Justia Health Law Opinion Summaries

Troy Williams pleaded guilty to various federal offenses, including drug trafficking, firearm possession by a felon, and money laundering, and was sentenced to 198 months in prison, which was below the applicable sentencing guideline range. Williams has a history of serious medical conditions—thrombophilia and recurrent deep vein thrombosis—that require ongoing management, including regular blood testing and medication. Nearly ten years into his sentence, Williams sought compassionate release, asserting that inadequate medical care at his current facility placed him at risk of severe health complications or death.After Williams filed his pro se motion for compassionate release in the United States District Court for the Northern District of Ohio, counsel was appointed to supplement his arguments. Williams claimed the Bureau of Prisons was not providing sufficient medical care, particularly after his transfer to FCI Coleman, where he alleged infrequent blood testing and interruptions in medication. He also argued the sentencing factors under 18 U.S.C. § 3553(a) favored his release. The district court reviewed his medical records and expert testimony from the prison’s clinical director, ultimately finding that Williams’s care was not so deficient as to amount to extraordinary and compelling circumstances. The district court further concluded that, even if such circumstances were present, the sentencing factors did not support early release. Williams timely appealed.The United States Court of Appeals for the Sixth Circuit reviewed the district court’s denial for abuse of discretion, considering legal questions de novo and factual findings for clear error. The Sixth Circuit held that the district court did not clearly err in finding that Williams’s medical care was adequate and that his situation did not present extraordinary and compelling circumstances under the relevant Sentencing Commission policy statement. Accordingly, the Sixth Circuit affirmed the denial of Williams’s motion for compassionate release. View "United States v. Williams" on Justia Law

A group of Texas hospitals challenged a 2023 regulation issued by the Secretary of Health and Human Services. The regulation excluded certain patients, who received benefits under Texas’s uncompensated care pool demonstration project, from the Medicaid fraction calculation for Disproportionate Share Hospital (DSH) payments. This change threatened to reduce the hospitals’ Medicare DSH payments and make some hospitals ineligible for the 340B drug discount program, which relies on the DSH percentage.The hospitals initially sought a hearing before the Provider Reimbursement Review Board (PRRB), arguing the new regulation was unlawful. The PRRB determined it lacked jurisdiction because there was no “final determination” regarding a specific hospital’s payment amount, as required for PRRB review. The hospitals then filed suit in the United States District Court for the Northern District of Texas, which reached the merits, granted summary judgment for the hospitals, and vacated the regulation. The Secretary of Health and Human Services appealed this decision.The United States Court of Appeals for the Fifth Circuit reviewed the case and concluded that the district court lacked subject-matter jurisdiction. The Fifth Circuit held that claims arising under the Medicare statute must first be presented to the agency for a “final decision” before judicial review is available, consistent with 42 U.S.C. § 405(g). Because the hospitals had not presented their claims through the required administrative process—specifically, by submitting cost reports and receiving a final reimbursement determination—they failed to satisfy the nonwaivable presentment requirement. The court also rejected the argument that the channeling requirement did not apply or that it amounted to a complete preclusion of judicial review. Accordingly, the Fifth Circuit reversed the district court’s judgment and remanded the case. View "Baylor All Saints Med Ctr v. Kennedy" on Justia Law

A New Jersey physician wished to provide medical aid in dying to terminally ill patients, including nonresidents seeking this service under New Jersey’s law that permits doctor-assisted suicide. The relevant statute allows only New Jersey residents, with a prognosis of six months or fewer to live, to request and obtain a prescription for life-ending medication. Patients must demonstrate residency through various documents and satisfy several procedural safeguards. The plaintiff, a physician, challenged the law’s residency requirement after two terminally ill nonresidents who had joined the suit died during the course of litigation.The United States District Court for the District of New Jersey dismissed the complaint. The court reasoned that the right to receive medical aid in dying was neither a fundamental privilege nor a fundamental right requiring extension to nonresidents under the Privileges and Immunities Clause or the Equal Protection Clause. It further found the law was not economic protectionism and survived rational-basis review. The plaintiff appealed this decision.The United States Court of Appeals for the Third Circuit affirmed the District Court’s dismissal. It held that New Jersey’s restriction of doctor-assisted suicide to its own residents does not violate the Privileges and Immunities Clause because there is no longstanding tradition making such access a fundamental privilege, nor does it violate the Equal Protection Clause, as there is no fundamental right to assisted suicide or to interstate travel for this purpose. The Third Circuit also determined that the law does not offend the dormant Commerce Clause since it is a moral rather than commercial regulation and does not discriminate against out-of-state economic interests. The court concluded that New Jersey’s residency requirement is constitutionally permissible, justified by the state’s interests in protecting doctors, avoiding interstate friction, and safeguarding patients. View "Bryman v. Murphy" on Justia Law

The case involves a woman, M.S., who was the subject of a petition filed by the State in May 2024, alleging she was mentally ill and dangerous under Nebraska law. The petition was supported by statements from M.S.’ daughter, who described recent concerning behavior, including M.S. bringing a gun to her daughter’s home, appearing paranoid, and exhibiting signs of being out of touch with reality. M.S. was admitted to a psychiatric facility pending commitment proceedings, and a hearing was held before the Mental Health Board of the Fourth Judicial District. During the proceedings, M.S. was represented by counsel and objected to certain testimony on confrontation and hearsay grounds.The Mental Health Board overruled M.S.’ motion for a continuance and proceeded with the commitment hearing, where it heard testimony from a psychiatrist, M.S.’ daughter, and M.S. herself. The Board found, by clear and convincing evidence, that M.S. suffered from bipolar I disorder, manic with psychosis, and was dangerous to herself and others. The Board ordered inpatient treatment and authorized forced medication. M.S. appealed to the District Court for Douglas County, arguing that her rights to confrontation were violated, that inadmissible hearsay was admitted, and that the evidence was insufficient to support her commitment. The district court affirmed the Board’s decision, ruling that any errors in admitting certain evidence were harmless because the facts were otherwise established in the record.On further appeal, the Nebraska Supreme Court reviewed the district court’s decision. It held that confrontation rights under both the U.S. and Nebraska Constitutions, as extended by statute to mental health commitment proceedings, are trial rights that do not apply to pretrial hearings. The court further found that the challenged statements by family members were admissible under the medical purpose exception to the hearsay rule. The court concluded that clear and convincing evidence supported the findings that M.S. was mentally ill and dangerous, and that the treatment ordered was the least restrictive alternative. The district court’s order was affirmed. View "In re Interest of M.S." on Justia Law

A pharmacist in Florida, serving as the pharmacist-in-charge at a pharmacy called NH Pharma, was indicted for conspiracy to commit health-care fraud and several counts of health-care fraud. The indictment alleged that he defrauded Medicare by billing for drugs different than those he dispensed and for prescriptions never filled. The pharmacy’s owner cooperated with the government after pleading guilty to conspiracy. At trial, the prosecution presented evidence that the pharmacist and the owner prepared compounded medications using unreimbursable ingredients while billing Medicare for more expensive, reimbursable ones, and attempted to cover up the discrepancies during audits. There was also evidence, including video and witness testimony, that the pharmacist had stolen about $200,000 in cash from the pharmacy. Three Medicare beneficiaries testified that they never received or believed they were prescribed the medications billed in their names.The United States District Court for the Middle District of Florida admitted evidence of the uncharged cash theft, ruling it was intrinsic to the case. The court also excused a potential defense witness, a part-owner and pharmacy technician, from testifying after she invoked her Fifth Amendment right against self-incrimination, and declined to recommend immunity for her. After a jury found the pharmacist guilty on all counts, he moved for a new trial based on statements made by the pharmacy owner in her own sentencing memorandum, arguing they constituted newly discovered evidence. The district court denied this motion.The United States Court of Appeals for the Eleventh Circuit affirmed the convictions. It held that the district court did not abuse its discretion by denying a new trial because the statements were not new evidence, nor material, nor likely to produce a different result. The appellate court also found no abuse of discretion in admitting the theft evidence, declining to compel witness immunity, and not conducting an in-camera hearing, and rejected constitutional claims raised by the defendant. View "USA v. Beasley" on Justia Law

This case involves allegations of Medicare fraud under the False Claims Act (FCA) against MD Labs, an independent clinical laboratory. Between 2017 and 2019, OMNI Healthcare, a medical practice, sent MD Labs nearly 600 requests for PCR urinary tract infection (UTI) tests, which are more costly than traditional bacterial urine culture (BUC) tests. OMNI, acting on the instruction of its owner, directed staff to order only PCR tests, even when providers had requested BUC tests, with the admitted intention of building a Medicare fraud case against MD Labs. There is no evidence MD Labs knew of OMNI's intentions; MD Labs simply received and processed test orders submitted by physicians.The United States District Court for the District of Massachusetts reviewed the case after discovery and cross-motions for summary judgment. OMNI alleged that MD Labs “knowingly” submitted false claims to Medicare by seeking reimbursement for medically unnecessary PCR tests. MD Labs argued it was entitled to rely on the ordering physician’s determination of medical necessity and that it lacked the required scienter for FCA liability. The district court granted summary judgment to MD Labs, finding that OMNI had not produced sufficient evidence that MD Labs “knowingly” submitted false claims.On appeal, the United States Court of Appeals for the First Circuit affirmed the district court’s decision. The court held, as a matter of first impression in the circuit, that a laboratory generally may rely on a doctor’s order as evidence that a test is medically necessary for FCA purposes, absent evidence of fraud or other improper conduct by the lab. OMNI failed to present evidence that MD Labs had actual knowledge, was deliberately indifferent, or recklessly disregarded the medical necessity of the tests ordered. Accordingly, summary judgment was affirmed for MD Labs on all federal and state claims. View "United States, ex rel. Omni Healthcare Inc. v. MD Spine Solutions LLC" on Justia Law

A medical device company that manufactures spinal devices was indicted, along with its CEO and CFO, for allegedly paying bribes to surgeons through a sham consulting program in violation of the Anti-Kickback Statute. The indictment claimed the surgeons did not provide bona fide consulting services, but were paid to use and order the company’s devices in surgeries covered by federal health care programs. The company’s CFO, who is not a shareholder but is one of only two officers, allegedly calculated these payments based on the volume and value of surgeries performed with the company’s devices. During the development of the consulting program, the company retained outside counsel to provide legal opinions on the agreements’ compliance with health care law, and those opinions were distributed to the surgeons.After the grand jury returned the indictment, the United States District Court for the District of Massachusetts addressed whether the CFO’s plan to argue at trial that the involvement of outside counsel negated his criminal intent would effect an implied waiver of the company’s attorney-client privilege. The district court initially found that if the CFO or CEO invoked an “involvement-of-counsel” defense, it would waive the corporation’s privilege over communications with counsel. Following dismissal of charges against the company, the district court focused on whether the officers collectively could waive the privilege, concluded they could, and ruled that the CFO’s planned defense would constitute an implied waiver, allowing disclosure of certain privileged communications to the government. The district court stayed its order pending appeal.The United States Court of Appeals for the First Circuit vacated the district court’s waiver order and remanded. The Court of Appeals held that (1) the record was insufficient to determine whether the CFO alone had authority to waive the company’s privilege, and (2) not every involvement-of-counsel defense necessitates a waiver. The appellate court directed the district court to reassess the issue in light of changed circumstances and to consider less intrusive remedies before finding an implied waiver. View "United States v. SpineFrontier, Inc." on Justia Law

A nurse practitioner working in Georgia became involved in a nationwide Medicare fraud scheme between 2018 and 2019. She took part-time telemedicine jobs and reviewed patient charts for durable medical equipment (DME) prescriptions, such as neck and knee braces. The scheme involved submitting thousands of DME orders to Medicare for patients who had not actually been examined or treated as required by law. Federal investigators discovered she was signing orders, attesting to patient assessments and medical necessity, despite never contacting or examining the patients. Several orders were found to be fraudulent, such as prescribing braces to deceased or bedridden patients, or to patients with amputated limbs. She received compensation per chart reviewed, and her records indicated knowledge of the fraudulent nature of the activity.The United States District Court for the Southern District of Georgia presided over her trial, where she was charged with conspiracy, health care fraud, making false statements, aggravated identity theft, and related offenses. The jury found her guilty on sixteen counts but acquitted her of conspiracy to commit health care fraud. At sentencing, the district court applied a two-level enhancement for obstruction of justice based on perjury, citing her false testimony and inconsistencies. Her motion for a new trial was denied as untimely; the court rejected her claim of excusable neglect due to her attorney’s actions.On appeal, the United States Court of Appeals for the Eleventh Circuit reviewed four main issues: sufficiency of evidence, the lack of a deliberate ignorance jury instruction, the sentencing enhancement for perjury, and the denial of her new trial motion. The appellate court found sufficient evidence for all convictions, held that the absence of the deliberate ignorance instruction did not prejudice her substantial rights, affirmed the obstruction of justice enhancement, and found no abuse of discretion in the denial of the new trial motion. The Eleventh Circuit affirmed her convictions and sentence. View "USA v. Beaufils" on Justia Law

Two healthcare professionals operated a clinic specializing in pain management in Kentucky. One owned and managed the clinic, while the other served as its medical director. Together, they implemented a scheme to maximize profits by routinely ordering and billing insurers for both basic and more expensive, specialized urine drug tests for patients, regardless of actual medical need. The clinic eventually acquired in-house testing equipment to further increase billing. Staff raised concerns about the medical necessity of the tests and the reliability of the equipment, but the practice continued. The clinic also billed for tests conducted on malfunctioning equipment and for tests whose results could not be used for patient care due to processing delays.A grand jury indicted both individuals for conspiracy to commit health care fraud, substantive health care fraud, and (for one defendant) unlawful distribution of controlled substances. Both defendants went to trial in the United States District Court for the Eastern District of Kentucky. The jury convicted one defendant of health care fraud, and the other of both health care fraud and conspiracy to commit health care fraud. After denying post-trial motions for acquittal and new trial, the district court sentenced both to below-Guidelines imprisonment terms, after calculating loss amounts based on insurer payments for unnecessary testing, with a discount for tests likely to have been medically necessary.The United States Court of Appeals for the Sixth Circuit reviewed the convictions and sentences. The court held there was sufficient evidence to support both defendants’ convictions, upheld the district court’s evidentiary rulings (including admission of propensity and patient death evidence with limiting instructions), found no variance between the indictment and proof at trial, and determined that one defendant’s conflict-of-interest waiver was valid. The court also affirmed the district court’s methodology for estimating loss amounts for sentencing and restitution. The Sixth Circuit affirmed all convictions and sentences. View "United States v. Siefert" on Justia Law

A group of long-term care providers and their associated management company filed cost reports for 2015 with the Mississippi Division of Medicaid (DOM), reporting dividends received from three insurance companies as “other income” rather than offsetting them against insurance costs. This reporting practice had been consistently followed and accepted by DOM for over two decades. When DOM audited the 2015 cost reports around 2018, it changed its approach by offsetting these dividends against current insurance costs, thereby affecting reimbursement rates for services provided by the providers.After DOM made these adjustments, the providers sought reconsideration, but DOM upheld its decision. The providers then pursued an administrative appeal, where a hearing officer found DOM’s adjustments supported by substantial evidence and not arbitrary or capricious, recommending affirmation of DOM’s actions. DOM’s executive director adopted this recommendation. The providers appealed to the Hinds County Chancery Court, which affirmed DOM’s decision, concluding that the State Plan required reference to the Provider Reimbursement Manual (PRM) for guidance, and that DOM acted within its authority and did not violate any statutory or constitutional rights. The chancellor also found no evidence of a written internal policy regarding the treatment of such dividends.On appeal, the Supreme Court of Mississippi reviewed whether DOM’s actions were arbitrary and capricious, whether public notice of the change was required, and other issues. The Court held that DOM’s abrupt reversal of its long-standing unwritten internal policy, without reasonable explanation or public notice, was arbitrary and capricious. The Court further found that public notice was required under federal regulations for significant policy changes affecting payment rates. Accordingly, the Supreme Court of Mississippi reversed the decisions of DOM and the chancery court and rendered judgment in favor of the providers. View "Hattiesburg Medical Park Management Corp. v. Mississippi Division of Medicaid" on Justia Law