The Ninth Circuit affirmed the district court's dismissal of plaintiffs' claim that their insurer, Blue Shield, violated the Medical Loss Ratio (MLR) provision of the Patient Protection and Affordable Care Act (ACA). The MLR is the ratio between what an insurer pays out in claims for medical services and the revenue it takes in. The panel held that there was no basis in the language, history, intent or spirit of the ACA to narrow the MLR by excluding payments for services rendered by out-of-network physicians. In this case, the MLR was properly calculated under federal law by including the settlement reimbursements for medical services by nonnetwork providers. Therefore, the district court correctly recognized the services were covered by the plan and the payments were made. View "Morris v. California Physicians' Service" on Justia Law

The Supreme Court affirmed Defendant’s convictions and sentences, holding that the Arizona Health Care Cost Containment System (AHCCCS) statutory scheme, Ariz. Rev. Stat. 36-2901 to -2999.57, abrogates and creates an exception to Arizona’s statutory physician-patient privilege, Ariz. Rev. Stat. 13-4062(4), in cases of suspected AHCCCS fraud. Defendant was convicted of defrauding AHCCCS for lying about having cancer so her abortion would fall within the exception to the rule that AHCCCS does not cover abortions except when necessary to save a woman’s life or to protect her health. On appeal, Defendant argued that the superior court erred by admitting her medical records and by allowing her physicians to testify against her. The court of appeals affirmed, holding that the AHCCCS statutes abrogated the physician-patient privilege in cases of suspected AHCCCS fraud. The Supreme Court affirmed, holding (1) the legislature’s grant of brand authority to AHCCCS to investigate suspected fraud necessarily implies an exception to the privilege for internal AHCCCS investigations and proceedings; and (2) the AHCCCS statutes implicitly abrogate the privilege in the criminal investigation and prosecution of suspected AHCCCS fraud because the provisions at issue exhibit an intent to provide law enforcement access to patient information when investigating and prosecuting AHCCCS fraud. View "State v. Zeitner" on Justia Law

MSPA, a firm that obtains Medicare Secondary Payer Act (MSP Act) claims and brings them on behalf of Medicare Advantage Organizations (MAOs), filed suit against Tenet over a delayed reimbursement of $286. The Eleventh Circuit affirmed the district court's grant of Tenet's motion to dismiss. The court held that MSPA had standing to invoke a federal court's jurisdiction because it suffered an injury in fact when it had to wait seven months for appropriate reimbursement and it validly assigned the right to vindicate that injury to La Ley Recovery Systems, who in turn validly assigned it to MSPA. On the merits, the court held that the MSP Act's private cause of action was only available in the case of a primary plan which fails to provide for primary payment (or appropriate reimbursement). In this case, MSPA did not sue a primary plan, but instead, it sued two medical services providers. Because private MSP Act plaintiffs could only sue primary plans, and MSPA had not done so, its claim was not plausible on its face. Therefore, the district court correctly dismissed MSPA's complaint for failure to state a claim. View "MSPA Claims 1, LLC v. Tenet Florida, Inc." on Justia Law

Nita and her husband, Kirtish, pled guilty to defrauding Medicare (18 U.S.C. 1347), based on having forged physicians’ signatures on diagnostic reports and having conducted diagnostic testing without the required physician supervision. The government then brought this civil action for the same fraudulent schemes against Nita, Nita’s healthcare company (Heart Solution), Kirtish, and Kirtish’s healthcare company (Biosound). The district court granted the government summary judgment, relying on the convictions and plea colloquies in the criminal case, essentially concluding that Nita had admitted to all elements and issues relevant to her civil liability. Nita and Heart Solution appealed. The Third Circuit affirmed Nita’s liability under the False Claims Act, 31 U.S.C. 3729(a)(1)(A) and for common law fraud but vacated findings that Heart Solution is estopped from contesting liability and damages for all claims and Nita is estopped from contesting liability and damages for the remaining common law claims. The district court failed to dissect the issues that were determined in the criminal case from those that were not, lumping together Nita and Heart Solution, even though Heart Solution was not involved in the criminal case. It also failed to disaggregate claims Medicare paid to Nita and Heart Solution from those paid to Kirtish and Biosound. The plea colloquy did not clarify ownership interests in the companies; who, specifically, made certain misrepresentations; nor whether one company was paid the entire amount or whether the payments were divided between the companies. View "Doe v. Heart Solution PC" on Justia Law

The Second Circuit certified the following question to the New York Court of Appeals: Does New York Public Health Law Section 230(11)(b) create a private right of action for bad faith and malicious reporting to the Office of Professional Medical Conduct? View "Haar v. Nationwide Mutual Fire Insurance Co." on Justia Law

Hospitals challenged the method the Secretary used to calculate the volume-decrease adjustment (VDA) for certain fiscal years during the mid-2000s, as well as the Administrator's classification of certain costs as variable costs when calculating the adjustment. The Eighth Circuit affirmed the district court's decision to uphold the Secretary's actions and held that the Secretary's interpretation of the relevant regulations was a reasonable interpretation of the plain language of the Medicare statute. Given the lack of guidance in the statute and the substantial deference the court affords to the agency, the Secretary's decision reasonably complied with the mandate to provide full compensation. That the Secretary has prospectively adopted a new interpretation was not a sufficient reason to find the Secretary's prior interpretation arbitrary or capricious. The court also held that the Secretary's interpretation of the relevant regulations in these cases was clearly consistent with their text, and the costs at issue were reasonably classified as variable costs. View "Unity HealthCare v. Azar" on Justia Law

The Fifth Circuit affirmed the district court's grant of summary judgment to HHS in an action under the Administrative Procedure Act arising from a demonstration project deviating from the ordinary Medicare reimbursement rules. In this case Texas Tech could keep the additional fees it received for implementing the project only if its care management model achieved cost savings. When the government determined that Texas Tech failed to do so, it demanded return of about $8 million in fees. As a preliminary matter, the court held that the demonstration agreement was not a procurement contract and the HHS Departmental Appeals Board had jurisdiction over this case. On the merits, the court held that it need not resolve whether the Board erred in suggesting that the common law of contracts never informs grant disputes, because, even if it did, the Board made valid findings justifying the rejection of Texas Tech's various contract theories. The court rejected Texas Tech's contention that CMS breached the demonstration agreement by failing to provide an appropriately matched control group; by refusing to allow Texas Tech to access relevant Medicare claims data; and by engaging RTI to evaluate whether differences between the intervention and control groups may have accounted for the apparent lack of cost savings. Finally, the court held that, although the Board did not expressly address two common law contract doctrines -- mistake and impracticability -- it did make findings that doom those two defenses. View "Texas Tech Physicians Assoc. v. US Department of Health and Human Services." on Justia Law

Petitioner Andrew Panaggio appealed a decision of the New Hampshire Compensation Appeals Board (board). Petitioner suffered a work-related injury to his lower back in 1991; a permanent impairment award was approved in 1996 and in 1997, he received a lump sum settlement. Petitioner continued to suffer ongoing pain as a result of his injury and has experienced negative side effects from taking prescribed opiates. In 2016, the New Hampshire Department of Health and Human Services determined that Panaggio qualified as a patient in the therapeutic cannabis program, and issued him a New Hampshire cannabis registry identification card. Panaggio purchased medical marijuana and submitted his receipt to the workers’ compensation insurance carrier for reimbursement. The respondent-carrier, CNA Insurance Company, denied payment on the ground that “medical marijuana is not reasonable/necessary or causally related” to his injury. The board denied his request for reimbursement from the respondent.On appeal, Panaggio argued the board erred in its interpretation of RSA 126-X:3, III, and when it based its decision in part on the fact that possession of marijuana is illegal under federal law. The New Hampshire Supreme Court reversed in part and remanded for further proceedings. Specifically, the Court determined that because the board found that Panaggio’s use of medical marijuana was reasonable, medically necessary, and causally related to his work injury, the board erred when it determined the insurance carrier was prohibited from reimbursing Panaggio for the costs of purchasing medical marijuana. The Court determined that because the board’s order failed to sufficiently articulate the law that supported the board’s legal conclusion and failed to provide an adequate explanation of its reasoning regarding federal law, it was impossible for the Court to discern the grounds for the board’s decision sufficient for it to conduct meaningful review. Accordingly, the case was remanded to the board for a determination of these issues in the first instance. View "Appeal of Panaggio" on Justia Law

The Supreme Court affirmed the district court’s decision denying Dr. LeGrand P. Belnap discovery as to allegedly defamatory statements made by Drs. Ben Howard and Steven Mintz in peer review meetings, holding that there is no bad faith exception to Utah R. Civ. P. 26(b)(1). At issue was whether there is a bad faith exception to discovery and evidentiary privileges under Rule 26(b)(1) for statements made and documents prepared as part of a health care provider’s peer review process. Dr. Belnap was denied discovery as to alleged defamatory statements concerning Dr. Belnap’s application for surgical privileges at Jordan Valley Medical Center. Dr. Belnap filed this interlocutory appeal, arguing that Rule 26(b)(1) includes a bad faith exception. The Supreme Court disagreed, holding (1) there is no bad faith exception to Rule 26(b)(1)’s peer review privilege; and (2) even looking to the legislative history, there is still no bad faith exception. View "Belnap v. Howard" on Justia Law

In 2016, St. Luke’s Health System, Ltd. accepted an indigent patient suffering from meningitis, seizures, and brain lesions. The patient was ready for transfer to another medical facility by February 18, 2016, but was refused by multiple care providers because they did not want to admit an indigent patient without a payor source. St. Luke’s finally contracted with Life Care, another medical facility, to take the patient on the condition that St. Luke’s would guarantee payment for a thirty day period. The patient was transferred to Life Care on March 9, 2016. St. Luke’s applied for medical indigency benefits covering the period of time from the patient’s initial hospitalization until she was transferred to the Life Care facility. Gem County initially approved the application for benefits through February 3, 2016. St. Luke’s appealed that determination, and after a hearing, the Board approved medical indigency benefits from January 26, 2016, until February 18, 2016. The Board entered a written determination titled “Amended Determination of Approval for County Assistance” which set forth the various bills that were approved for payment, but did not in any way reflect the denial of benefits or the reasoning of the Board. St. Luke’s then sought judicial review of the Amended Determination before the district court, which affirmed the Board’s decision. St. Luke’s appealed. The Idaho Supreme Court vacated the Board’s Amended Determination because it did not reflect the partial denial of benefits and because there were no findings of fact or conclusions of law setting forth the basis for the Board’s denial. View "St. Lukes v. Bd of Commissioners of Gem Co" on Justia Law