Justia Health Law Opinion SummariesArticles Posted in U.S. 3rd Circuit Court of Appeals
Hagans v. Comm’r of Soc. Sec.
Until 2003, Hagans worked as a security guard and as a sanitation worker. At 44 years old, Hagans required open-heart surgery. Hagans claims additional medical problems relating to his cerebrovascular and respiratory systems, hypertension and dysphagia, insomnia, and back pain. He has been diagnosed with depression. Hagans began receiving disability benefits as of January 30, 2003. In September, 2004, pursuant to an updated Residual Function Capacity assessment showing his condition had improved, SSA determined that Hagans was no longer eligible for benefits. The ALJ considered several evaluations of Hagans’s condition, most of which were completed in mid-2004, and found that he was capable of engaging in substantial gainful activity, although he could not perform his past relevant work. The Appeals Council denied review; the district court affirmed. The Third Circuit affirmed, after determining that “relatively high” deference should be afforded to SSA’s Acquiescence Ruling interpreting the cessation provision of 42 U.S.C. 423(f) as referring to the time of the SSA’s initial disability determination. SSA correctly evaluated Hagans’s condition as of the date on which the agency first found that Hagans’s eligibility for disability benefits ceased. Substantial evidence supported the conclusion that Hagans was not fully disabled as of that date. View "Hagans v. Comm'r of Soc. Sec." on Justia Law
Nichole Medical Equip & Supply, Inc. v. Tricenturion, Inc.
TriCenturion audited Nichole Medical as a Program Safeguard Contractor under the Medicare Integrity Program, 42 U.S.C. 395ddd(a), and concluded that Nichole “might” be improperly billing for medical equipment; that Nichole had received overpayments; and that it had not maintained sufficient medical records to establish reasonableness or medical necessity. TriCenturion directed Nichole’s carrier, HealthNow, to withhold payments. TriCenturion calculated the actual overpayment of several specific claims, used those as a representative sampling, and extrapolated an overpayment amount for all relevant claims. The Attorney General found no evidence of fraud and refused to prosecute; HealthNow stopped withholding payments. TriCenturion instructed HealthNow’s successor to re-institute the offset. Nichole went out of business, but pursued an appeal. An ALJ determined that Nichole was entitled to reimbursement on some, but not all, appealed claims and found that the process for arriving at the extrapolated overpayment was flawed. The Medicare Appeals Council found that all 39 claims had been reopened and reviewed improperly. The district court dismissed Nichole’s suit against TriCenturion, which alleged torts and breach of the statutory duty of care under 42 U.S.C. 1320c-6(b). The Third Circuit affirmed. Defendants are immune from suit as officers or employees of the Secretary of the Department of Health and Human Services. View "Nichole Medical Equip & Supply, Inc. v. Tricenturion, Inc." on Justia Law
Roye v. Atty Gen. of the United States
Roye, a 58-year-old native of Jamaica, was admitted to the U.S. in 1984 as the spouse of a citizen. In 1992, he pled guilty to aggravated assault and endangering the welfare of a child by having sexual intercourse with his eight-month old daughter. The trial judge sentenced Roye to six to 20 years’ imprisonment but strongly recommended transfer into a psychiatric facility. Fourteen years later, DHS charged him as removable under 8 U.S.C. 1227(a)(2)(A)(iii). An Immigration Judge found that Roye granted for deferral of removal under the Convention Against Torture. The IJ emphasized testimony indicating “that mentally ill detainees and prisoners are often sexually and physically assaulted in the Jamaican prison system because of the nature of their mental illness” and that Roye will be homeless in Jamaica due to a lack of family ties. The BIA ordered immediate removal. The Third Circuit reversed, holding that the BIA must review the conclusion that the evidence demonstrates that Roye’s persecutors will physically and sexually abuse him in a manner that rises to the level of torture under the CAT, and decide whether Jamaican public officials will consent to or acquiesce in such abuse. View "Roye v. Atty Gen. of the United States" on Justia Law
Jewish Home of E. PA v. Centers for Medicare and Medicaid Servs.
Jewish Home of Eastern Pennsylvania (JHEP) provides nursing care to Medicare beneficiaries and is required to comply with the mandatory health and safety requirements for participation. JHEP must submit to random surveys conducted by state departments of health. In 2005, the Pennsylvania Department of Health conducted a survey that concluded that JHEP had eight regulatory deficiencies, including violations of 42 C.F.R. 483.25(h)(2), which requires a facility to ensure that each resident receives adequate supervision and assistance with devices to prevent accidents. Based on those deficiencies and those found in a 2006 survey, the Center for Medicare and Medicaid Services imposed fines totaling $17,150 and $12,800. JHEP claimed that the allegations of noncompliance were based on the inadmissible disclosure of privileged‖ quality assurance records and that the monetary penalties violated its right to equal protection because they were the product of selective enforcement based on race and religion. An ALJ upheld the fines against JHEP. The Third Circuit denied a petition for review. View "Jewish Home of E. PA v. Centers for Medicare and Medicaid Servs." on Justia Law
Humana Med. Plan Inc. v. GlaxoSmithKline LLC
Humana sued, alleging that Glaxo was obligated to reimburse Humana for expenses Humana had incurred treating its insureds’ injuries resulting from Glaxo’s drug, Avandia. Humana runs a Medicare Advantage plan. Its complaint asserts that, pursuant to the Medicare Act, Glaxo is in this instance a “primary payer” obligated to reimburse Humana as a “secondary payer.” The district court dismissed, agreeing with Glaxo that the Medicare Act did not provide Medicare Advantage organizations with a private cause of action to seek such reimbursement. The Third Circuit reversed and remanded. The Medicare Secondary Payer Act, in 42 U.S.C. 1395y(b)(3)(A), provides Humana with a private cause of action against Glaxo. Even if the provision is ambiguous, regulations issued by the Centers for Medicare and Medicaid Services make clear that the provision extends the private cause of action to MAOs. View "Humana Med. Plan Inc. v. GlaxoSmithKline LLC" on Justia Law
In Re: Schering Plough Corp.
Plaintiffs, a putative nationwide class of third-party payors and a putative nationwide class of individual patient-consumers who paid for prescriptions, sued pharmaceutical manufacturers alleging that they paid for oncology and hepatitis drugs that were ineffective or unsafe for the off-label uses for which they were prescribed and that defendants pursued illegal marketing campaigns to persuade physicians to prescribe the drugs for those uses. While physicians are not prohibited from prescribing drugs for off-label uses, manufacturers are generally prohibited by the Federal Food, Drug and Cosmetic Act, 21 U.S.C. 301, from manufacturing, marketing, or selling for off-label use. Defendant had pled guilty to a criminal charge brought by the FDA and agreed to pay fine of $180 million and to pay $255 million to resolve civil claims that it defrauded Medicare, Medicaid, and the VA. The district court dismissed, for lack of standing, claims under the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. 1961, the New Jersey RICO statute, N.J.S. 2C:41-1, and other state statutory and common law causes of action. The Third Circuit affirmed, finding that plaintiffs failed to establish a causal connection between the alleged misconduct and the alleged harm. View "In Re: Schering Plough Corp." on Justia Law
Sutter v. Oxford Health Plans, L.L.C.
By their 1998 Primary Care Physician Agreement, the parties agreed that Dr. Sutter would provide primary care health services to members of Oxford's managed care network in exchange for predetermined reimbursement. They agreed to arbitrate any disputes. A dispute arose when Sutter accused Oxford of improperly denying, underpaying, and delaying reimbursement of physicians' claims. Sutter filed a complaint on behalf of himself and a class of health care providers, alleging breach of contract and other violations of New Jersey law. The state court granted Oxford’s motion to compel arbitration. The arbitrator determined that the agreement allowed for class arbitration. The arbitrator entered a Partial Final Class Determination Award. Oxford sought to vacate, arguing that the arbitrator disregarded the law by ordering class arbitration. The district court denied Oxford's motion and the Sixth Circuit affirmed. Arbitration proceeded on a classwide basis. Oxford later moved to vacated, based on the 2010 Supreme Court decision, Stolt-Nielsen S.A. v. AnimalFeeds International Corp. The district court denied the motion. The Third Circuit affirmed. The arbitrator endeavored to interpret the parties' agreement within the bounds of the law and his interpretation was not irrational. Nothing more is required under the Federal Arbitration Act. View "Sutter v. Oxford Health Plans, L.L.C." on Justia Law
Powell v. Dr. Symons
In consolidated cases, the Third Circuit addressed the FRCP 17 obligation to appoint counsel in cases involving parties who appear to be incompetent. The court held that the court abused its discretion in not appointing a representative for a prisoner for his suit (42 U.S.C. 1983), asserting deliberate indifference to medical needs. After multiple extensions, the inmate explained that he was in a psychiatric facility for four months. The judge denied further extensions and requests to appoint counsel. Meanwhile, he pled guilty to threats against the President and mailing threatening communications. A psychiatrist concluded that the inmate suffered delusional disorder, that some of his conduct is beyond his control, and that he has limited cognitive abilities. The court granted a motion to withdraw the plea, finding the inmate mentally incompetent. In the civil case, the judge, aware of the criminal proceedings, noted his concerns about mental competence, but again denied a motion to appoint counsel, stating that "it is unlikely that counsel could be found." The district court dismissed his case. In the other case, the court remanded for a determination of Rule 17 obligations. View "Powell v. Dr. Symons" on Justia Law
Macfarlan v. Ivy Hill SNF, LLC
Plaintiff, a maintenance director, had a stroke and began leave under the Family and Medical Leave Act, 29 U.S.C. 612(a)(1) in January 2008. He received disability benefits from Unum. The doctor cleared him to return to work starting on May 1, with conditions that he not work more than four hours per day or lift loads in excess of 20 pounds. The administrator notified plaintiff that part-time work was not available. The doctor cleared him to work full-time, but did not change the lifting restriction. On April 20, the employer terminated plaintiff's employment and notified him that he would not be rehired with lifting restrictions. Until July 2008, when the restrictions were lifted, he received benefits from Unum. The district court rejected claims under the Americans with Disabilities Act, the Pennsylvania Human Relations Act, and the FMLA. The Third Circuit affirmed. The FMLA does not require an employer to provide reasonable accommodation to facilitate return to an equivalent position following leave. Entitlement to restoration requires that the employee be able to perform essential job functions without accommodation. Having represented to Unum that he was disabled, plaintiff was estopped from claiming that he was able to perform all essential functions. View "Macfarlan v. Ivy Hill SNF, LLC" on Justia Law
Lomando v. United States
Decedent was treated at a non-profit clinic, by volunteer physicians. The U.S. Department of Health and Human Services deemed those physicians to be Public Health Service employees (Public Health Service Act, 42 U.S.C. 233(o)), immune from suit under the Federal Tort Claims Act, 28 U.S.C. 1346, 2671-2680. A suit against the U.S. was the exclusive remedy for alleged malpractice at the clinic. Decedent also treated at a facility where physicians did not enjoy those protections. Her estate sued the U.S., the clinic, the other facility, the doctors at that facility, and their physicians' group. The district court granted summary judgment for the clinic, predicated on immunity under the New Jersey Charitable Immunity Act (NJCIA), and ultimately dismissed. The Third Circuit affirmed, except for remanding with respect to the physicians' group. The trial court properly held that the U.S. was immune from suit under the NJCIA, which provides that a similarly-placed private employer would be entitled to the defense. The court properly held that the treatment provided constituted emergency medicine, so that N.J. Stat. 2A:53A-41 applied and one of plaintiff's experts was not qualified to testify. The court erred in not considering treatment by a physicians' assistant in considering claims against her employer, the physicians' group.