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Hospitals challenged the methodology that the Department used to calculate the "outlier payment" component of their Medicare reimbursements for 2008, 2009, 2010, and 2011. At issue was whether the Department's decision to continue with its methodology after the 2007 fiscal year was arbitrary in light of accumulating data about the methodology's generally sub-par performance. The DC Circuit held in Banner Health v. Price, 867 F.3d 1323 (D.C. Cir. 2017) (per curiam), that the Department's decision to wait a bit longer before reevaluating its complex predictive model was reasonable, because the Department had, at best, only limited additional data for 2008 and 2009 and because the 2009 data suggested that hospitals were paid more than expected. In this appeal, the court held that Banner Health foreclosed the hospitals' challenges to the Department's failure to publish a proposed draft rule during the 2003 rulemaking process and the Department's failure to account for the possibility of reconciliation claw-backs in setting the 2008, 2009, 2010, and 2011 thresholds. Finally, the court held that, while the hospitals' frustration with the Department's frequently off-target calculations was understandable, the methodology had not sunk to the level of arbitrary or capricious agency action. View "Billings Clinic v. Azar" on Justia Law

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This matter stemmed from a lawsuit filed by the State of Mississippi against the defendant pharmacies. The State alleged deceptive trade practices and fraudulent reporting of inflated “usual and customary” prices in the defendant’s reimbursement requests to the Mississippi Department of Medicaid. The State argued that Walgreens, CVS, and Fred’s pharmacies purposefully misrepresented these prices to obtain higher prescription drug reimbursements from the State. Finding that the circuit court was better equipped to preside over this action, the DeSoto County Chancery Court transferred the matter to the DeSoto County Circuit Court in response to the defendants’ request. Aggrieved, the State timely filed an interlocutory appeal disputing the chancellor’s decision to transfer the case. After a thorough review of the parties’ positions, the Mississippi Supreme Court found that though the chancery court properly could have retained the action, the chancellor correctly used his discretion to transfer the case, allowing the issues to proceed in front of a circuit-court jury. As a result, the Supreme Court affirmed the chancellor’s decision. View "Mississippi v. Walgreen Co." on Justia Law

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Harvey Cohoon was diagnosed with a treatable form of cancer and was residing at Victoria Healthcare Center while he underwent treatment and recovered from various injuries he had suffered. For 19 days, Cohoon did well at Victoria Center. On the 20th day, he was observed to have difficulty swallowing thin liquids, and after evaluation, his diet was changed. Plaintiff contended that change was not properly communicated to the kitchen, and that night he was served a dinner that did not comport with his new diet. Less than 20 minutes after being served dinner, a nurse found him in respiratory arrest. The paramedics had to remove large pieces of chicken from his throat before intubating him. More pieces of chicken were removed from his airway at the hospital. He died the following day due to complications from oxygen deprivation to his brain. Donna Cochrum, Cohoon’s niece, filed suit against Victoria Center, asserting causes of action for elder abuse and negligence. As personal representative of Cohoon’s estate, Cochrum asserted a wrongful death cause of action. A jury returned a verdict in favor of Cochrum on all causes of action. Subsequently, the trial court granted a motion for judgment notwithstanding the verdict (JNOV), finding insufficient evidence of recklessness to support the elder abuse cause of action. It also adjusted the remaining damages pursuant to Civil Code section 3333.2. Cochrum appealed the amended judgment, contending the evidence supported the elder abuse cause of action. Two of the defendants cross-appealed, contending the court improperly applied the Medical Injury Compensation Reform Act of 1975 cap. Finding no reversible error, the Court of Appeal affirmed the amended judgment. View "Cochrum v. Costa Victoria Healthcare, LLC" on Justia Law

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The California Legislature reduced Medicaid hospital payments 10 percent between 2008-2011; the federal agency administering the Medicaid program approved the rate reductions. Hospitals alleged the reductions violated the Medicaid Act (42 U.S.C. 1396), which sets out procedural and substantive requirements the state must follow when establishing reimbursement rates. Hospitals unsuccessfully sought to have the rates declared void and almost $100 million in recalculated rates. The court of appeal affirmed, concluding that healthcare providers alleging a violation of section 1396a(a)(30)(A) may not obtain a writ of mandate against state officials to contest Medicaid rates approved by the federal agency that administers the program. Their recourse is an administrative action against the federal agency that approved the rates. While plaintiffs may obtain a writ of mandate for violations of the procedural requirements of section 13(A), no such violation occurred here. View "Santa Rosa Memorial Hospital v. Kent" on Justia Law

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The Court of Appeals affirmed the judgments of the circuit court and Court of Special Appeals that there were no errors of procedure or substantive law on the part of Respondents - the University of Maryland Baltimore Washington Medical Center (Hospital) and the Maryland Department of Health - and the administrative law judge (ALJ) in determining that Petitioner met the requirements for involuntary admission to the psychiatric unit of the Hospital. The Court held (1) the ALJ did not err in finding that Petitioner’s hearing on involuntary admission complied with the ten-day deadline for an involuntary admission hearing set forth in Md. Code Ann. Health-Gen. 10-632(b); and (2) there was substantial support in the record for the ALJ’s finding that Petitioner presented a danger to the life or safety of herself or of others at the time of the hearing. View "In re J.C.N." on Justia Law

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Memorial Hospital at Gulfport and Singing River Health System (“Hospitals”) sought judicial review of a June 24, 2016 administrative decision which found the Division of Medicaid’s (“DOM’s”) 2014 Fiscal Year Methodology “correctly interprets statutes and regulations and is neither arbitrary or capricious.” The chancellor affirmed the decision of DOM. Finding no evidence in the record before it that DOM failed to comply with Sections 43-13-117 and 43-13-145 in allocating and distributing supplemental payments to Mississippi hospitals, the Mississippi Supreme Court affirmed. View "Memorial Hospital at Gulfport v. Dzielak" on Justia Law

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From 1996-2011 Pennsylvania claimed the costs of a training program, the Pennsylvania Restraint Reduction Initiative, “to train long-term care facility staff in the use of alternative measures to physical and chemical restraints,” as administrative costs under its Medicaid program, 42 U.S.C. 1396b(a)(7) . The Centers for Medicare & Medicaid Services (CMS) reimbursed Pennsylvania for about $3 million. After an audit, CMS sought a return of the money on the ground that funds spent on training programs are not reimbursable as administrative costs under Medicaid. CMS relied heavily on a 1994 State Medicaid Director Letter. The Appeals Board, district court, and Third Circuit rejected the state’s arguments that the 1994 Letter was an invalid substantive rule, that the Letter’s text does not exclude the training costs from reimbursement, that the Letter imposed an ambiguous condition on a federal grant, that the Appeals Board abused its discretion in denying discovery, that the HHS Grants Administration Manual limits the disallowance period to three years, and that the district court should have taken judicial notice of the 2015 CMS Question and Answer document concerning training costs. The court noted CMS could have reimbursed Pennsylvania if Pennsylvania factored the amount into its rate-setting scheme instead of claiming it as administrative costs. View "Commonwealth of Pennsylvania Department of Human Services v. United States" on Justia Law

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The Supreme Court held that Montana law does not preclude physical restraint of a seriously mentally ill individual during transportation from a courtroom to a hospital or mental health facility. The district court ordered J.J., who suffered from severe and chronic mental illness, involuntarily committed to Montana State Hospital (MSH). Thereafter, J.J. requested that he not be handcuffed in the sheriff’s vehicle on the way to MSH. The district court denied the request. The Supreme Court affirmed, holding that while Mont. Code Ann. 53-21-146 provides patients a statutory right to be free from physical restraint, nothing in the plain language of the statute leads to the conclusion that it applies to transportation. Further, Montana law enforcement officers owe the public a general duty to preserve the peace and protect the public from harm inflicted by third persons. Because J.J.’s potential for serious injury or harm was high and foreseeable, the district court did not abuse its discretion when it failed to grant J.J.’s request not to be handcuffed during transportation. View "In re J.J." on Justia Law

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The Secretary appealed the district court's order enjoining him from enforcing a Medicaid policy set forth in a Frequently Asked Questions document (FAQ 33), which purported to clarify the methodology for calculating the maximum amount of financial assistance available to hospitals, like Children's Hospital, that serve a disproportionate number of low-income or special needs patients (DSHs). The Fourth Circuit held that the district court correctly determined that the policy set forth in FAQ 33 constituted a "legislative rule" and thus the Administrative Procedure Act mandated that the agency establish the FAQ 33 policy through notice-and-comment rulemaking. Therefore, the court affirmed the district court's judgment enjoining the Secretary from enforcing the policy set forth in FAQ 33 against Children's Hospital. The court declined to reach the substantive challenge and vacated the part of the district court's opinion addressing whether the policy conflicts with the language of 42 U.S.C. 1396r-4(g). View "Children's Hospital v. Azar" on Justia Law

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The Supreme Court held that, in dismissing the Commonwealth’s petition to have Troy Lamar Giddens, Sr. civilly committed as a sexually violent predator, the trial court misapplied the relevant statute, Va. Code 37.2-905.1. Moreover, the evidence did not support dismissal. The trial court dismissed the Commonwealth’s petition, concluding that the burden was on the Commonwealth to prove that Giddens was eligible for the sexually violent predator program and that the Commonwealth failed to show that Giddens' score on Static-99, the test designed to assess the recidivism risk of adult male sexual offenders, was scored correctly. The Supreme Court reversed, holding that Giddens did not show gross negligence or willful misconduct, which was required for him to prevail under section 37.2-905.1. View "Commonwealth v. Giddens" on Justia Law