Justia Health Law Opinion Summaries
Articles Posted in U.S. Court of Appeals for the Eleventh Circuit
Vargas v. Lincare, Inc.
Jaime Vargas and Francis R. Alvarez, former employees of medical supplier Lincare, Inc., and its subsidiary Optigen, Inc., filed a qui tam complaint under the False Claims Act (FCA). They alleged that Optigen engaged in fraudulent practices, including systematic upcoding of durable medical equipment, improper kickback arrangements, waiver of co-pays, and shipment of unordered supplies. The relators claimed that Optigen billed CPAP batteries and accessories under codes designated for ventilator accessories, waived patient co-pays without assessing financial hardship, shipped CPAP supplies automatically without patient requests, and paid kickbacks to healthcare providers for referrals.The case was initially filed in the Eastern District of Virginia and later transferred to the Middle District of Florida. The United States declined to intervene, and the District Court unsealed the complaint. The relators filed multiple amended complaints, each of which was dismissed by the District Court for failing to meet the heightened pleading standard of Federal Rule of Civil Procedure 9(b). The District Court dismissed the fourth amended complaint, holding that it still failed to plead sufficient facts with the requisite specificity.The United States Court of Appeals for the Eleventh Circuit reviewed the case. The court affirmed the District Court's dismissal of the relators' claims regarding improper kickback arrangements, waiver of co-pays, and automatic shipment of supplies, finding that these allegations lacked the necessary specificity and failed to identify any actual false claims submitted to the government. However, the court reversed the dismissal of the upcoding claim, holding that the relators had pleaded sufficient facts with particularity to withstand a motion to dismiss. The court remanded the case for further proceedings limited to the upcoding issue. View "Vargas v. Lincare, Inc." on Justia Law
Milner v. Baptist Health Montgomery
Dr. Jeffery D. Milner, a physician, brought a qui tam action under the False Claims Act (FCA) against Baptist Health Montgomery, Prattville Baptist, and Team Health. Milner alleged that while working at a hospital owned by the defendants, he discovered that they were overprescribing opioids and fraudulently billing the government for them. He claimed that he was terminated in retaliation for whistleblowing after reporting the overprescription practices to his superiors.Previously, Milner filed an FCA retaliation lawsuit against the same defendants in the U.S. District Court for the Northern District of Alabama, which was dismissed with prejudice for failure to state a claim. The court found that Milner did not sufficiently allege that he engaged in protected conduct under the FCA or that his termination was due to such conduct. Following this dismissal, Milner filed the current qui tam action in the U.S. District Court for the Middle District of Alabama. The district court dismissed this action as barred by res judicata, relying on the Eleventh Circuit's decisions in Ragsdale v. Rubbermaid, Inc. and Shurick v. Boeing Co.The United States Court of Appeals for the Eleventh Circuit reviewed the case and affirmed the district court's dismissal. The court held that Milner's qui tam action was barred by res judicata because it involved the same parties and the same cause of action as his earlier retaliation lawsuit. The court found that both lawsuits arose from a common nucleus of operative fact: the defendants' alleged illegal conduct and Milner's discovery of that conduct leading to his discharge. The court also noted that the United States, which did not intervene in the qui tam action, was not barred from pursuing its own action in the future. View "Milner v. Baptist Health Montgomery" on Justia Law
Chapman v. Dunn
Michael Chapman, an Alabama inmate, sued prison officials and staff for deliberate indifference to his medical needs, violating the Eighth Amendment. Chapman alleged that an untreated ear infection led to severe injuries, including mastoiditis, a ruptured eardrum, and a brain abscess. He also claimed that the prison's refusal to perform cataract surgery on his right eye constituted deliberate indifference. The district court granted summary judgment for all defendants except the prison’s medical contractor, which had filed for bankruptcy.The United States District Court for the Middle District of Alabama found Chapman’s claim against nurse Charlie Waugh time-barred and ruled against Chapman on other claims, including his request for injunctive relief against Commissioner John Hamm, citing sovereign immunity. The court also concluded that Chapman’s claims against other defendants failed on the merits and dismissed his state-law claims without prejudice.The United States Court of Appeals for the Eleventh Circuit reviewed the case. The court reversed the district court’s determination that Chapman’s claim against Waugh was time-barred, finding that Chapman’s cause of action accrued within the limitations period. The court vacated the district court’s judgment for Waugh and remanded for reconsideration in light of the recent en banc decision in Wade, which clarified the standard for deliberate indifference claims. The court also vacated the judgment for Hamm on Chapman’s cataract-related claim for injunctive relief, as sovereign immunity does not bar such claims. Additionally, the court vacated the summary judgment for all other defendants due to procedural errors, including inadequate notice and time for Chapman to respond, and remanded for further consideration. View "Chapman v. Dunn" on Justia Law
Silva v. Baptist Health South Florida
The Eleventh Circuit reversed the grant of summary judgment to defendants on plaintiff's suit alleging unlawful discrimination because plaintiffs could not effectively communicate with hospital staff in the absence of auxiliary aids or services. The Eleventh Circuit held that plaintiffs had Article III standing to seek prospective injunctive relief; rejected the district court's substantive standard for liability; and concluded that for an effective-communication claim brought under the Americans with Disabilities Act (ADA), 42 U.S.C. 12101 et seq., and Section 504 of the Rehabilitation Act of 1973 (RA), 29 U.S.C. 794, there is no requirement that a plaintiff show actual deficient treatment or to recount exactly what plaintiff did not understand. Rather, the relevant inquiry is whether the hospitals' failure to offer an appropriate auxiliary aid impaired the patient's ability to exchange medically relevant information with hospital staff. In this case, plaintiffs have offered sufficient evidence to survive summary judgment where the record demonstrated that plaintiffs' ability to exchange medically relevant information was impaired. On remand, the district court was directed to consider the deliberate-indifference issue in regards to monetary damages. View "Silva v. Baptist Health South Florida" on Justia Law
MSP Recovery LLC v. AllState Ins. Co.
The seven consolidated cases in this appeal all involve attempts by assignees of a health maintenance organization (HMO) to recover conditional payments via the Medicare Secondary Payer Act's (MSP Act), 42 U.S.C. 1395y(b)(2)(B)(ii), (b)(3)(A), private cause of action. At issue is whether a contractual obligation, without more (specifically, without a judgment or settlement agreement from a separate proceeding), can satisfy the “demonstrated responsibility” requirement of the private cause of action provided for by the MSP Act. The court held that a plaintiff suing a primary plan under the private cause of action in the MSP Act may satisfy the demonstrated responsibility prerequisite by alleging the existence of a contractual obligation to pay. A judgment or settlement from a separate proceeding is not necessary. Therefore, the court vacated the district courts' judgments and remanded for further proceedings. View "MSP Recovery LLC v. AllState Ins. Co." on Justia Law
Humana Medical Plan v. Western Heritage Ins. Co.
Humana filed suit against Western, alleging claims for double damages pursuant to the Medicare Secondary Payer Act (MSP), 42 U.S.C. 1395y(b)(3)(A), private cause of action and for a declaratory judgment regarding Western’s obligation to reimburse Humana for Medicare benefits that Humana paid on behalf of its Medicare Advantage plan enrollee. The district court granted summary judgment to Humana. At issue, as a matter of first impression, is whether the MSP private cause of action permits a Medicare Advantage Organization (MAO) to sue a primary payer that refuses to reimburse the MAO for a secondary payment. The court joined the Third Circuit and held that an MAO may sue a primary payer under the MSP private cause of action. Accordingly, the court affirmed the judgment. View "Humana Medical Plan v. Western Heritage Ins. Co." on Justia Law
Florida Agency for Health Care Admin. v. Bayou Shores
The Secretary determined that Bayou Shores was not in substantial compliance with the Medicare program participation requirements, and that conditions in its facility constituted an immediate jeopardy to residents’ health and safety. The bankruptcy court assumed authority over Medicare and Medicaid provider agreements as part of the debtor’s estate, enjoined the Secretary from terminating the provider agreements, determined for itself that Bayou Shores was qualified to participate in the provider agreements, required the Secretary to maintain the stream of monetary benefit under the agreements, reorganized the debtor’s estate, and finally issued its Confirmation Order. The district court upheld the Secretary’s jurisdictional challenge and reversed the Confirmation Order with respect to the assumption of the debtor’s Medicare and Medicaid provider agreements. The court concluded that the statutory revision in this case does not demonstrate Congress's clear intention to vest the bankruptcy courts with jurisdiction over Medicare claims. Therefore, the court agreed with the district court that the bankruptcy court erred as a matter of law when it exercised subject matter jurisdiction over the provider agreements in this case. The bankruptcy court was without 28 U.S.C. 1334 jurisdiction under the 42 U.S.C. 405(h) bar to issue orders enjoining the termination of the provider agreements and to further order the assumption of the provider agreements. Accordingly, the court affirmed the judgment. View "Florida Agency for Health Care Admin. v. Bayou Shores" on Justia Law
Allstate Ins. Co. v. Vizcay
Allstate filed suit against multiple defendants, alleging claims of fraud, negligent misrepresentation, and unjust enrichment. Defendants are medical clinics that appointed Dr. Sara Vizcay as their medical director. Allstate’s central allegation is that Dr. Vizcay failed to systematically review billings as required by Florida’s Health Care Clinic Act, Fla. Stat. 400.990 et seq., which caused the clinics to submit unlawful or fraudulent insurance claims to Allstate. A jury found the clinics liable and awarded damages to Allstate. The clinics challenge the jury’s verdict, and the district court’s denial of their dispositive motions, on numerous grounds. The court held that, under Florida law, there is judicial remedy for a licensed clinic’s violation of the Clinic Act; a licensed clinic can be held responsible for its medical director’s failure to comply with the duties enumerated in the Clinic Act; the evidence is sufficient to support the jury’s finding that Dr. Vizcay failed to substantially comply with those duties; Allstate's fraud claims are not barred by Florida's statute of limitations; and the district court did not err in denying defendants' motions to bifurcate the trial. Accordingly, the court affirmed the judgment. View "Allstate Ins. Co. v. Vizcay" on Justia Law
Vitreo Retinal Consultants v. U.S. Dep’t of Health & Human Servs.
VRC filed suit against HHS and the Secretary, seeking the recoupment of payments VRC returned to Medicare after it was issued notice of an overpayment. At issue is the reimbursement rate of the intravitreal injection of Lucentis. VRC did not follow the Lucentis label’s instructions limiting dosage to one per vial. Instead, VRC treated up to three patients from a single vial. Because VRC was extracting up to three doses from a single vial, it was reimbursed for three times the average cost of the vial and three times the amount it would have received had it administered the drug according to the label. The court affirmed the denial of recoupment, concluding that VRC's charge to Medicare did not reflect its expense and was not medically reasonable; the Secretary's decision was supported by substantial evidence; and VRC is liable for the overpayment. View "Vitreo Retinal Consultants v. U.S. Dep't of Health & Human Servs." on Justia Law
Eternal Word Television Network v. Secretary
In these consolidated appeals, plaintiff challenged the regulations implementing the contraceptive mandate of the Affordable Care Act, 42 U.S.C. 300gg-13(a), arguing that the regulations’ accommodation for nonprofit organizations with a religious objection to providing contraceptive coverage violates the Religious Freedom Restoration Act (RFRA), 42 U.S.C. 2000bb, et seq. The court concluded that the regulations do not substantially burden plaintiffs' religious exercise and, alternatively, because (1) the government has compelling interests to justify the accommodation, and (2) the accommodation is the least restrictive means of furthering those interests. The court rejected EWTN’s challenges under the Establishment and Free Exercise Clauses because the accommodation is a neutral, generally applicable law that does not discriminate based on religious denomination. The court also rejected EWTN’s challenge under the Free Speech Clause because any speech restrictions that may flow from the accommodation are justified by a compelling governmental interest and are thus constitutional. View "Eternal Word Television Network v. Secretary" on Justia Law