Justia Health Law Opinion Summaries

Tennessee family medicine physicians, mostly in rural areas, received increased Medicaid payments in 2013-2014. In 2015 Tennessee’s Medicaid agency, TennCare, brought an administrative action to “recoup” an average of more than $100,000 per physician, alleging that the physicians had not met the 60-percent requirement of the Final Medicaid Payment Rule. Under 42 U.S.C. 13961(a)(13(C), a state plan for medical assistance must provide payment for primary care services furnished in 2013 and 2014 by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine at a specified rate; “primary specialty designation” was interpreted to mandate that the physician either show board certification in that specialty or that 60 percent of her recent Medicaid billings were for certain primary care services. The Sixth Circuit affirmed summary judgment in favor of the physicians, declaring the Rule invalid. The Centers for Medicare and Medicaid Services interpreted “a physician with a primary specialty designation” to have different meanings in parallel provisions of the Affordable Care Act although the context was the same. There is no 60-percent-of-billings requirement in 42 U.S.C. 1396a(a). The phrase “a physician with a primary specialty designation” means in section 1396a(a) the same thing that the agency said it means in section 1395l(x): a physician who has himself designated, as his primary specialty, one of the specialties recited in those provisions. View "Averett v. United States Department of Health & Human Services" on Justia Law

The Supreme Court denied the writ of prohibition sought by the West Virginia Regional Jail Authority (WVRJA) seeking to have the Court prohibit the circuit court from enforcing its order denying the WVRJA's motion to dismiss Bobbi Bryant's complaint against it as time barred, holding that WVRJA failed to demonstrate that the circuit court's order was clearly erroneous.The WVRJA moved to dismiss Bryant's complaint on the sole basis that the claims asserted against it were barred by the applicable statute of limitations. The circuit court found that because the statute of limitations was appropriately tolled as to the co-defendant and because Bryant alleged a civil conspiracy cause of action the statute of limitation as to the co-defendant was imputed to the WVRJA. The WVRJA then filed a petition for writ of prohibition with the Supreme Court. The Supreme Court denied the petition, holding that the circuit court did not commit clear legal error in denying WVRJA's motion to dismiss the complaint as time barred, based on the applicable statute of limitations, such that a writ of prohibition is warranted. View "State ex rel. Regional Jail Authority v. Honorable Carrie Webster" on Justia Law

Respondent R.M. appealed a circuit court order that renewed his involuntary admission to New Hampshire Hospital for the purpose of allowing him to remain on a conditional discharge for a period of five years. Respondent was a 30-year-old man who had been hospitalized on multiple occasions as a result of schizophrenia. When respondent doesn't take his prescribed anti-psychotic medication, he becomes paranoid, violent, and suicidal. In addition, he experienced hallucinations, paranoid delusions, and difficulties with impulse control and exhibited “a serious level of aggression.” Respondent was first hospitalized in 2010 after voicing suicidal ideation, stating that he would be “better off dead.” Pertinent here, was admitted on an emergency basis again in February 2015 due to concerns of suicidal threats, incapacity, and his paranoid belief that people were conspiring against him. In early March 2019, a few weeks before the respondent’s three-year conditional discharge was set to expire, the local community mental health center filed a petition to renew his conditional discharge. On appeal, respondent challenged the sufficiency of the evidence and argued the five-year renewal was not the least restrictive treatment option. Finding no reversible error, the New Hampshire Supreme Court affirmed. View "In re R.M." on Justia Law

Advantage Health filed suit, alleging that HHS's continuing recoupment of overpayments before completion of the severely delayed administrative process was denying it procedural due process. The district court granted a preliminary injunction, enjoining HHS from withholding Medicare payments to Advantage Health to effectuate recoupment of any alleged overpayments.The Fourth Circuit held that the injunction entered in this collateral proceeding, which prohibits HHS from recouping overpayments in accordance with applicable law, was inappropriately entered because the delay of which Advantage Health complains could have been and still can be avoided by bypassing an ALJ hearing and obtaining judicial review on a relatively expeditious basis, as Congress has provided. Therefore, this administrative review process did not deny Advantage Health procedural due process and thus Advantage Health has not demonstrated a likelihood of success on the merits. View "Accident, Injury and Rehabilitation, PC v. Azar" on Justia Law

The Court of Appeals answered in the negative a question certified to it by the United States Court of Appeals for the Second Circuit asking whether N.Y. Pub. Health Law 230(11)(b) creates a private right of action for bad faith and malicious reporting to the Office of Professional Medical Conduct, holding that there is not indication that the legislature intended to create a private right of action in section 230(11)(b).Plaintiff, a surgeon, treated four injured patients insured by Defendant and submitted claims to Defendant in connection with each patient. Defendant later filed complaints with the Office of Professional Medical Conduct (OPMC) alleging insurance fraud. After OPMC declined to impose discipline against Plaintiff, Plaintiff commenced this action asserting that Defendant's complaints lacked a good-faith basis in violation of section 230(11)(b) and interposed a separate caused of action for defamation. Defendant moved to dismiss the complaint, arguing that section 230(11)(b) does not imply a private right of action. The federal district court granted the motion. On appeal, the Second Circuit certified the above question to the Court of Appeals. The Court of Appeals held that the statutory text and legislative history of the statute do not imply a legislative intent to create a right of action under section 230(11)(b). View "Haar v. Nationwide Mutual Fire Insurance Co." on Justia Law

In 2012, Sauvageau became a Lakewood resident, paying for her residency through her pension and Social Security income without other government assistance. Sauvageau stopped paying in August 2013. On October 28, 2013, Lakewood sent her a notice of involuntary transfer or discharge. Sauvageau’s counsel requested a hearing. She applied for Medicaid benefits; the application was denied on January 13, 2014. On February 10, 2014, at a prehearing conference, Lakewood argued that, under the Nursing Home Care Act (210 ILCS 45/1-101), the Department could not conduct a hearing more than 10 days from the date of a resident’s request. The ALJ denied Lakewood’s motion. The hearing was conducted on March 24, 2014. In April 2014, the ALJ recommended that the involuntary discharge be approved. On May 6, the Department’s final administrative decision approved Lakewood’s notice of involuntary discharge. Sauvageau left Lakewood on May 29, 2014. Lakewood sought review, asserting that the Department lacked authority to exceed the statutory 10-day hearing time and 14-day decision time for involuntary transfer or discharge proceedings. The Illinois Supreme Court held that section 3-411 of the Act is directory because it does not contain negative language precluding the Department from conducting a hearing beyond the 10-day time period and because the rights of nursing home residents will not be generally injured by a directory construction. View "Lakewood Nursing and Rehabilitation Center, LLC v. Department of Public Health" on Justia Law

This matter came from two separate lawsuits commenced in the Pennsylvania courts of common pleas which were subsequently removed to federal district courts on the basis of diversity jurisdiction, and thereafter consolidated for disposition by the United States Court of Appeals for the Third Circuit. Appellee William Scott was covered by an automobile insurance policy issued by Appellant Travelers Commercial Insurance Company. Appellee Samantha Sayles was covered by an automobile policy issued by Appellant Allstate Insurance Company. Allstate’s policy contained a clause, similar to the one in Scott’s policy, providing that, in order to receive first-party medical benefits, the insured had to submit to mental and physical examinations by physicians selected by the insurance company at the company’s behest before medical benefits were paid. Both appellees were injured in separate car accidents, and their respective insurance companies refused to pay their medical bills. The United States Court of Appeals for the Third Circuit certified a question of Pennsylvania law to the Pennsylvania Supreme Court: Does an automobile insurance policy provision, which required an insured seeking first-party medical benefits under the policy to submit to an independent medical exam whenever the insurer requires and with a doctor selected by the insurer, conflict with 75 Pa.C.S. Section 1796(a) of the Pennsylvania Motor Vehicle Financial Responsibility Law (“MVFRL”), such that the requirement was void as against public policy? After review, the Supreme Court concluded that the provision indeed conflicted with Section 1796(a), and was void as against public policy. View "Sayles. v. Allstate Ins Co." on Justia Law

Appellants Jonathan Saksek and Joshua Winter challenged a superior court decision to affirm summary judgment in favor of Appellees Janssen Pharmaceuticals, Inc., Johnson & Johnson Company, and Janssen Research and Development, LLC (collectively, “Janssen”). Saksek and Winter were two of a large number of men who filed suit against Janssen, alleging that they developed gynecomastia as a result of their ingestion of Risperdal, an antipsychotic drug manufactured by Janssen. In 2014, Janssen filed two motions for summary judgment, which were nominally directed at Saksek’s and Winter’s cases, but had language affecting all Risperdal plaintiffs: the companies sought a global ruling that all claims accrued for statute of limitations purposes no later than October 31, 2006, when Janssen changed the Risperdal label to reflect a greater association between gynecomastia and Risperdal. The trial court ruled that all Risperdal-gynecomastia claims accrued no later June 31, 2009. The superior court disagreed, ruling that all such claims accrued no later than Janssen’s preferred date (October 31, 2006). Concluding that the superior court erred in granting summary judgment at all in Saksek’s and Winter’s cases, the Pennsylvania Supreme Court vacated its decision and remanded to the trial court for further proceedings. View "In Re: Risperdal Litig." on Justia Law

The Supreme Court reversed the judgment of the district court determining that a regulation of the Great Falls/Cascade County City-County Board of Health (Board) was invalid, holding that the Board was entitled to summary judgment.The Board claimed that Totem Beverages, Inc. violated the regulation at issue, which was intended to provide clarity regarding smoking shelters. Totem brought this action seeking injunctive and declaratory relief. The district court granted Totem's motion for summary judgment and denied the Board's, concluding that the regulation conflicted with the Montana Clean Indoor Air Act (MCIAA) and Department of Health and Human Services (DPHHS) rules, in violation of Mont. Code Ann. 50-2-116(2)(c)(vi). Both parties appealed. The Supreme Court reversed and remanded for further proceedings, holding (1) the regulation did not conflict with the MCIAA or DPHHS rules; and (2) the district court erred by dismissing Totem's selective enforcement claim. View "Totem Beverages, Inc. v. Great Falls-Cascade County City-County Board of Health" on Justia Law

The Supreme Court affirmed the decision of the administrative hearing commission determining that certain pain treatment service items used in compounding medications do not fall under the use tax exemption in Mo. Rev. Stat. 144.054.2 for materials used or consumed in compounding a product, holding that the commission correctly determined that the Interventional Center for Pain Management (Center) did not qualify for the compounding exemption under section 144.054.2.The director of revenue assessed $69,311 in tax liability for a five-year period against Center after discovering that Center did not file a use tax return or pay use tax on certain out-of-state purchases. Center contested use tax liability for certain items used for the injection of prescription drug compounds, asserting that the devices were exempt from use tax as materials used in compounding operation under section 144.054.2. The administrative hearing petition upheld the assessment. The Supreme Court affirmed, holding that Center failed to meet its burden of proof to prove its purchases were used in the compounding of a product for sale, as required for the compounding exemption under section 144.054.2. View "Interventional Center for Pain Management v. Director of Revenue" on Justia Law