Justia Health Law Opinion Summaries

A physician employed jointly by a Kansas hospital and its parent health system alleged that he was fired and later reported to the state medical licensing board in retaliation for reporting another doctor’s alleged sexual harassment of nurses. The physician had served in various roles at the hospital, including as Chief Medical Officer, and had made a formal complaint about a colleague’s conduct. After an internal investigation into an unrelated anonymous complaint about the physician’s own conduct, the hospital terminated his employment and subsequently referred several of his cases for outside peer review, which led to reports being filed with the state licensing board.The United States District Court for the District of Kansas granted summary judgment to the hospital and health system on the physician’s Title VII retaliation claims, finding that he could not show the reasons for his termination or the reports to the licensing board were pretextual. The court also declined to exercise supplemental jurisdiction over related state law claims. The physician appealed.The United States Court of Appeals for the Tenth Circuit reviewed the case de novo. It held that the physician presented sufficient evidence for a reasonable jury to find that the hospital’s internal investigation and subsequent actions were motivated by retaliatory animus, particularly under a “cat’s paw” theory, where biased subordinates influenced the ultimate decisionmakers. The court found genuine disputes of material fact regarding whether the stated reasons for termination and reporting were pretextual, including evidence of disparate treatment and an unfair investigation. The Tenth Circuit reversed the grant of summary judgment on both Title VII retaliation claims and remanded for further proceedings. It also directed the district court to reconsider whether to exercise supplemental jurisdiction over the state law claims. View "Byrnes v. St. Catherine Hospital" on Justia Law

Fifty-six Texas emergency-medicine physician groups provided out-of-network emergency care to patients insured by twenty-four Blue Cross Blue Shield-affiliated plans from outside Texas. The physician groups sought reimbursement for their services, relying on assignments of benefits obtained from patients during hospital registration. The Blue Plans paid only part of the billed amounts, and the physician groups pursued appeals through the provider appeals process, but often received generic or no responses. After partial payments and unsuccessful appeals, the physician groups filed suit, alleging underpayment for 290,000 claims. Following a settlement, most claims were dismissed, and the district court selected 182 representative bellwether claims for summary judgment.The United States District Court for the Northern District of Texas granted summary judgment for the Blue Plans on all bellwether claims. The court found that the physician groups lacked standing due to issues with the assignments, such as ambiguous language, lack of written evidence for some claims, and anti-assignment provisions in the underlying plans. The court also held that the physician groups failed to exhaust administrative remedies, as they did not use the member appeals process specified in the plans, and dismissed some claims as time-barred. Final judgment was entered for the Blue Plans, and the physician groups appealed.The United States Court of Appeals for the Fifth Circuit reviewed the district court’s decision de novo. The Fifth Circuit affirmed summary judgment only for claims where no written assignment was produced, finding the physician groups’ evidence insufficient. For the remaining claims, the Fifth Circuit vacated summary judgment and remanded for further proceedings. The court held that ambiguities in assignment language created factual disputes, that assignments of “all rights” could include the right to sue, and that the district court applied the wrong legal standard to estoppel regarding anti-assignment clauses and exhaustion of administrative remedies. The case was remanded for further evidentiary determinations. View "Angelina Emergency Medicine Associates PA v. Blue Cross" on Justia Law

An employee of a telecommunications company, who also served as a union representative, was charged with defrauding a pharmacy benefits management company by orchestrating the submission of fraudulent claims for compounded medications. The government alleged that he induced another individual to obtain medically unnecessary compounded drugs and arranged for a doctor to sign prescriptions without a medical examination or determination of necessity. The prescriptions were then used to submit claims to the company’s health plan, and the employee received a percentage of the reimbursement. The government further alleged that the employee paid the individual to participate in the scheme and later instructed him to lie to investigators.The United States District Court for the District of New Jersey granted the defendant’s motion to dismiss the superseding indictment. The court found that the indictment failed to allege any actionable misrepresentation or omission under 18 U.S.C. § 1347, did not specify how the fraudulent claims were submitted or by whom, and did not identify any false statements or omissions in the claims. The court also expressed concern about the use of the term “medically unnecessary,” finding it vague and undefined.On appeal, the United States Court of Appeals for the Third Circuit reviewed the sufficiency of the indictment de novo. The Third Circuit held that the indictment adequately alleged an implicit misrepresentation: that the prescriptions, incorporated into the claims, falsely implied medical necessity and a legitimate doctor-patient relationship. The court found that such implicit misrepresentations are actionable under the health care fraud statute. The court also determined that the indictment’s language was sufficiently clear to apprise the defendant of the charges. Accordingly, the Third Circuit reversed the District Court’s dismissal and remanded the case for further proceedings. View "USA v. Mattia" on Justia Law

Nita and Kirtish Patel operated two companies that provided mobile diagnostic medical services. To obtain Medicare reimbursement for neurological testing, they falsely represented that a licensed neurologist would supervise the tests. In reality, Kirtish, who lacked a medical license, wrote the reports, and Nita forged a physician’s signature. Their fraudulent scheme generated over $4 million, including substantial Medicare payments.In 2014, a former employee filed a sealed qui tam action in the United States District Court for the District of New Jersey, alleging healthcare fraud and asserting claims under the False Claims Act. The Patels were subsequently arrested and each pleaded guilty to one count of healthcare fraud. Their plea agreements did not address or preclude future civil or administrative actions. After their guilty pleas, the Government intervened in the qui tam action and obtained summary judgment against the Patels, relying on collateral estoppel from their criminal admissions. The District Court trebled the Medicare loss and imposed civil penalties, resulting in a judgment exceeding $7 million. Nita appealed, and the United States Court of Appeals for the Third Circuit affirmed her liability under the False Claims Act.Both Patels later moved to vacate their criminal sentences under 28 U.S.C. § 2255, arguing ineffective assistance of counsel because their attorneys did not advise them that their guilty pleas could have collateral estoppel effects in the civil qui tam action. The District Court denied their motions, finding that counsel’s performance was not objectively unreasonable and that the Patels were aware their plea agreements did not preclude civil actions.On appeal, the United States Court of Appeals for the Third Circuit held that the Sixth Amendment does not require criminal defense counsel to advise clients of collateral consequences such as civil liability under the False Claims Act. The court affirmed the District Court’s judgment, concluding that Padilla v. Kentucky’s holding is limited to deportation consequences and does not extend to civil liability. View "Patel v. USA" on Justia Law

A health care provider operating imaging centers in Wake County, North Carolina, and a major hospital system both applied for a Certificate of Need (CON) to acquire a new fixed MRI scanner, as required by state law. The state’s 2021 plan determined that only one additional scanner could be approved in the county. The provider sought to place the scanner in Wake Forest, while the hospital system proposed a location in Raleigh. After a competitive review, the North Carolina Department of Health and Human Services awarded the CON to the hospital system, finding its application more effective under certain comparative factors.The provider challenged this decision in the Office of Administrative Hearings, alleging the agency’s review was flawed and prejudicial. The administrative law judge (ALJ) found that the agency’s comparative analysis contained errors, deviated from established practices, and was based on subjective judgment rather than expertise or proper procedure. The ALJ reversed the agency’s decision and awarded the CON to the provider, also finding that the provider suffered substantial prejudice from the denial.On appeal, the North Carolina Court of Appeals affirmed the ALJ’s decision, holding that the appellants failed to challenge specific findings of fact, which made those findings binding on appeal. The court applied the whole record review standard, focusing on whether substantial evidence supported the ALJ’s decision.The Supreme Court of North Carolina reviewed the case and held that, under current law, the ALJ’s final decision—not the agency’s—is the focus of judicial review, and a high degree of deference is owed to the ALJ’s findings. The Court affirmed the lower court’s judgment regarding the comparative analysis but reversed on the issue of substantial prejudice, finding that the provider, as a denied applicant, was inherently prejudiced by the agency’s decision. The award of the CON to the provider was affirmed. View "Pinnacle Health Servs. of N.C. LLC v. N.C. Dep't of Health & Hum. Servs" on Justia Law

An individual was admitted to a hospital after a medical emergency and, following treatment, was held for mental health concerns. Hospital staff petitioned for his transport to a designated evaluation facility, citing symptoms of serious mental illness and inability to make rational decisions. Although the court ordered immediate transport for evaluation, the individual remained at the hospital for two weeks due to lack of capacity at evaluation facilities. After a hearing, the court found this prolonged detention violated his substantive due process rights and ordered his release. However, the individual remained at the hospital for three more days, after which the hospital filed a second petition based on new information. The court granted this petition, and the individual was detained for an additional nine days before being transported for evaluation.The Superior Court of the State of Alaska, Third Judicial District, Anchorage, first dismissed the initial petition and ordered the individual's release, finding the extended detention unconstitutional. Upon the hospital’s second petition, the court approved another period of detention, reasoning that new information justified the renewed hold and that delays were due to facility refusals and capacity issues. After the individual was finally transported and evaluated, the evaluation facility petitioned for a 30-day commitment, which the superior court granted following a hearing.The Supreme Court of the State of Alaska reviewed the case. It held that the second period of detention, especially when considered alongside the prior extended detention, violated the individual’s substantive due process rights because the nature and duration of the detention were not reasonably related to the limited purpose of facilitating immediate transportation for evaluation. The court also found that the State failed to prove by clear and convincing evidence that commitment was the least restrictive alternative. Accordingly, the Supreme Court vacated both the superior court’s order upholding the second detention and the 30-day commitment order. View "In the Matter of the Necessity for the Hospitalization of: Tavis J." on Justia Law

A personal care assistance provider agency in Minnesota was audited by the Department of Human Services (DHS) for recordkeeping deficiencies related to its provision of services under the state’s Medicaid program. The agency, which served both traditional and PCA Choice recipients, was found to have various documentation errors, including missing or incomplete care plans and timesheets, as well as timesheets lacking required elements. DHS did not allege fraud or that services were not provided, but sought to recover over $420,000 in payments, arguing that these deficiencies constituted “abuse” under state law and justified monetary recovery.After an evidentiary hearing, an administrative law judge (ALJ) recommended limited recovery for some missing documentation but rejected most of DHS’s claims, finding that DHS had not shown the deficiencies resulted in improper payments. The DHS Commissioner disagreed, ordering full repayment. The Minnesota Court of Appeals reversed the Commissioner’s decision, holding that DHS must prove not only that the provider engaged in “abuse” but also that the abuse resulted in the provider being paid more than it was entitled to receive. The court also determined that provider agencies must maintain care plans for both traditional and PCA Choice recipients in their files.The Minnesota Supreme Court affirmed in part, reversed in part, and remanded. It held that, to obtain monetary recovery under Minn. Stat. § 256B.064, subd. 1c(a), DHS must prove either: (1) the provider engaged in conduct described in subdivision 1a and, had DHS known of the conduct before payment, it would have been legally prohibited from paying under a statute or regulation independent of subdivision 1a; or (2) the payment resulted from an error such that the provider received more than authorized by law. The Court also held that provider agencies must keep care plans for all PCA services, including PCA Choice, in their files. View "In the Matter of the SIRS Appeal by Best Care, LLC" on Justia Law

An advanced practice registered nurse in Texas, who maintained an active nursing license and a Prescriptive Authority Number, did not have a current prescriptive-authority agreement with a physician, as required by Texas law to prescribe drugs. She was not accused of any misconduct but was attending an educational program to transition careers. Because she lacked a prescriptive-authority agreement, the Drug Enforcement Administration (DEA) initiated proceedings to revoke her federal Certificate of Registration, which allows her to handle controlled substances.An administrative law judge within the DEA recommended revocation, finding that she was “without state authority to handle controlled substances.” The Administrator of the DEA adopted this recommendation and revoked her registration. The nurse then petitioned for review directly to the United States Court of Appeals for the Fifth Circuit, as permitted by statute.The United States Court of Appeals for the Fifth Circuit reviewed the DEA’s action and concluded that the agency exceeded its statutory authority under 21 U.S.C. § 824(a)(3). The court held that the statute requires both the loss of a state license or registration and the lack of state authorization to handle controlled substances before the DEA may revoke a registration. Because the nurse still held all relevant state licenses and registrations, the court determined that the DEA lacked authority to revoke her registration solely due to the absence of a prescriptive-authority agreement. The court granted the petition for review, vacated the DEA’s revocation order, and remanded the case to the agency for further proceedings consistent with its opinion. View "DeWitt v. Drug Enforcement Administration" on Justia Law

A staff member at a university medical school morgue, Cedric Lodge, engaged in a scheme over several years in which he dissected, stole, and sold body parts from cadavers that had been donated for research and education. After Lodge’s federal indictment became public, forty-seven relatives of individuals whose remains were potentially mishandled sued the university, the managing director of the anatomical gift program (Cicchetti), and the program manager (Fay). The plaintiffs alleged that the university and its staff failed to ensure the dignified treatment and disposition of donated remains, pointing to inadequate security and oversight, and referenced a similar prior scandal at another institution.The cases were consolidated in the Massachusetts Superior Court, where the defendants moved to dismiss all claims, arguing they were protected by the “good faith” immunity provision of the Uniform Anatomical Gift Act (UAGA). The Superior Court judge granted the motion, finding that the complaints did not plausibly suggest the defendants failed to act in good faith or were legally responsible for Lodge’s actions.The Supreme Judicial Court of Massachusetts reviewed the case after transferring it from the Appeals Court. The court held that the UAGA’s good faith immunity applies to the entire anatomical donation process, including the final disposition of remains. The court further held that the plaintiffs’ allegations against the university and Cicchetti, if true, could support a finding of “peculiarly pervasive noncompliance” with the act, sufficient to infer a lack of good faith and defeat the motion to dismiss at this stage. However, the court found the allegations against Fay insufficient to overcome the good faith defense. The court reversed the dismissal as to the university and Cicchetti (except for respondeat superior claims), affirmed dismissal as to Fay, and remanded for further proceedings. View "Weiss v. President and Fellows of Harvard College" on Justia Law

A group of more than 80 former at-will employees of a nonprofit healthcare system in Washington were terminated after refusing to comply with a COVID-19 vaccination mandate issued by their employer, which was in response to an August 2021 proclamation by the state’s governor requiring healthcare workers to be vaccinated. The employees alleged that, at the time, only an “investigational” vaccine authorized for emergency use was available, and they claimed their rights were violated when they were penalized for refusing it. They also argued they were not adequately informed of their right to refuse the vaccine.The United States District Court for the Western District of Washington first dismissed all claims against the governor, then dismissed the federal claims against the healthcare system, and denied the employees’ motions for leave to amend and reconsideration. The district court also declined to exercise supplemental jurisdiction over the remaining state-law claims against the healthcare system.The United States Court of Appeals for the Ninth Circuit reviewed the case and affirmed the district court’s dismissal. The Ninth Circuit held that none of the employees’ statutory or non-constitutional claims, which were based on various federal statutes, regulations, agreements, and international treaties, alleged specific and definite rights enforceable under 42 U.S.C. § 1983. The court also found that the employees’ constitutional claims failed: the Fourteenth Amendment substantive due process claim was foreclosed by Jacobson v. Massachusetts and Health Freedom Defense Fund, Inc. v. Carvalho; the procedural due process claim failed because at-will employment is not a constitutionally protected property interest; and the equal protection claim failed because the mandate survived rational-basis review. The court further held that amendment of the federal claims would be futile and upheld the district court’s dismissal of the state law claims against the governor and its decision to decline supplemental jurisdiction over the state law claims against the healthcare system. View "Curtis v. Inslee" on Justia Law