Justia Health Law Opinion Summaries

A hospital must provide “necessary stabilizing treatment” for any person in an “emergency medical condition,” 42 U.S.C. 1395dd(b), Health & Saf. Code 1317(a). California’s Knox-Keene Act (section 1340) requires that the patient's health insurance plan reimburse the hospital for providing “emergency services and care.” If the hospital and plan do not have an existing contract, the plan must pay the “reasonable and customary value." If a plan without a contract pays reimbursement that the hospital believes is below the “reasonable and customary value,” the hospital may sue the plan in quantum meruit for the shortfall.The court of appeal held that a hospital may not additionally sue for the tort of intentionally paying an amount that is less than what a jury might later determine is the “reasonable and customary value” of the services, and thereby obtain punitive damages, nor may the hospital sue for injunctive relief under California’s unfair competition law to enjoin the plan from paying too little in possible future claims. In the quantum meruit claim, a trial court properly instructs the jury that the “reasonable value” of emergency medical services is “the price that a hypothetical willing buyer would pay a hypothetical willing seller for the services, [when] neither [is] under compulsion to buy or sell, and both hav[e] full knowledge of all pertinent facts.” Rejecting challenges to several evidentiary rulings, the court affirmed the jury’s verdict finding that the plan paid the suing hospital the reasonable and customary value of its emergency medical services. View "Long Beach Memorial Medical Center v. Kaiser Foundation Health Plan, Inc." on Justia Law

Family Rehab brought a procedural due process claim arguing that it is entitled to third step review before recoupment of Medicare overpayments. The district court granted summary judgment in favor of Family Rehab, and entered a permanent injunction barring HHS from recouping the disputed funds until the completion of third step review under 42 C.F.R. 405.1036(c)–(d).However, in reaching its decision, the district court did not have the benefit of the Fifth Circuit's decision in Sahara Health Care Inc. v. Azar, 975 F.3d 523 (5th Cir. 2020), in which the court rejected a similar due process claim under nearly identical facts. In this case, Family Rehab's claims all involve documentation issues that do not require cross-examination and credibility determinations. The court explained that Family Rehab's claims could have been resolved in the first two steps of administrative review by producing the relevant documents. Accordingly, the court reversed the district court's judgment. View "Family Rehabilitation, Inc. v. Becerra" on Justia Law

Mitchell swallowed 60 Naproxen tablets. With her husband, she arrived at the Hospital emergency department on May 27, 2017, alert, oriented, and with no acute distress. The physician noted no motor deficits or sensory deficits. A nurse placed an IV catheter in Mitchell’s forearm. Nearly two hours later, Mitchell walked to the toilet with assistance from her husband, then walked back to her bed without assistance. On the way back, Mitchell fell, causing abrasions to her face and severely injuring her knee. The nursing staff had no reason to suspect Mitchell presented a high fall risk because she did not complain of dizziness; they had no observed balance problems. An x-ray and CT scan of Mitchell’s knee showed serious injuries. Mitchell was referred to physical therapy and was discharged from Hospital.Mitchell filed her complaint, alleging general negligence and premises liability on May 17, 2019. The hospital argued that the complaint alleged professional negligence, rather than general negligence or premises liability, and was barred under Code of Civil Procedure section 340.5’s one-year limitations period. Mitchell acknowledged that the condition of the floor did not contribute to her fall. The court of appeal affirmed the dismissal of the complaint. The nursing staff’s decision to not assist Mitchell in walking to the restroom was “integrally related” to her medical care. View "Mitchell v. Los Robles Regional Medical Center" on Justia Law

As part of a request to receive a higher reimbursement rate, plaintiff Family Health Centers of San Diego (Family Health) submitted a cost report detailing the reimbursable costs incurred by its clinics in providing covered services to Medi-Cal patients. Because the costs were not allowable Medi-Cal costs, Family Health eliminated them from its cost report. As part of an audit, however, defendant State Department of Health Care Services (the Department) determined the costs should not have been eliminated from the cost report. Instead, the Department reclassified the costs to a nonreimbursable cost center, which had the effect of disallowing a proportionate share of the clinics’ administrative overhead costs. Family Health filed an administrative appeal to dispute the audit adjustments, but, after a formal hearing, its appeal was denied. Family Health then filed a petition for a writ of mandate challenging the administrative decision, which also was denied. On appeal, Family Health contended the Department did not establish a proper basis for reclassifying the costs to a nonreimbursable cost center, and that the decision to reclassify the costs was not supported by substantial evidence. Family Health separately argued that a significant subset of the costs should not have been included in the nonreimbursable cost center because they were not costs at all. After review, the Court of Appeal found no reversible error and affirmed the judgment denying the petition. View "Family Health Centers of San Diego v. State Dept. of Health Care Service" on Justia Law

Smith’s hip resurfacing implant consists of a metal ball that covers the top of the femur and a cup that fits inside the hip socket. When a surgeon puts these ball-and-cup surfaces in the joint, the polished metal surfaces are supposed to allow smoother movement than the damaged bone or cartilage they replace. Gall, who had hip resurfacing surgery for his left hip, recovered and became physically active. Years later, convinced his implant was unsatisfactory, Gall sued Smith.Gall argued that Smith failed to properly warn Gall’s surgeon, Dr. Hernandez, about the risks of using Smith’s product. The trial court granted Smith summary judgment because Hernandez independently knew these risks and whether Smith gave Hernandez redundant warnings did not matter. Gall also argued that Smith’s product was defective. The trial court granted summary judgment because Gall did not show anything was wrong with his implant. Gall did show Smith’s quality control procedures once failed to satisfy regulatory authorities, but the court concluded this fact did not imply the parts Gall received were defective. The court of appeal affirmed. Gall’s claims share the same causation element and Gall did not establish causation. View "Gall v. Smith & Nephew, Inc." on Justia Law

Dr. Polansky was an official at the Centers for Medicare and Medicaid Services (CMS) before consulting for EHR, a “physician advisor” company that provides review and billing certification services to hospitals and physicians that bill Medicare. Polansky became concerned that EHR was systematically enabling its client hospitals to over-admit patients by certifying inpatient services that should have been provided on an outpatient basis.In 2012, Polansky filed suit under the False Claims Act (FCA), 31 U.S.C. 3729, alleging EHR was causing hospitals to bill the government for inpatient stays that were not “reasonable and necessary” for diagnosis or treatment as required by the Medicare program, 42 U.S.C. 1395y(a)(1)(A). His complaint remained under seal for two years while the government conducted its own investigation and ultimately determined it would not participate in the case.In 2019, the government notified the parties that it intended to dismiss the entire action under 31 U.S.C. 3730(c): “[t]he Government may dismiss the action notwithstanding the objections of the [relator]” so long as the relator receives notice and an opportunity to be heard on the Government’s motion. The district court eventually granted the motion. The Third Circuit affirmed. The government is required to intervene before moving to dismiss and its motion must meet the standard of FRCP 41(a). The district court acted within its discretion in granting the government’s motion. View "Polansky v. Executive Health Resources Inc" on Justia Law

The First Circuit affirmed the rulings of the district court denying the Commission of the New Hampshire Department of Health and Human Services' motion to dismiss Plaintiffs' complaints against her, holding that Plaintiffs' allegations of error were without merit.Plaintiffs were (1) a class of individuals who claimed to have been held against their will without due process on the basis of a certification of their need for emergency mental health treatment, and (2) a group of hospitals who claimed to have been forced to retain persons certified to be in need of such treatment. The Commissioner moved to dismiss the claims based on Eleventh Amendment immunity and Plaintiffs' asserted lack of standing. The district court denied the motion to dismiss. The First Circuit affirmed, holding that there was no merit to the Commissioner's challenges to the district court's standing and Eleventh Amendment immunity rulings. View "Doe v. Shibinette" on Justia Law

Petitioners Governor Jay Inslee, the State of Washington, the Washington Department of Corrections, and Cheryl Strange, secretary of the Department of Corrections, sought the Washington Supreme Court's accelerated direct discretionary review of an order of the Franklin County Superior Court denying petitioners’ motion to change venue to Thurston County Superior Court in an action brought by respondent Jeffrey Johnson challenging proclamations the governor issued requiring certain state employees to be vaccinated against COVID-19 by October 18, 2021. The merits of the underlying suit were not before the Court. In an order issued on October 11, 2021, the Court determined that mandatory venue for this action was in Thurston County Superior Court under RCW 4.12.020(2), and therefore granted petitioners’ motion for accelerated discretionary review, reversed the order of the Franklin County Superior Court, and remanded to that court with directions to grant petitioners’ motion to change venue without delay. In this opinion, the Court explained the reasoning underlying its order. View "Johnson v. Inslee" on Justia Law

In April 2020, the district court entered a preliminary injunction and provisionally certified nationwide subclasses of ICE detainees with risk factors or disabilities placing them at heightened risk of severe illness and death from COVID-19. The court found that plaintiffs were likely to succeed on claims of deliberate indifference to the medical needs of detainees, punitive conditions of confinement, and violation of the Rehabilitation Act, 29 U.S.C. 794. The preliminary injunction imposed a broad range of obligations on the federal government.The Ninth Circuit reversed, stating that neither the facts nor the law supported a judicial intervention of this magnitude. The plaintiffs did not make a clear showing that ICE acted with deliberate indifference to medical needs or in reckless disregard of health risks. If a particular condition or restriction of pretrial detention is reasonably related to a legitimate governmental objective, it does not, alone, amount to punishment; there was a legitimate governmental objective here, ICE was holding detainees because they were suspected of having violated the immigration laws or were otherwise removable. ICE’s national directives did not create excessive conditions of “punishment.” Rejecting the Rehabilitation Act claim, the court stated that the plaintiffs at most demonstrated that they were subjected to inadequate national policies; they did not show they were treated differently from other detainees “solely by reason” of their disabilities. View "Fraihat v. United States Immigration and Customs Enforcement" on Justia Law

The estates of New Jersey nursing home residents, who died from COVID-19, alleged that the nursing homes acted negligently in handling the COVID-19 pandemic. The nursing homes removed the case to federal court. The district court dismissed the cases for lack of subject-matter jurisdiction.The Third Circuit affirmed rejecting three arguments for federal jurisdiction: federal-officer removal, complete preemption of state law, and the presence of a substantial federal issue. The 2005 Public Readiness and Emergency Preparedness Act (PREP Act), 42 U.S.C. 247d-6d, 247d6e, which protects certain individuals—such as pharmacies and drug manufacturers—from lawsuits during a public-health emergency, was invoked in March 2020 but does not apply because the nursing homes did not assist or help carry out the duties of a federal superior. The PREP Act creates an exclusive cause of action for willful misconduct but the estates allege only negligence, not willful misconduct; those claims do not fall within the scope of the exclusive federal cause of action and are not preempted. The PREP Act’s compensation fund is not an exclusive federal cause of action. The estates would properly plead their state-law negligence claims without mentioning the PREP Act, so the PREP Act is not “an essential element" of the state law claim. View "Estate of Joseph Maglioli v. Alliance HC Holdings, LLC" on Justia Law