Justia Health Law Opinion Summaries

Bruce Kelley and his spouse, Nancy Kelley, filed a medical malpractice lawsuit in Vermont state court after Bruce Kelley was paralyzed from the waist down while residing at Franklin County Rehabilitation Center (FCRC). They alleged that Dr. Teig Marco, employed by Richford Health Center, Inc. (RHC), negligently treated Kelley, leading to his paralysis. RHC is a federally funded community health center deemed a member of the Public Health Service under the Federally Supported Health Centers Assistance Act (FSHCAA).The United States intervened and removed the case to federal district court, asserting that RHC and Dr. Marco were covered under the Federal Tort Claims Act (FTCA) due to their deemed status. The United States District Court for the District of Vermont held an evidentiary hearing and determined that the FSHCAA did not apply to Dr. Marco’s treatment of Kelley because Kelley was not a patient of RHC, and the treatment did not fall under the specified statutory criteria for nonpatients. Consequently, the District Court remanded the case to state court for lack of subject matter jurisdiction.The United States Court of Appeals for the Second Circuit reviewed the case and affirmed the District Court's decision. The appellate court agreed that Kelley was not a patient of RHC and that Dr. Marco’s treatment did not meet the criteria for FTCA coverage for nonpatients under the FSHCAA. The court concluded that the treatment did not qualify as after-hours coverage or emergency treatment and that RHC had not sought a particularized determination of coverage from the Department of Health and Human Services. Therefore, the remand to state court was appropriate, and the District Court's order was affirmed. View "Kelley v. Richford Health Center, Inc." on Justia Law

The case involves Joseph Betro, Mohammed Zahoor, Tariq Omar, and Spilios Pappas, who conspired to defraud Medicare by administering medically unnecessary back injections and bribing patients with opioid prescriptions. They fraudulently billed these injections as “facet injections” to receive higher reimbursements. Additionally, they ordered unnecessary urine drug tests and referred patients to ancillary services in exchange for kickbacks. Despite patient complaints about the ineffectiveness and pain of the injections, the defendants continued their fraudulent practices.A jury in the United States District Court for the Eastern District of Michigan convicted the defendants of conspiracy to commit healthcare fraud and wire fraud under 18 U.S.C. § 1349 and healthcare fraud under 18 U.S.C. § 1347. The defendants filed motions for a new trial, which the district court denied. They then appealed their convictions and sentences, raising various challenges related to the prosecution, evidence admission, jury instructions, and sentencing calculations.The United States Court of Appeals for the Sixth Circuit reviewed the case and affirmed the district court’s judgments. The court found sufficient evidence to support the jury’s findings that the defendants knowingly participated in the fraudulent scheme. The court also held that the district court did not abuse its discretion in denying the motions for a new trial, admitting evidence, or instructing the jury. The sentences imposed were deemed procedurally and substantively reasonable, with the court noting that the district court had appropriately calculated the loss amounts and applied relevant sentencing enhancements. View "United States v. Betro" on Justia Law

In August 2020, Joe Willie Cannon, an inmate at Anamosa State Penitentiary (ASP), injured his right wrist while playing basketball. He sought medical attention from ASP staff, including nurses and a doctor, but experienced delays and inadequate treatment. Cannon alleged that the medical staff's failure to promptly diagnose and treat his wrist injury, which was later found to be a displaced fracture, constituted deliberate indifference to his serious medical needs, violating his Eighth Amendment rights.The United States District Court for the Northern District of Iowa denied summary judgment to four defendants—Dr. Michael Dehner and Nurses Amy Shipley, Courtney Friedman, and Barbara Devaney—who claimed qualified immunity. The court found that a reasonable jury could conclude that the defendants acted with deliberate indifference to Cannon's medical needs. The defendants appealed this interlocutory order.The United States Court of Appeals for the Eighth Circuit reviewed the case de novo. The court concluded that the district court failed to properly apply the principle that each defendant's knowledge and conduct must be individually assessed. The appellate court found that the nurses' actions, including their assessments and treatment plans, did not amount to deliberate indifference. Similarly, Dr. Dehner's decisions, including ordering an X-ray and referring Cannon to an orthopedic specialist, were based on his medical judgment and did not constitute deliberate indifference.The Eighth Circuit held that each appellant was entitled to qualified immunity because Cannon failed to prove that any of them acted with deliberate indifference to his serious medical needs. The court reversed the district court's order and remanded the case for further proceedings consistent with its opinion. View "Cannon v. Dehner" on Justia Law

Manish Kumar was involved in a scheme to smuggle misbranded prescription drugs and controlled substances into the United States from March 2015 to August 2019. Kumar, an Indian national, was a partner in Mihu, a New Delhi-based company that sold generic versions of drugs like Viagra, Cialis, Adderall, and tramadol without FDA approval or proper prescriptions. Kumar managed call centers in India where representatives made false statements to U.S. customers, claiming the drugs were FDA-approved and that no prescriptions were needed. Kumar was arrested in August 2019 on unrelated identity theft charges and later charged in Massachusetts with conspiracy to smuggle drugs, distribute controlled substances, and make false statements. He pled guilty to all charges in October 2022.The United States District Court for the District of Massachusetts sentenced Kumar to 87 months in prison. The court applied a fraud cross-reference in the Sentencing Guidelines and accepted the government's estimate of the loss amount involved in the offense, which was approximately $3.8 million. Kumar objected to both the application of the fraud cross-reference and the loss amount calculation, arguing that the evidence was insufficient.The United States Court of Appeals for the First Circuit reviewed the case. The court held that the fraud cross-reference was correctly applied because the false statements made by call center representatives were within the scope of Kumar's conspiracy and were made in furtherance of the criminal activity. The court also found that the sentencing court did not clearly err in its loss amount calculation, as it relied on detailed government estimates and supporting data. The First Circuit affirmed Kumar's 87-month sentence. View "United States v. Kumar" on Justia Law

The case involves a class action lawsuit brought by several minor children, through their legal guardians, against the Commissioner of the Georgia Department of Community Health. The plaintiffs challenged the Department's practices regarding the provision of skilled nursing services under the Medicaid Act. Specifically, they contested the Department's use of a scoresheet to determine the number of skilled nursing hours and the practice of reducing those hours as caregivers learn to perform skilled tasks.The United States District Court for the Northern District of Georgia granted summary judgment in favor of the plaintiffs. The court ruled that the Department's review process did not give appropriate weight to the recommendations of treating physicians and that the practice of reducing skilled nursing hours as caregivers learn skilled tasks violated the Medicaid Act. The district court issued permanent injunctions requiring the Department to approve the skilled nursing hours prescribed by the patients' treating physicians.The United States Court of Appeals for the Eleventh Circuit reviewed the case and reversed the district court's decision. The appellate court held that the Department's review process, which includes the use of a scoresheet to determine a presumptive range of skilled nursing hours, complies with the Medicaid Act. The court also found that the practice of reducing skilled nursing hours as caregivers learn skilled tasks is reasonable and does not violate the Act. The court vacated the permanent injunctions and remanded the case for further proceedings. The appellate court did not address the plaintiffs' challenge regarding the consideration of caregiver capacity, as the district court had ruled that issue moot. The appeal of the preliminary injunctions was deemed moot following the vacatur of the permanent injunctions. View "M.H. v. Commissioner, Georgia Dept. of Community Health" on Justia Law

The plaintiffs, Medicare beneficiaries with chronic illnesses, rely on home health aides for essential care. They allege that Medicare-enrolled providers have either refused to provide in-home care or offered fewer services than entitled, attributing this to the policies of the Secretary of Health and Human Services. They sought systemwide reforms through a lawsuit.The United States District Court for the District of Columbia dismissed the plaintiffs' complaint for lack of Article III standing. The court found that the plaintiffs failed to plausibly allege that their requested relief would redress any harm. The court noted that the injuries were caused by private home health agencies (HHAs) not before the court and that it was speculative whether enjoining the Secretary would change the HHAs' behavior. The court also found the plaintiffs' requested relief too general, making it difficult to evaluate its potential impact.The United States Court of Appeals for the District of Columbia Circuit reviewed the case and affirmed the district court's dismissal. The appellate court held that the plaintiffs failed to demonstrate redressability, a key component of standing. The court noted that the plaintiffs' injuries stemmed from the independent choices of private HHAs, and it was speculative that the requested injunctions would prompt these agencies to change their behavior. The court emphasized that the plaintiffs did not provide sufficient evidence to show that the Secretary's enforcement policies were a substantial factor in the HHAs' decisions. Consequently, the plaintiffs lacked standing to bring the suit, and the dismissal for lack of jurisdiction was affirmed. View "Johnson v. Becerra" on Justia Law

Nevada Health CO-OP, a health insurance provider, received two loans from the Centers for Medicare & Medicaid Services (CMS) under the Affordable Care Act’s CO-OP program. These loans included a start-up loan and a solvency loan. In 2015, Nevada Health faced financial difficulties and was placed into receivership by the Nevada Commissioner of Insurance. CMS subsequently terminated the loan agreement and began offsetting payments owed to Nevada Health against the start-up loan debt.The United States Court of Federal Claims reviewed the case and granted summary judgment in favor of the Nevada Commissioner of Insurance, acting as the receiver for Nevada Health. The court found that the government improperly withheld statutory payments owed to Nevada Health under the ACA. The court also held that the government could not invoke 31 U.S.C. § 3728 to withhold these payments in the future.The United States Court of Appeals for the Federal Circuit reviewed the case. The court affirmed the lower court’s judgment that the government improperly withheld payments owed to Nevada Health. The court held that the loan agreement subordinated the government’s claim to those of policyholders and basic operating expenses, thus precluding the government from asserting offset rights to jump ahead of these senior creditors. However, the appellate court vacated the portion of the lower court’s order that addressed the government’s ability to invoke 31 U.S.C. § 3728, ruling that the lower court exceeded its jurisdiction by addressing this issue, which was not raised by the parties. View "Richardson v. United States" on Justia Law

Eva Mae Givens applied for Medicaid assistance in Washington, D.C., but the District miscalculated her copay, requiring her to pay an extra $2,000 per month. Givens requested an administrative hearing to contest the miscalculation, but D.C. did not provide a timely hearing as required by federal law. Givens then filed a lawsuit under 42 U.S.C. § 1983, seeking injunctive and declaratory relief for a fair hearing and monetary damages for the overpayments. While the case was pending, D.C. held a hearing, corrected the miscalculation, and sent back-payments to the nursing homes, but not to Givens. Givens passed away shortly after the hearing.The United States District Court for the District of Columbia dismissed the case with prejudice, ruling that the claims were moot because D.C. had provided the hearing and corrected the miscalculation. The court also held that Givens failed to state a claim for relief. Givens' children, who sought to be substituted as plaintiffs, appealed the decision.The United States Court of Appeals for the District of Columbia Circuit reviewed the case. The court affirmed the dismissal of the fair-hearing claims as moot but noted that the dismissal should have been without prejudice. The court found that the calculation claim was not moot because Givens had not received compensation for the overpayments she made. However, the court held that the calculation claim failed to plausibly allege a violation of federal rights under § 1983, as Givens did not identify a specific municipal policy or custom that caused the miscalculation.The appellate court vacated the district court's order dismissing the case with prejudice and remanded the case. The district court was instructed to dismiss the moot fair-hearing claims without prejudice and to either dismiss the calculation claim without prejudice or provide a detailed explanation for a dismissal with prejudice. View "Givens v. Bowser" on Justia Law

Angela Midthun-Hensen and Tony Hensen sought insurance coverage for therapies for their daughter K.H.'s autism from Group Health Cooperative between 2017 and 2019. The insurer denied coverage, citing a lack of evidence supporting the effectiveness of speech therapy for a child K.H.'s age and sensory-integration therapy for autism at any age. The family's employer-sponsored plan only covered "evidence-based" treatments. After several medical reviews and appeals upheld the insurer's decision, the parents sued, alleging violations of the Employee Retirement Income Security Act (ERISA) and state law regarding autism coverage.The United States District Court for the Western District of Wisconsin ruled in favor of the insurer, finding no violations of state law or ERISA. The plaintiffs then focused on their claim that the insurer's actions violated the Mental Health Parity and Addiction Equity Act (MHPAEA), which mandates equal treatment limitations for mental and physical health benefits. They argued that the insurer applied the "evidence-based" requirement more stringently to autism therapies than to chiropractic care, which they claimed lacked scientific support.The United States Court of Appeals for the Seventh Circuit reviewed the case and affirmed the district court's decision. The appellate court found that the insurer's reliance on medical literature, which varied in its recommendations based on patient age, was permissible under the Parity Act. The court also noted that the plaintiffs failed to demonstrate that the insurer's treatment limitations for mental health benefits were more restrictive than those applied to "substantially all" medical and surgical benefits, as required by the statute. The court concluded that the plaintiffs' focus on a single medical benefit was insufficient to prove a violation of the Parity Act. View "Midthun-Hensen v. Group Health Cooperative of South Central, Inc.," on Justia Law

Residents of St. Croix, Virgin Islands, sued Limetree Bay Terminals and Limetree Bay Refining after the companies reopened an oil refinery that released oil mist onto nearby properties, contaminating water supplies. The residents, who rely on cisterns for water, claimed the contamination posed health risks. The companies attempted to clean the cisterns and compensate affected residents, but not all residents had access to clean water. The residents sought a preliminary injunction to require the companies to provide bottled water.The District Court for the Virgin Islands granted the preliminary injunction, finding that both Terminals and Refining were responsible for the contamination under their federal operating permit. The court determined that the residents were likely to succeed on the merits of their case and faced irreparable harm without access to clean water. The court limited the bottled-water program to residents in certain neighborhoods who received need-based government assistance and required the residents to post a $50,000 bond.The United States Court of Appeals for the Third Circuit reviewed the case and affirmed the District Court's decision. The Third Circuit agreed that the residents were likely to succeed on the merits and faced irreparable harm. The court also found that the balance of equities and public interest favored the residents. The Third Circuit upheld the $50,000 bond, noting that the District Court had carefully considered the residents' ability to pay and the relative hardships to each party. The court concluded that the District Court had properly applied the law and exercised its discretion in granting the preliminary injunction and setting the bond amount. View "Boynes v. Limetree Bay Ventures LLC" on Justia Law