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The Medicare statute precludes judicial review of estimates used to make certain payments to hospitals for treating low-income patients. At issue was whether this preclusion provision barred challenges to the methodology used to make the estimates. The DC Circuit held that it could not review the Secretary's method of estimation without also reviewing the estimate. Therefore, the two were inextricably intertwined and 42 U.S.C. 1395ww(r)(3)(A) precludes review of both. The court held that Florida Health Sciences Center, Inc. v. Secretary of HHS, 830 F.3d 515 (D.C. Cir. 2016), -- not ParkView Medical Associates v. Shalala, 158 F.3d 146 (D.C. Cir. 1998) -- was controlling in this case. In Florida Health, the court held that section 1395ww(r)(3) barred review because the plaintiff was simply trying to undo the Secretary's estimate of the hospital's uncompensated care by recasting its challenge to the Secretary's choice of data as an attack on the general rules leading to her estimate. Here, DCH was simply trying to undo the Secretary's estimate of its uncompensated care by recasting its challenge to that estimate as an attack on the underlying methodology. View "DCH Regional Medical Center v. Azar" on Justia Law

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The Medicare program offers additional payments to institutions that serve a “disproportionate number” of low-income patients, 42 U.S.C. 1395ww(d)(5)(F)(i)(I), calculated using the hospital’s “Medicare fraction.” The fraction’s denominator is the time the hospital spent caring for patients entitled to Medicare Part A benefits; the numerator is the time the hospital spent caring for Part-A-entitled patients who were also entitled to income support payments under the Social Security Act. Medicare Part C (Medicare Advantage) was created in 1997. Part C, beneficiaries may choose to have the government pay their private insurance premiums rather than pay for their hospital care directly. Part C enrollees tend to be wealthier than Part A enrollees, so counting them makes the fraction smaller and reduces hospitals’ payments. In 2014, the Medicare website indicated that fractions for fiscal year 2012 included Part C patients. Hospitals sued, claiming violation the Medicare Act’s requirement to provide public notice and a 60-day comment period for any “rule, requirement, or other statement of policy . . . that establishes or changes a substantive legal standard governing . . . the payment for services.” The Supreme Court affirmed the D.C. Circuit in agreeing with the hospitals. The government has not identified a lawful excuse for neglecting its statutory notice-and-comment obligations. The 2014 announcement established or changed a “substantive legal standard” not an interpretive legal standard. The Medicare Act and the Administrative Procedures Act do not use the word “substantive” in the same way. The Medicare Act contemplates that “statements of policy” can establish or change a “substantive legal standard." Had Congress wanted to follow the APA in the Medicare Act and exempt interpretive rules and policy statements from notice and comment, it could have cross-referenced the APA exemption, 5 U.S.C. 553(b)(A). View "Azar v. Allina Health Services" on Justia Law

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Medicare pays for doctors’ home visits if a patient is homebound. Mobile Doctors offered physician services to homebound Medicare beneficiaries, hiring doctors who assigned their Medicare billing rights to the company. Upon receipt of payment, Mobile would pay the physician-employee a percentage of what Mobile received from billing Medicare. Many of Mobile’s patients did not actually qualify as homebound. Some doctors signed certifications for additional unneeded treatment from companies that provided at-home nursing or physical therapy services—companies that had referred the patients to Mobile. Mobile submitted Medicare codes for more serious and more expensive diagnoses or procedures than the provider actually diagnosed or performed. Mobile instructed physicians to list at least three diagnoses in the patient file; if the doctors did not list enough, a staff member added more. Mobile only paid the physicians if they checked at least one of the top two billing codes. Doctors who billed for the higher of the top two codes were paid more. Mobile also paid for “standing orders” for testing, although Medicare prohibits testing done under standing orders. Daneshvar joined Mobile as a physician in 2012. After following Mobile’s policies Daneshvar was convicted of conspiracy to commit healthcare fraud but found not guilty of healthcare fraud; he was sentenced to 24 months' imprisonment. The Sixth Circuit affirmed. Daneshvar’s trial was fair; none of the district court’s rulings during that proceeding should be reversed. There was no reversible error with his sentencing. View "United States v. Daneshvar" on Justia Law

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The longstanding dispute between UPMC; UPE, a/k/a Highmark Health and Highmark, Inc. (collectively, “Highmark”); and the Commonwealth of Pennsylvania's Office of the Attorney General (“OAG”) is again before the Pennsylvania Supreme Court. This time, the issue centered on the parties’ rights and obligations under a pair of Consent Decrees that, since 2014, governed the relationship between UPMC and Highmark with regard to the provision and financing of certain healthcare services to their respective insurance subscribers. The Consent Decrees were scheduled to terminate on June 30, 2019. Following the Supreme Court's decision in "Shapiro I," on February 7, 2019, OAG filed a four-count petition at Commonwealth Court to Modify Consent Decrees (“Petition”), thus commencing the underlying litigation. OAG argued the Commonwealth Court erred in concluding that Shapiro I controlled this case, and in so doing, misapplied the applicable principles of contract law. Highmark argued the Commonwealth Court erred in imposing a “materiality” limitation upon the Modification Provision, observing that nothing therein precluded modification of “unambiguous” and “material” terms of the Consent Decrees, as the Supreme Court characterized the termination date in Shapiro I. UPMC counters that OAG’s proposed use of the Modification Provision is contrary to the parties’ intent, in that the intent of the Consent Decrees, UPMC contends, was to establish a five-year transition period for UPMC and Highmark to wind down their contractual relationships, and thereby to minimize disturbance to the health care industry and to avoid sudden disruption of health care consumers’ expectations. The Supreme Court agreed with OAG and Highmark that the Commonwealth Court erred in concluding this case was controlled by Shapiro I. Further, the Court determined OAG and Highmark have set forth a plausible construction of the Modification Provision. The Court remanded this matter back to the Commonwealth Court to interpret the contested provision, and to reconsider the question of extension of the Consent Decrees. View "Pennsylvania v. UPMC, et al." on Justia Law

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In this guardianship proceeding, the Supreme Court denied mandamus relief, holding that the trial court did not abuse its discretion by refusing to disqualify counsel for the guardianship applicant due to a purported conflict of interest. Jamie Rogers, represented by Alfred Allen, filed an application for temporary guardianship of Verna Thetford's person and a management trust for her estate. Verna moved to disqualify Allen as Jamie's counsel, asserting that Allen had represented Verna and that she objected to his representation of Jamie in violation of his fiduciary duties to her. The trial court denied the motion to disqualify and appointed Jamie as temporary guardian for Verna. Verna argued before the Supreme Court that the Texas Disciplinary Rules of Professional Conduct required that Allen be disqualified. The Supreme Court held (1) the Rules permit such representation in limited circumstances and that a trial court's decision regarding disqualification, based on a careful, thorough consideration of the evidence, is entitled to great deference by an appellate court; and (2) there was no reason to disturb the trial court's discretion in this case. View "In re Thetford" on Justia Law

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The Supreme Court reversed the portion of the county court's decision ordering Douglas County to pay the balance of the attorney fees owed by a former guardian-conservator to the successor guardian-conservator, holding that the county court's order did not conform to the law and was not supported by competent evidence. In 2007, a guardian-conservatorship was established for Alice H. In Douglas County. Pamela Grimes was appointed her guardian-conservator. In 2012, the court appointed Jodie McGill to serve as Alice's guardian-conservator. In 2016, the county court surcharged Grimes $37,505.70 in attorney fees to McGill. Grimes paid only a portion of the fees. In 2018, McGill asked the county court to order Douglas County to pay the balance. The court granted that request. The Supreme Court reversed, holding that the order neither conformed to the law nor was supported by competent evidence. View "In re Guardianship & Conservatorship of Alice H." on Justia Law

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In this case involving involuntary civil commitment due to mental illness, the Supreme Court held that an individual may not be said to have been "discharged" from a facility within the meaning of Mass. Gen. Laws ch. 123 if his iberty has not been restored. D.L. was held involuntarily at Pembroke Hospital on a temporary basis due to mental illness. When Pembroke's petition to extend D.L.'s confinement was denied, Pembroke purportedly "discharged" D.L. but also detained and transported him without his permission to a second hospital for another mental health evaluation. This evaluation led to an order for involuntary confinement. The Appellate Division found that there was no abuse of the involuntary commitment procedure under Mass. Gen. Laws ch. 123, 12. The Supreme Court disagreed, holding that Pembroke violated chapter 123 by failing to discharge D.L. after the denial of its petition to continue D.L.'s confinement. View "Pembroke Hospital v. D.L." on Justia Law

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The Supreme Court reversed the decision of the Commissioner of Human Services determining that RS Eden, a supervised living facility where J.W. received treatment before voluntarily leaving and dying of a drug overdose five days later, was responsible for maltreatment of J.W. by neglect, holding that the Commission's decision was not supported by substantial evidence. RS Eden appealed the maltreatment determination to the court of appeals, which affirmed. The Supreme Court reversed, holding that that Commissioner's finding of maltreatment for neglect for RS Eden's failure to obtain a waiver or to confer with a prescribing physicians was not supported by substantial evidence because RS Eden complied with the rules regarding the disposition of controlled substances and took reasonable steps to protect its client. View "In re Appeal by RS Eden" on Justia Law

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The Supreme Court affirmed the decision of the court of appeals dismissing J.W.K.'s appeal challenging the sufficiency of the evidence extending his commitment, holding that J.W.K.'s sufficiency challenge was moot. J.W.K. was originally committed in February 2016 for six months under Wis. Stat. 51.20. In July 2016, Portage County filed a petition seeking to extend J.W.K.'s commitment for twelve months. The circuit court found the statutory dangerousness standard was satisfied and extended J.W.K.'s commitment for twelve months. J.W.K. filed a notice of appeal. Thereafter, in 2017, the County filed a petition seeking another twelve-month extension of J.W.K.'s commitment, which the circuit court granted. The court of appeals dismissed J.W.K.'s appeal as moot. The Supreme Court affirmed, holding that reversing the expired 2016 order for insufficient evidence would have no effect on subsequent recommitment orders because later orders stand on their own under the language of section 51.20. View "Portage County v. J.W.K." on Justia Law

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Plaintiff Elizabeth Lawson alleged she incurred damages as the result of an emergency room nurse informing a police officer that she was intoxicated, had driven to the hospital, and was intending to drive home. The trial court granted defendant Central Vermont Medical Center (CVMC) summary judgment based on its determination that nothing in the record supported an inference that the nurse’s disclosure of the information was for any reason other than her good-faith concern for plaintiff’s and the public’s safety. In this opinion, the Vermont Supreme Court recognized a common-law private right of action for damages based on a medical provider’s unjustified disclosure to third persons of information obtained during treatment. Like the trial court, however, the Supreme Court concluded CVMC was entitled to judgment as a matter of law because, viewing the material facts most favorably to plaintiff and applying the relevant law adopted here, no reasonable factfinder could have determined the disclosure was for any purpose other than to mitigate the threat of imminent and serious harm to plaintiff and the public. Accordingly, the Supreme Court affirmed the trial court’s judgment. View "Lawson v. Central Vermont Medical Center" on Justia Law