United States District Court for the Middle District of Florida dismissed the provider’s complaint, finding that judicial review of IDR awards is limited to the grounds set forth in the Federal Arbitration Act (FAA), and that the provider’s allegations did not meet the heightened pleading requirements for fraud. The court also dismissed the arbitrator from the case with prejudice, holding that the No Surprises Act does not create a cause of action against IDR entities.On appeal, the United States Court of Appeals for the Eleventh Circuit affirmed the district court’s dismissal. The Eleventh Circuit held that the No Surprises Act incorporates the FAA’s limited grounds for vacating arbitration awards and that the provider failed to adequately plead fraud or undue means under those standards. The court also found that the arbitrator did not exceed its authority and that it was not necessary to name the arbitrator as a defendant to challenge the award. The judgment of the district court was affirmed in full. View "REACH Air Medical Services LLC v. Kaiser Foundation Health Plan Inc." on Justia Law

Several individuals, representing a class, challenged a health insurance company’s refusal to cover gender-affirming care for transgender individuals diagnosed with gender dysphoria. The company, acting as a third-party administrator for employer-sponsored, self-funded health plans, denied coverage for such treatments based on explicit plan exclusions requested by the employer sponsors. Some plaintiffs also alleged that they were denied coverage for treatments that would have been covered for other diagnoses, such as precocious puberty, but were denied solely because of the concurrent diagnosis of gender dysphoria.The United States District Court for the Western District of Washington certified the class and granted summary judgment in favor of the plaintiffs. The district court rejected the company’s arguments that it was not subject to Section 1557 of the Affordable Care Act because its third-party administrator activities were not federally funded, that it was merely following employer instructions under ERISA, and that it was shielded by the Religious Freedom Restoration Act (RFRA). The district court also found that the exclusions constituted sex-based discrimination under Section 1557.On appeal, the United States Court of Appeals for the Ninth Circuit agreed with the district court that the company is subject to Section 1557, that ERISA does not require administrators to enforce unlawful plan terms, and that RFRA does not provide a defense in this context. However, the Ninth Circuit held that the district court’s analysis of sex-based discrimination was undermined by the Supreme Court’s intervening decision in United States v. Skrmetti, which clarified the application of sex discrimination standards to exclusions for gender dysphoria treatment. The Ninth Circuit vacated the summary judgment and remanded the case for further proceedings to consider whether, under Skrmetti, the exclusions at issue may still constitute unlawful discrimination, particularly in cases involving pretext or proxy discrimination or where plaintiffs had other qualifying diagnoses. View "PRITCHARD V. BLUE CROSS BLUE SHIELD OF ILLINOIS" on Justia Law

A hospital operating in Weston, West Virginia, sought to construct a new facility approximately four miles from its current location, at a cost of about $56 million. The hospital’s current site is about sixteen miles from another hospital in Buckhannon, which holds a critical access hospital (CAH) designation, allowing it to receive higher Medicare and Medicaid reimbursements. The Buckhannon hospital argued that the construction of the new facility within twelve mountainous miles of its own would jeopardize its CAH status and financial stability.Previously, the West Virginia Health Care Authority denied the Weston hospital’s application for a certificate of need, finding that the project would harm the Buckhannon hospital and was not a superior alternative under state law. The Intermediate Court of Appeals of West Virginia affirmed this denial. However, after legislative amendments in 2023 raised the capital expenditure threshold for certificate of need requirements to $100 million, the Weston hospital requested a determination from the Authority as to whether its new project required such a certificate. The Authority, applying an unwritten guideline, concluded that a certificate of need was unnecessary for the relocation of an existing facility within the same service area if the cost was below the new threshold. The Intermediate Court of Appeals affirmed this decision, finding the relevant statute ambiguous and deferring to the Authority’s interpretation.The Supreme Court of Appeals of West Virginia reviewed the case and held that the statutory language requiring a certificate of need for the “construction . . . of a health care facility” is clear and unambiguous. The court determined that the construction of a new hospital building, even as a relocation, falls within this requirement, regardless of the capital expenditure amount. The court reversed the decisions of the lower courts and remanded the case to the Authority for further proceedings consistent with its interpretation. View "St. Joseph's Hospital of Buckhannon v. Stonewall Jackson Memorial Hospital Co." on Justia Law

A trade association representing the dietary supplement industry challenged a New York law that prohibits the sale of dietary supplements marketed for weight loss or muscle building to individuals under eighteen. The law was enacted in response to concerns about health risks to minors from such supplements. The statute defines covered products based on how they are labeled or marketed, and authorizes the Attorney General to seek injunctions against violators. The association argued that the law violates the First Amendment, is unconstitutionally vague, and is preempted by federal law.The United States District Court for the Southern District of New York denied the association’s motion for a preliminary injunction, finding that the association was unlikely to succeed on the merits of its claims, had not shown irreparable harm, and that the balance of equities and public interest weighed against granting relief. The District Court later dismissed the vagueness and preemption claims but allowed the First Amendment claim to proceed.On appeal, the United States Court of Appeals for the Second Circuit affirmed the District Court’s denial of a preliminary injunction. The Second Circuit held that the law satisfies intermediate scrutiny under the Central Hudson test for commercial speech, finding that New York has a substantial interest in protecting minors’ health, that the law directly advances that interest, and that it is not more extensive than necessary. The court also concluded that the age verification requirement does not unconstitutionally compel speech, that the statute is not unconstitutionally vague or overbroad, and that it is not preempted by federal law. The court further found that the association failed to demonstrate irreparable harm or that the public interest favored an injunction. The order denying the preliminary injunction was affirmed. View "Council for Responsible Nutrition v. James" on Justia Law

The plaintiff received medical care at Sanford medical facilities in Fargo, North Dakota, in April 2022. He alleged that Sanford and its staff, including nurse Shannon Mulinex, refused to provide him pain medication, verbally abused and humiliated him, failed to investigate his complaints, engaged in a pattern of hostile conduct, and discharged him against his wishes. Based on these events, he brought six claims for intentional infliction of emotional distress (IIED), as well as claims for general negligence, defamation, discrimination, and violation of the Emergency Medical Treatment and Labor Act.The District Court of Cass County, East Central Judicial District, reviewed the case after Sanford moved for summary judgment. Sanford argued that the plaintiff failed to serve an expert affidavit within three months as required by North Dakota law for professional negligence claims, and that the IIED claims did not allege conduct sufficiently extreme and outrageous. The district court denied the plaintiff’s oral motion for a continuance, finding he had received adequate notice of the hearing. The court granted summary judgment, dismissing all claims, concluding that several IIED claims required an expert affidavit and the remaining IIED claims did not meet the legal threshold for extreme and outrageous conduct. A supplemental order granted summary judgment to Mulinex for the same reasons.On appeal, the Supreme Court of North Dakota affirmed the district court’s amended judgment. The Supreme Court held that the district court did not abuse its discretion in denying a continuance, that the plaintiff had not preserved the issue of additional discovery for appeal, and that the requirement for an expert affidavit applied to IIED claims involving medical decisions. The court further held that the conduct alleged in the remaining IIED claims did not rise to the level of extreme and outrageous conduct as a matter of law. The amended judgment of dismissal was affirmed. View "McMahon v. Sanford" on Justia Law

The State petitioned to involuntarily commit J.L.O., alleging she suffered from schizophrenia and posed a danger to herself or others. The petition relied on a report by a licensed clinical social worker (LCSW) who examined J.L.O. the day before the petition was filed. The District Court appointed a licensed professional counselor to examine J.L.O., and scheduled a hearing for January 2, 2024, within the statutory five-day window. J.L.O. was detained at the Montana State Hospital pending the hearing. The State provided J.L.O.’s counsel with the LCSW’s report only after the hearing, and it was discovered that the LCSW was not certified as a “professional person” under Montana law.J.L.O.’s counsel moved to dismiss the commitment petition, arguing that the State failed to have J.L.O. examined by a qualified professional person within the required timeframe. The State conceded the LCSW’s lack of certification but argued that J.L.O.’s request for a continuance waived the five-day hearing deadline. The Fourth Judicial District Court denied the motion to dismiss and proceeded with the commitment process, ultimately appointing a certified professional person who did not personally examine J.L.O. but relied on records and secondhand information. The District Court committed J.L.O. to the Montana State Hospital for up to ninety days and authorized involuntary medication.The Supreme Court of the State of Montana reviewed the case and held that the District Court erred by denying J.L.O.’s motion to dismiss. The Supreme Court found that the statutory requirements for involuntary commitment—including examination by a qualified professional person within the five-day hearing deadline—were not met, and that the error was not harmless. The Supreme Court reversed the District Court’s Order of Commitment. View "In re J.L.O." on Justia Law

An inpatient rehabilitation facility employed a sales representative who raised concerns about the facility’s use of nonclinical personnel in the preadmission screening process required for Medicare reimbursement. The sales representative was terminated after five months of employment. Shortly thereafter, she filed a qui tam action under the False Claims Act, alleging that the facility presented false claims to Medicare, used false records to obtain payment, and conspired to submit false claims. She amended her complaint multiple times, and the government declined to intervene in the case.The United States District Court for the Southern District of Texas reviewed the second amended complaint after the defendant moved to dismiss under Rule 12(b)(6). The magistrate judge recommended dismissal of all claims, finding the complaint insufficiently plausible and lacking the particularity required by Rules 8(a) and 9(b). The magistrate judge also recommended denying leave to further amend the complaint as futile under Rule 16. The district court adopted these recommendations, entered final judgment, and dismissed the case with prejudice. The plaintiff timely appealed.The United States Court of Appeals for the Fifth Circuit reviewed the district court’s dismissal de novo and the denial of leave to amend for abuse of discretion. The Fifth Circuit held that the complaint failed to plead sufficient facts to support the elements of a False Claims Act violation, specifically the falsity of the claims and the connection between the alleged conduct and the submission of false claims. The court also found that amendment would be futile, as the plaintiff had already amended her complaint twice without remedying the deficiencies. The Fifth Circuit affirmed the district court’s dismissal of the claims with prejudice. View "Gentry v. Encompass Health Rehabilitation Hospital of Pearland, L.L.C." on Justia Law

Eskender Getachew, a medical doctor in Columbus, Ohio, operated a clinic treating patients with opioid addiction. The government alleged that Dr. Getachew unlawfully prescribed controlled substances, particularly Subutex, at rates far exceeding medical norms, often without verifying patients’ claimed allergies to naloxone. Evidence at trial included testimony from an undercover officer, clinic staff, and an expert who identified repeated deviations from accepted medical practice, such as prescribing drugs without documented need and ignoring signs of drug diversion. The jury found Dr. Getachew guilty on eleven counts of unlawful distribution of controlled substances and not guilty on four counts.The United States District Court for the Southern District of Ohio presided over the trial. After conviction, Dr. Getachew was sentenced to concurrent six-month terms and three years of supervised release. He moved for a new trial, arguing ineffective assistance of counsel during plea negotiations and requested an evidentiary hearing, which the district court denied. Dr. Getachew appealed, challenging the sufficiency of the evidence, the deliberate-ignorance jury instruction, the content of that instruction, his absence at the return of the verdict, and the denial of an evidentiary hearing.The United States Court of Appeals for the Sixth Circuit reviewed the case. The court held that the evidence was sufficient to support the jury’s finding that Dr. Getachew knowingly issued unauthorized prescriptions. It found no plain error in the deliberate-ignorance instruction or its content. The court determined that Dr. Getachew’s absence at the verdict’s return did not affect his substantial rights and that the district court did not abuse its discretion in denying an evidentiary hearing on the new trial motion. The Sixth Circuit affirmed the district court’s judgment. View "United States v. Getachew" on Justia Law