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A three-year “risk corridors” program described in the Patient Protection and Affordable Care Act, 42 U.S.C. 18001, implemented by the Department of Health and Human Services (HHS), was intended to promote participation in insurance exchanges. Participating insurers, whose costs of providing coverage exceeded the premiums received (using a statutory formula) were to be paid a share of their excess costs while participating plans whose premiums exceeded their costs would pay in a share of their profits. The program “permit[ted] issuers to lower [premiums] by not adding a risk premium" for uncertainties in the 2014-2016 markets. The actual total "payments in"were less than requested "payments out" and Congress prohibited HHS from using its appropriations for the program. Prorated payments were issued. The insurer filed suit. The Federal Circuit affirmed summary judgment in favor of the government. The statute created an obligation of the government to pay exchange participants the amount indicated by the statutory formula but riders in the FY 2015 and 2016 appropriations bills repealed or suspended the obligation to make payments out in an aggregate amount exceeding payments in. Congress made the policy choice to cap payments. No statement or action by the government evinced an intention to form a contract; the risk corridors program was simply an incentive program. Because there was no contract, the insurer’s “takings” claim also failed. View "Land of Lincoln Mutual Health Insurance Co. v. United States" on Justia Law

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A three-year “risk corridors” program described in the Patient Protection and Affordable Care Act, 42 U.S.C. 18001, implemented by the Department of Health and Human Services (HHS), was intended to promote participation in insurance exchanges. Participating insurers, whose costs of providing coverage exceeded the premiums received (using a statutory formula) were to be paid a share of their excess costs while participating plans whose premiums exceeded their costs would pay in a share of their profits. The program “permit[ted] issuers to lower [premiums] by not adding a risk premium" for uncertainties in the 2014-2016 markets. The actual total "payments in"were less than requested "payments out" and Congress prohibited HHS from using its appropriations for the program. Prorated payments were issued. Moda filed suit. The Claims Court granted Moda partial summary judgment as to liability, stipulated to be $209,830,445.79. Dozens of other insurers filed actions, with mixed results. The Federal Circuit reversed. The statute created an obligation of the government to pay exchange participants the amount indicated by the statutory formula but riders in the FY 2015 and 2016 appropriations bills repealed or suspended the obligation to make payments out in an aggregate amount exceeding payments in. Congress made the policy choice to cap payments. No statement by the government evinced an intention to form a contract; the statute, its regulations, and HHS’s conduct simply created an incentive program. View "Moda Health Plan, Inc. v. United States" on Justia Law

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Gillispie, an RN, worked for the Medical Center, addressing possible medical errors. In October 2012, a pregnant patient, “E.R.,” went to the Center’s emergency room complaining of pain and vaginal bleeding. After examining E.R., Center personnel discharged her, telling her to “[g]o directly to Uniontown Hospital” to see a gynecologist. The Center had no gynecologist on staff. Center personnel did not transport E.R. Two days later, Cowie, the Center’s CEO, held a meeting to investigate whether E.R.’s discharge violated the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. 1395dd, or triggered reporting requirements. Gillispie contends that she insisted at two meetings that EMTALA required a report, but Cowie instructed the attendees not to report. Pennsylvania Department of Health representatives subsequently investigated a complaint regarding another patient, L.S.; Gillispie stated that Cowie had falsely told L.S.’s family that nurses had been disciplined for L.S.’s treatment. Cowie terminated Gillispie’s employment. Gillispie later reported the Center’s discharge of E.R., then filed suit under EMTALA’s whistleblower protection provision. The Third Circuit affirmed summary judgment in favor of the defendants. Gillispie did not give anyone at the Center any information about E.R.’s discharge that they were not already aware of, so she did not make a report and did not engage in activity protected by EMTALA’s whistleblower provision. Gillispie’s complaint with respect to L.S. have a statutory remedy, so she may not also allege a public policy-based wrongful discharge claim. View "Gillispie v. Regionalcare Hospital Partners, Inc." on Justia Law

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Brookdale employed Prather to review Medicare claims before their submission for payment. Many of these claims were missing required certifications from physicians attesting to the need for the medical services provided. Certifications must “be obtained at the time the plan of care is established or as soon thereafter as possible.” 42 C.F.R. 424.22(a)(2).Prather filed a complaint under the False Claims Act, 31 U.S.C. 3729, alleging an implied false certification theory. The district court dismissed her complaint. The Sixth Circuit reversed in part, holding that Prather had pleaded two claims with the required particularity and that the claims submitted were false. On remand, the district court dismissed Prather's Third Amended Complaint in light of the Supreme Court’s 2016 clarification of the materiality element of an FCA claim. The Sixth Circuit reversed. Prather sufficiently alleged the required materiality element; the timing requirement in section 424.22(a)(2) is an express condition of payment and Prather alleges that the government paid the claims submitted by the defendants without knowledge of the non-compliance, making those payments irrelevant to the question of materiality. Section 424.22(a)(2) is a mechanism of fraud prevention, which the government has consistently emphasized in guidance regarding physician certifications and Prather adequately alleged “reckless disregard” of compliance and whether this requirement was material. View "Prather v. Brookdale Senior Living Community" on Justia Law

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The DC Circuit affirmed the district court's dismissal based on lack of subject matter jurisdiction of CMS's decision declining to hear Mercy Hospital's challenge to its reimbursement rate for fiscal years 2002 through 2004. The Administrator interpreted a statutory provision that precluded administrative and judicial review of the reimbursement rate to also preclude review of the underlying formula that helped determine that rate. The court concluded from the Medicare statute's plain language in 42 U.S.C. 1395ww(j) that "prospective payment rates" means step-two rates. The court held that the preclusion paragraph barred review of step-two rates and the statutory adjustments. View "Mercy Hospital, Inc. v. Azar" on Justia Law

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Act 900, Arkansas Code Annotated 17-92-507, an amendment to the state's then-existing maximum allowable cost (MAC) law that governed the conduct of pharmacy benefits managers, was preempted by the Employee Retirement Income Security Act (ERISA) and Medicare Part D statutes. The Eighth Circuit affirmed the district court's ERISA ruling in this case, but reversed the Medicare Part D ruling. The court remanded for entry of judgment for PCMA. View "Pharmaceutical Care Management v. Rutledge" on Justia Law

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A pharmacy has a limited legal duty to take reasonable steps to notify a patient and his or her prescribing physician of the need for prior authorization each time the patient tries to fill a prescription. Only the pharmacy, and not the physician or the patient, is notified by a health insurer when a prescribing physician must complete a prior authorization form and submit it to the insurer. In this case, prior authorization was necessary for Yarushka Rivera to obtain insurance coverage for Topamax, a medication she needed to control life-threatening seizures. When Rivera reached age nineteen, her insurer refused to pay for the prescription because it had not received the necessary prior authorization form. Rivera, who was unable to afford the medication without insurance, suffered a fatal seizure at the age of nineteen. Plaintiff brought this action for wrongful death and punitive damages against Walgreen Eastern Co., Inc. The superior court concluded that Walgreens had no legal duty to Rivera to notify Rivera’s prescribing physician of the need for prior authorization. The Supreme Court reversed, holding that Walgreens owed a legal duty of care to take reasonable steps to notify Rivera and her prescribing physician of the need for prior authorization each time Rivera tried to fill her prescription. View "Correa v. Schoeck" on Justia Law

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In this case alleging health care liability claims, the trial court erred by allowing Plaintiff to amend her complaint after the expiration of the statute of limitations to substitute as a defendant a health care provider to which Plaintiff had not sent pre-suit notice. The Supreme Court reversed the decisions of the trial court and court of appeals, holding that Plaintiff did not comply with the mandatory pre-suit notice provision of the Tennessee Health Care Liability Act, Tenn. Code Ann. 29-26-121(a)(1), because she did not give written pre-suit notice of the potential claim to the health care provider she later sought to substitute as a defendant after the expiration of the statute of limitations. View "Runions v. Jackson-Madison County General Hospital District" on Justia Law

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The Ninth Circuit reversed the district court's grant of summary judgment for defendant in an action challenging an Employee Retirement Income Security Act (ERISA) plan's denial of a claim. The plan denied plaintiff's claim for the cost of an inpatient stay in a residential mental health treatment facility. The panel held that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 did not require that the plan's coverage for stays at licensed inpatient residential treatment facilities had to be no more restrictive than stays at skilled nursing facilities. The panel explained that the Parity Act precluded the plan from deciding that it would provide room and board reimbursement at licensed skilled nursing facilities for medical and surgical patients, but not at residential treatment facilities for mental health patients. View "Danny P. v. Catholic Health Initiatives" on Justia Law

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A former small-town doctor, defendant Joel Miller, was charged with multiple counts of health-care fraud, money laundering, and distributing a controlled substance outside the usual course of professional treatment, as well as one count of making a false statement on an application submitted to the Drug Enforcement Administration. A jury acquitted him on all of the financial charges as well as several of the drug distribution charges, but found him guilty on seven counts of distributing a controlled substance, and one count of making a false statement to the DEA. The district court granted Defendant’s post-judgment motion for acquittal on one of the controlled-substances counts based on an error in the indictment. The court then sentenced him to forty-one months of imprisonment on the six remaining distribution counts, plus a consecutive sentence of nineteen months on the false-statement count, for a total sentence of sixty months of imprisonment. Defendant appealed his convictions and sentence. The Tenth Circuit found no error in the imposition of defendant’s sentence on the six distribution counts; however the Court reversed and remanded on the false statement count. The Court was persuaded that trial court proceedings “broadened the possible bases for conviction beyond those found in the operative charging document. …we are persuaded that the trial proceedings in this case effected a constructive amendment.” View "United States v. Miller" on Justia Law