Justia Health Law Opinion Summaries

The State petitioned to involuntarily commit J.L.O., alleging she suffered from schizophrenia and posed a danger to herself or others. The petition relied on a report by a licensed clinical social worker (LCSW) who examined J.L.O. the day before the petition was filed. The District Court appointed a licensed professional counselor to examine J.L.O., and scheduled a hearing for January 2, 2024, within the statutory five-day window. J.L.O. was detained at the Montana State Hospital pending the hearing. The State provided J.L.O.’s counsel with the LCSW’s report only after the hearing, and it was discovered that the LCSW was not certified as a “professional person” under Montana law.J.L.O.’s counsel moved to dismiss the commitment petition, arguing that the State failed to have J.L.O. examined by a qualified professional person within the required timeframe. The State conceded the LCSW’s lack of certification but argued that J.L.O.’s request for a continuance waived the five-day hearing deadline. The Fourth Judicial District Court denied the motion to dismiss and proceeded with the commitment process, ultimately appointing a certified professional person who did not personally examine J.L.O. but relied on records and secondhand information. The District Court committed J.L.O. to the Montana State Hospital for up to ninety days and authorized involuntary medication.The Supreme Court of the State of Montana reviewed the case and held that the District Court erred by denying J.L.O.’s motion to dismiss. The Supreme Court found that the statutory requirements for involuntary commitment—including examination by a qualified professional person within the five-day hearing deadline—were not met, and that the error was not harmless. The Supreme Court reversed the District Court’s Order of Commitment. View "In re J.L.O." on Justia Law

An inpatient rehabilitation facility employed a sales representative who raised concerns about the facility’s use of nonclinical personnel in the preadmission screening process required for Medicare reimbursement. The sales representative was terminated after five months of employment. Shortly thereafter, she filed a qui tam action under the False Claims Act, alleging that the facility presented false claims to Medicare, used false records to obtain payment, and conspired to submit false claims. She amended her complaint multiple times, and the government declined to intervene in the case.The United States District Court for the Southern District of Texas reviewed the second amended complaint after the defendant moved to dismiss under Rule 12(b)(6). The magistrate judge recommended dismissal of all claims, finding the complaint insufficiently plausible and lacking the particularity required by Rules 8(a) and 9(b). The magistrate judge also recommended denying leave to further amend the complaint as futile under Rule 16. The district court adopted these recommendations, entered final judgment, and dismissed the case with prejudice. The plaintiff timely appealed.The United States Court of Appeals for the Fifth Circuit reviewed the district court’s dismissal de novo and the denial of leave to amend for abuse of discretion. The Fifth Circuit held that the complaint failed to plead sufficient facts to support the elements of a False Claims Act violation, specifically the falsity of the claims and the connection between the alleged conduct and the submission of false claims. The court also found that amendment would be futile, as the plaintiff had already amended her complaint twice without remedying the deficiencies. The Fifth Circuit affirmed the district court’s dismissal of the claims with prejudice. View "Gentry v. Encompass Health Rehabilitation Hospital of Pearland, L.L.C." on Justia Law

Eskender Getachew, a medical doctor in Columbus, Ohio, operated a clinic treating patients with opioid addiction. The government alleged that Dr. Getachew unlawfully prescribed controlled substances, particularly Subutex, at rates far exceeding medical norms, often without verifying patients’ claimed allergies to naloxone. Evidence at trial included testimony from an undercover officer, clinic staff, and an expert who identified repeated deviations from accepted medical practice, such as prescribing drugs without documented need and ignoring signs of drug diversion. The jury found Dr. Getachew guilty on eleven counts of unlawful distribution of controlled substances and not guilty on four counts.The United States District Court for the Southern District of Ohio presided over the trial. After conviction, Dr. Getachew was sentenced to concurrent six-month terms and three years of supervised release. He moved for a new trial, arguing ineffective assistance of counsel during plea negotiations and requested an evidentiary hearing, which the district court denied. Dr. Getachew appealed, challenging the sufficiency of the evidence, the deliberate-ignorance jury instruction, the content of that instruction, his absence at the return of the verdict, and the denial of an evidentiary hearing.The United States Court of Appeals for the Sixth Circuit reviewed the case. The court held that the evidence was sufficient to support the jury’s finding that Dr. Getachew knowingly issued unauthorized prescriptions. It found no plain error in the deliberate-ignorance instruction or its content. The court determined that Dr. Getachew’s absence at the verdict’s return did not affect his substantial rights and that the district court did not abuse its discretion in denying an evidentiary hearing on the new trial motion. The Sixth Circuit affirmed the district court’s judgment. View "United States v. Getachew" on Justia Law

An Oregon nonprofit organization, whose board members are guided by sincerely held religious beliefs, challenged a state law requiring most employers to provide insurance coverage for abortion and contraceptive services. The organization’s governing documents and public statements reflect a commitment to traditional Judeo-Christian ethics, including opposition to abortion based on religious grounds. Although the law contains exemptions for certain religious employers, the organization does not qualify for any of these exceptions, a point not disputed by the state. The organization sought relief, arguing that being compelled to provide such coverage violates its rights under the First and Fourteenth Amendments.The United States District Court for the District of Oregon denied the organization’s request for a preliminary injunction and dismissed its complaint. The district court found there was doubt as to whether the organization’s opposition to abortion was genuinely religious in nature. It further concluded that the law was neutral and generally applicable, subject only to rational basis review, which it satisfied.On appeal, the United States Court of Appeals for the Ninth Circuit reversed the district court’s dismissal and vacated the denial of a preliminary injunction. The Ninth Circuit held that the organization’s beliefs are religious and sincerely held, and that the district court erred by not accepting these allegations as true at the motion to dismiss stage. The appellate court remanded the case for the district court to reconsider, in light of the Supreme Court’s decision in Catholic Charities Bureau, Inc. v. Wisconsin Labor & Industry Review Commission, whether the selective denial of a religious exemption to the organization violates the First Amendment. The Ninth Circuit expressed no opinion on the ultimate constitutional question, leaving it for the district court to address in the first instance. View "OREGON RIGHT TO LIFE V. STOLFI" on Justia Law

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