Montana’s Preferred Provider Agreements Act (MPPAA), Mont. Code Ann. 33-22-1701 to -1707, does not violate the Equal Protection Clause of the Montana Constitution. Plaintiff sought and received treatment from St. Peter’s Hospital for various injuries and symptoms. Because Plaintiff did not have health insurance the Hospital billed Plaintiff directly, but almost all of Plaintiff’s treatments costs were either covered by another party’s insurance or significantly discounted by the Hospital’s financial-need discount. Plaintiff brought this lawsuit arguing that the statutes authorizing the Hospital’s billing practices violate the Equal Protection Clause of the Montana Constitution. The district court concluded that the MPPAA creates similarly situated classes but does not violate Plaintiff’s equal protection rights. The Supreme Court affirmed, holding that the MPPAA, which authorizes the Hospital’s billing practices, does not deprive Plaintiff of her right to equal protection. View "Gazelka v. St. Peter's Hospital" on Justia Law

Plaintiffs were 23 federally qualified health centers (FQHC’s) and rural health clinics (RHC’s) that served medically underserved populations (the Clinics). The dispute before the Court of Appeal centered on coverage for adult dental, chiropractic, and podiatric services the FQHC’s and RHC’s provided to Medi-Cal patients for a period between 2009 and 2013. Prior to July 1, 2009, the Department processed and paid claims for these services. In 2009, in a cost-cutting measure due to budget problems, the Legislature enacted Welfare and Institutions Code section 14131.101 to exclude coverage for these services (and others) “to the extent permitted by federal law.” After the Department stopped paying claims for these services, various FQHC’s and RHC’s challenged the validity of section 14131.10, claiming it conflicted with federal Medicaid law. In California Assn. of Rural Health Clinics v. Douglas, 738 F.3d 1007 (9th Cir. 2013), the Ninth Circuit held section 14131.10 was invalid to the extent it eliminated coverage for these services when provided by FQHC’s and RHC’s because the federal Medicaid Act imposed on participating states the obligation to cover these services by these providers. In response to CARHC, the Department announced it would reimburse FQHC’s and RHC’s for these services for dates of service only on or after September 26, 2013, the date of the Ninth Circuit’s mandate. Seeking reimbursement for services provided prior to September 26, 2103, the Clinics petitioned for a writ of mandate to compel the Department to accept, process, and pay claims for these services for the period July 1, 2009, to September 26, 2013. The trial court granted the petition in part and entered judgment for the Clinics. The Department appeals. Characterizing the Clinics’ writ petition as a suit for damages, it contended: (1) sovereign immunity barred the Clinics’ claims for retroactive payment; (2) the CARHC decision was retroactive because the Medicaid Act is spending clause legislation and its terms were not sufficiently clear as to the requirement to cover adult dental, chiropractic, and podiatric services provided by FQHC’s and RHC’s; and (3) retroactive relief violated the separation of powers doctrine because it forces the Legislature to appropriate money. The Court of Appeal disagreed with the Department’s characterization of the Clinics’ lawsuit. "Rather than a suit for damages, the lawsuit seeks an order to compel performance of a mandatory duty and did not result in a money judgment. Under well-settled California law, such a mandamus proceeding is not barred by sovereign immunity. The Department’s contentions based on spending clause legislation and separation of powers are new arguments raised for the first time on appeal. We exercise our discretion to consider only the spending clause argument. We reject it because the Department has not shown its obligations under Medicaid law, as determined by CARHC, came as a surprise. The separation of powers argument raises factual issues about appropriations that should have been presented in the trial court and we decline to consider this new argument." Accordingly, the Court affirmed the judgment. View "American Indian Health etc. v. Kent" on Justia Law

In consolidated cases, the Pennsylvania Supreme Court granted allowance of appeal to determine whether and to what extent a hospital and a health care staffing agency have a legal duty to prevent a terminated employee from causing harm to patients at another health care facility. Plaintiffs claimed David Kwiatkowski, a radiology technician formerly employed at UPMC Presbyterian Hospital (“UPMC”), who was placed there by staffing agency Maxim Healthcare Services, Inc. (“Maxim”), engaged in the diversion and substitution of intravenous fentanyl. Specifically, Kwiatkowski injected himself with fentanyl from a preloaded syringe, refilled the syringe with saline or another substance, and then replaced the now-contaminated syringe where it could be used by others to inject patients. In doing so years later at a Kansas hospital, Kwiatkowski allegedly communicated hepatitis C to Plaintiffs, who were patients at that hospital. Pursuant to federal regulation, UPMC (but not Maxim) indisputably had a legal obligation to report the diversion of controlled substances to the United States Department of Justice’s Drug Enforcement Administration (“DEA”). UPMC failed to do so. The Superior Court determined that Plaintiffs established that both UPMC and Maxim (collectively, “Defendants”) had a duty to report Kwiatkowski’s misconduct to the DEA and to “law enforcement,” and that Defendants’ failure to do so could have provided a basis for negligence claims. The Supreme Court affirmed the Superior Court’s ruling with respect to UPMC, and reversed the Superior Court’s ruling to the extent it imposed the same duty upon Maxim. View "Walters v. Univ. of Pittsburgh Med. Ctr." on Justia Law

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

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

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

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

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

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

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