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Plaintiff-appellee Elizabeth Cates filed on her behalf and a putative class asserting claims against the defendant-appellee INTEGRIS Health, Inc. for breach of contract, violation of the Oklahoma Consumer Protection Act, deceit, specific performance, and punitive damages. INTEGRIS successfully moved to dismiss the claims based on the ground that they are all preempted by the Employee Retirement Income Security Act. Cates appealed. Because the trial court in this matter did not take into consideration the federal Tenth Circuit Court of Appeals’ decision in Salzer v. SSM Health Care of Oklahoma Inc., 762 F.3d 1130 (10th Cir. 2014), which was factually similar to the facts of this case and found that the plaintiff’s claims were not preempted, the Oklahoma Supreme Court reversed and remanded the trial court in this matter for reconsideration in light of Salzer. View "Cates v. Integris Health, Inc." on Justia Law

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Dr. Benjamin Reid, a licensed general surgeon, filed a complaint against KentuckyOne Health, Inc. (“Hospital”) alleging various claims arising from the Hospital’s review of Reid’s surgical privileges at the Hospital. The circuit court granted the Hospital’s motion for judgment on the pleadings, concluding that Reid failed to rebut the presumption that the Hospital was immune under the Health Care Quality Improvement Act of 1986 because the Hospital’s conduct with respect to Reid was related to its professional review activities. The court of appeals reversed, concluding that the Hospital had taken a “professional review action” against Reid rather than a “professional review activity.” The Supreme Court reversed, holding (1) a factual dispute existed as to whether the Hospital’s actions were merely “professional review activities” that would be entitled to immunity under the Act or whether they were “professional review actions,” and (2) therefore, the record was insufficient on the immunity question under the Act. View "KentuckyOne Health, Inc. v. Reid" on Justia Law

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This case turned on whether an attorney-in-fact who admitted her principal to a residential care facility for the elderly made a “health care” decision. If she did, as the trial court found, she acted outside the scope of her authority under the power of attorney, and the admission agreement she signed, and its arbitration clause this appeal sought to enforce, were void. On these facts the Court of Appeal concluded the decision was health care decision, and the attorney-in-fact who admitted her, acting under the PAL, was not authorized to make those kinds of decisions on behalf of the principal. As a result of this conclusion, the Court affirmed the trial court’s denial of a motion by the residential care facility to compel arbitration. Because the attorney-in-fact acting under the PAL did not have authority to admit the principal to the residential care facility for the elderly, her execution of the admission agreement and its arbitration clause were void. View "Hutcheson v. Eskaton Fountainwood Lodge" on Justia Law

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Critical Access Hospitals are reimbursed by Medicare for the reasonable and necessary costs of providing services to Medicare patients. The Medicaid program requires states to provide additional (DSH) payments to hospitals that serve a disproportionate share of low-income patients, 42 U.S.C. 1396a(a)(13)(A)(iv). In Kentucky, DSH payments are matched at 70% by the federal government. Kentucky’s contribution to DSH programs comes from payments from state university hospitals and Kentucky Provider Tax, a 2.5% tax on the revenue of various hospitals, including Appellants, The amount of DSH payments a hospital receives is unrelated to the amount of KP-Tax it paid. During the years at issue, DSH payments covered only 45% of Appellants' costs in providing indigent care. Appellants filed cost reports in 2009 and 2010 claiming their entire KP-Tax payment as a reasonable cost for Medicare reimbursement. Previously, they had received full reimbursement; for 2009 and 2010, however, the Medicare Administrative Contractor denied full reimbursement, offsetting the KP-Tax by the amount of DSH payments Appellants received. The Provider Reimbursement Review Board and Centers for Medicare and Medicaid Services upheld the decision. The Sixth Circuit affirmed, reasoning that the net economic impact of Appellants’ receipt of the DSH payment in relation to the cost of the KP-Tax assessment indicated that the DSH payments reduced Appellants’ expenses such that they constituted a refund. View "Breckinridge Health, Inc. v. Price" on Justia Law

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Since 2009, AIDS Support Group of Cape Cod, Inc. (ASGCC) has been operating a free hypodermic needle access program in a village in Barnstable. The Town of Barnstable ordered the cessation of the program, asserting that ASGCC was in violation of Mass. Gen. Laws ch. 94C, 27 and Mass. Gen. Laws ch. 111, 215. In response to the Town’s cease and desist order, ASGCC filed this action seeking injunctive relief and a declaration that its nonsale needle access program was not statutorily prohibited. The superior court judge reported the question to the Appeals Court, and the Supreme Judicial Court allowed ASGCC’s application for direct appellate review. The court remanded the matter to the superior court for entry of a declaration that neither statute prohibits ASGCC from engaging in free distribution of hypodermic needles and an injunction permanently enjoining enforcement of the Town’s order to cease and desist, holding that the plain language of the statutes does not proscribe free distribution of hypodermic needs by a private individual or organization such as ASGCC that does not operate a program implemented by the Department of Public Health. View "AIDS Support Group of Cape Cod, Inc. v. Town of Barnstable" on Justia Law

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Raymond, injured in a slip-and-fall accident, received medical treatment at Mercy Health Anderson Hospital. Strunk, injured in a car accident, received medical treatment at Mercy Health Clermont Hospital. Both have health insurance. Each of their insurers has an agreement with Mercy for the provision of services. Raymond and Strunk provided all information necessary for the hospital to submit claims. Mercy did not submit claims to the insurers. Instead, Avectus, on behalf of Mercy, sent letters to Raymond’s and Strunk’s attorneys stating the balance due for medical services and requesting that, to prevent collection efforts against their respective clients, the attorneys sign a “letter of protection” against any settlement or judgment, agreeing “to withhold and pay directly to Mercy Health the balance of any unpaid charges ... should my firm obtain any settlement or judgment for this patient." Raymond and Strunk claimed that Mercy and Avectus sought compensation from them for their medical expenses, in violation of Ohio Revised Code 1751.60. The district court dismissed. The Sixth Circuit reversed. The defendants sought payment “from a health-insuring corporation’s insured” while in a healthcare services contract with their health-insurance providers. The court rejected a claim that the defendants effectively sought compensation from a third party. View "Raymond v. Avectus Healthcare Solutions, LLC" on Justia Law

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Methodist and Saint Francis are the two largest hospitals in Peoria, Illinois. Saint Francis is considerably larger and more profitable. Methodist filed suit, charging Saint Francis with violating the Sherman Act by entering into exclusive contracts with insurance companies, covering more than half of all commercially-insured patients in the area. Methodist argued that it could not obtain a sufficiently high volume of patients to enable it to invest in improvements. The Seventh Circuit affirmed summary judgment in favor of Saint Francis, noting that health insurers regard Saint Francis as a “must have” hospital, because it provides certain services that the other hospitals in the area do not provide, such as solid-organ transplants, neonatal intensive care, and a Level 1 trauma center. The contracts are a form of requirements contract; an insurance company may get better rates from a hospital by agreeing to an exclusive contract, which will drive more business to the hospital. The contracts are of fixed duration; when they terminate, the insurance companies are free to contract with other hospitals. Competition-for-the-contract is protected by the antitrust laws and is common. The court noted that none of the other four area hospitals had joined the case and the Department of Justice declined to file a case. View "Methodist Health Services Corp v. OSF Healthcare System" on Justia Law

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Mr. J. was a proper subject of treatment within the meaning of Wis. Stat. 51.20(1) because he had rehabilitative potential. Mr. J., an adult suffering from paranoid schizophrenia, was subject to an involuntary commitment order and an order requiring him to undergo treatment and take medication prescribed for his condition. Waukesha County filed a petition to extend Mr. J’s involuntary commitment and treatment orders for an additional year. The circuit court granted the County’s petition and extended Mr. J’s involuntary commitment order for twelve months and further extended the medication and treatment order. The court of appeals affirmed. The Supreme Court affirmed, holding that the circuit court and the court of appeals properly concluded that Mr. J. was a proper subject of treatment within the meaning of the statute. View "Waukesha County v. J.W.J." on Justia Law

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Dr. Hosan Azomani seeks review of the Court of Appeals’ affirmance of his conviction and sentence for two counts of Medicaid fraud in violation of Mississippi Code Sections 43-13-213 and 43-13-215. Dr. Azomani practiced pediatric medicine under the name Children’s Medical Group of Greenville PLLC, in Greenville, Mississippi. In 2007, the Division of Medicaid conducted an audit of Dr. Azomani’s patient files, which revealed three coding errors. Though Dr. Azomani admitted to the errors, he claimed that he had not deliberately made the mistakes. The Mississippi Supreme Court granted certiorari to address venue and statute-of-limitations issues. Finding that venue was proper and that the claims were prosecuted within the statute of limitations, the Court affirmed the judgment of the Court of Appeals and affirmed the conviction and sentence of the trial court. View "Azomani v. Mississippi" on Justia Law

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Pacific Bay treated an individual who was a subscriber to a Blue Shield health plan. It submitted invoices to Blue Shield for payment for the services rendered to the subscriber. Pacific Bay contends it was underpaid and brought suit against Blue Shield to recover the additional amount it claimed to be owed. The court sustained Blue Shield's demurrer to the first amended complaint (FAC) without leave to amend, finding that Pacific Bay had not shown that it was entitled to any payment from Blue Shield. As an out-of-network, nonemergency service provider, Pacific Bay was entitled to payment for treating Blue Shield's subscriber under the terms of the applicable evidence of coverage (EOC). Pacific Bay did not allege Blue Shield paid it improperly under the EOC, nor did it argue that it could allege additional facts to support such a claim. Pacific Bay claimed it was underpaid. Against this backdrop, Pacific Bay's other allegations did not give rise to any valid cause of action. View "Pacific Bay Recovery v. Cal. Physicians' Services" on Justia Law