Justia Health Law Opinion Summaries

Articles Posted in US Court of Appeals for the Ninth Circuit
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The Ninth Circuit reversed the district court's dismissal of a qui tam action brought by relator under the False Claims Act, alleging that defendants submitted, or caused to be submitted, Medicare claims falsely certifying that patients' inpatient hospitalizations were medically necessary. After determining that it had jurisdiction, the panel held that a plaintiff need not allege falsity beyond the requirements adopted by Congress in the FCA, which primarily punishes those who submit, conspire to submit, or aid in the submission of false or fraudulent claims. The panel wrote that Congress imposed no requirement of proving "objective falsity," and the panel had no authority to rewrite the statute to add such a requirement. The panel held that a doctor’s clinical opinion must be judged under the same standard as any other representation. The panel explained that a doctor, like anyone else, can express an opinion that he knows to be false, or that he makes in reckless disregard of its truth or falsity. Therefore, a false certification of medical necessity can give rise to FCA liability. The panel also held that a false certification of medical necessity can be material because medical necessity is a statutory prerequisite to Medicare reimbursement. View "Winter v. Gardens Regional Hospital & Medical Center, Inc." on Justia Law

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Plaintiffs' challenges to HHS's 2019 Final Rule, implementing Title X of the Public Health Service Act, failed in light of Supreme Court approval of the 1988 regulations and the Ninth Circuit's broad deference to agencies' interpretations of the statutes they are charged with implementing. Section 1008 of Title X prohibits grant funds from being used in programs where abortion is a method of family planning. Specifically, plaintiffs challenged the "gag" rule on abortion counseling, where a counselor providing nondirective pregnancy counseling "may discuss abortion" so long as "the counselor neither refers for, nor encourages, abortion." The Final Rule also requires providers to physically and financially separate any abortion services from all other health care services. The panel held that the Final Rule is a reasonable interpretation of Section 1008; it does not conflict with the 1996 appropriations rider or other aspects of Title X; and its implementation of the limits on what Title X funds can support does not implicate the restrictions found in Section 1554 of the Patient Protection and Affordable Care Act (ACA). The panel also held that the Final Rule is not arbitrary and capricious because HHS properly examined the relevant considerations and gave reasonable explanations; because plaintiffs will not prevail on the merits of their legal claims, they are not entitled to the extraordinary remedy of preliminary injunction; and thus the district courts' preliminary injunction orders are vacated and the cases are remanded for further proceedings. View "California v. Azar" on Justia Law

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The Ninth Circuit affirmed the district court's grant of a preliminary injunction barring enforcement in several states of final federal agency rules that exempt employers with religious and moral objections from the Affordable Care Act's (ACA) requirement that group health plans cover contraceptive care without cost sharing. As a preliminary matter, the panel held that the plaintiff states had Article III standing to sue and that the appeal was not moot. The panel held that the district court did not abuse its discretion by concluding that the plaintiff states were likely to succeed on the merits of their Administrative Procedure Act (APA) claim or, at the very least, raised serious questions going to the merits. At the preliminary injunction stage, the panel held that the evidence was sufficient to hold that providing free contraceptive services was a core purpose of the Women's Health Amendment and that nothing in the statute permitted the agencies to determine exemptions from the requirement. Therefore, given the text, purpose, and history of the Women's Health Amendment, the district court did not err in concluding that the agencies likely lacked statutory authority under the ACA to issue the final rules. The panel also held that, regardless of the question of the agencies' authority under the Religious Freedom Restoration Act, the accommodation process likely did not substantially burden the exercise of religion. Furthermore, because appellants likely failed to demonstrate a substantial burden on religious exercise, there was no need to address whether the government had shown a compelling interest or whether it has adopted the least restrictive means of advancing that interest. Finally, the panel held that the district court did not abuse its discretion by concluding that the states were likely to suffer irreparable harm absent an injunction, and that the balance of equities tipped sharply in favor of the plaintiff states and that the public interest tipped in favor of granting the preliminary injunction. View "California v. The Little Sisters of the Poor" on Justia Law

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The Ninth Circuit reversed the district court's judgment in favor of Medicare in an action brought by CIGA, seeking declaratory relief after Medicare paid for and demanded reimbursement from CIGA for medical expenses of certain individuals whose workers' compensation benefits CIGA was administering. The panel held that Medicare, as a secondary payer, was entitled to seek reimbursement from a beneficiary's primary payer, typically private insurance. However, CIGA was not a primary plan, and specifically was not a workmen's compensation law or plan. Rather, the panel held that CIGA was an insolvency insurer of last resort. The panel explained that insurance regulation was a field traditionally occupied by the states, and it must presume that the Medicare secondary payer provisions do not preempt state insurance laws unless Congress clearly manifested its intent to do so. Furthermore, nothing in the Medicare statute or its implementing regulations suggested that Congress meant to interfere with state schemes to protect against insurer insolvencies. View "California Insurance Guarantee Assoc. v. Azar" on Justia Law

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The Ninth Circuit granted the Secretary's petition for review of the Commission's decision interpreting a provision of the Respiratory Protection Standard promulgated under the Occupational Safety and Health Act of 1970. The panel adopted the Secretary's interpretation of section 1910.134(d)(1)(iii) of the Act to require covered employers to evaluate the respiratory hazards at their workplaces whenever there is the "potential" for overexposure of employees to contaminants, in order to determine whether respirators are "necessary to protect the health" of employees. The panel explained that the text, structure, purpose, and regulatory history of the Standard all point in the same direction as the Secretary's interpretation. View "Secretary of Labor v. Seward Ship's Drydock, Inc." on Justia Law

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The Ninth Circuit denied a petition for review of a final order affirming a citation that Bergelectric violated OSHA's fall protection standards in 29 C.F.R. 1926.501(b)(1). The panel held that Bergelectric was not performing roofing work and that substantial evidence supported the finding that it did not comply with the stricter safety standards governing work on unprotected sides and edges. The panel held that substantial evidence supported the ALJ's conclusion that Bergelectric employees were subject to the danger of falling prior to proper use of the personal fall arrest systems, and thus the ALJ did not err in finding Bergelectric liable for violation of section 1926.501(b)(1). View "Bergelectric Corp. v. Secretary of Labor" on Justia Law

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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

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After federal agencies issued two interim final rules (IFRs) exempting employers with religious and moral objections from the Affordable Care Act requirement that group health plans cover contraceptive care without cost sharing, states filed suit to enjoin the enforcement of the IFRs. The Ninth Circuit affirmed that venue was proper in the Northern District of California; affirmed that plaintiff states have standing to sue based on procedural injury where the states have shown with reasonable probability that the IFRs will first lead to women losing employer-sponsored contraceptive coverage, which will then result in economic harm to the states; affirmed the preliminary injunction insofar as it barred enforcement of the IFRs in the plaintiff states; but vacated the portion of the injunction barring enforcement in other states because the scope of the injunction was overbroad. View "California v. Azar" on Justia Law

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The Ninth Circuit reversed the district court's grant of summary judgment for defendant in an action challenging an Employee Retirement Income Security Act (ERISA) plan's denial of a claim. The plan denied plaintiff's claim for the cost of an inpatient stay in a residential mental health treatment facility. The panel held that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 did not require that the plan's coverage for stays at licensed inpatient residential treatment facilities had to be no more restrictive than stays at skilled nursing facilities. The panel explained that the Parity Act precluded the plan from deciding that it would provide room and board reimbursement at licensed skilled nursing facilities for medical and surgical patients, but not at residential treatment facilities for mental health patients. View "Danny P. v. Catholic Health Initiatives" on Justia Law

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The Ninth Circuit affirmed the district court's grant of a preliminary injunction enjoining California Department of Public Health officials from enforcing the California Medical Waste Management Act (MWMA). The preliminary injunction enjoined Department officials from enforcing the Act on Daniels for the manner in which it disposed of medical waste at facilities outside of the State of California. The panel held that Daniels will likely succeed on the merits of its dormant Commerce Clause claim. Furthermore, the panel held that Department officials were entitled to qualified immunity because Daniels' constitutional rights under the dormant Commerce Clause were not clearly established at the time of the violation. Therefore, the panel reversed the denial of Department officials' motion to dismiss on the basis of qualified immunity. View "Daniels Sharpsmart, Inc. v. Smith" on Justia Law