Justia Health Law Opinion Summaries

This case arose out of a qui tam action against Prime Healthcare Services—Encino Hospital, LLC (Encino Hospital) and others to impose civil penalties for violation of the Insurance Fraud Prevention Act (IFPA), Insurance Code section 1871 et seq. The State of California and relator (Plaintiffs) appealed from a judgment entered after a bench trial in which the court found insufficient evidence to support their allegations that Defendants engaged in insurance fraud by billing insurers for services performed in a detox center for which they had no appropriate license, and by employing a referral agency to steer patients to the center.   The Second Appellate District affirmed the judgment. The court explained that, CDI alleged that Encino Hospital misrepresented to insurers that it was properly licensed to provide detox services when it was not. The trial court found no evidence suggesting that Defendants presented a false claim to any insurer. The court agreed, reasoning that no authority of which it is aware or to which it has been directed obligates Encino Hospital to hold any license other than its license as a general acute care hospital. Because Encino Hospital needed no separate license or approval, and no evidence showed it concealed any provider, the CDI’s cause of action for false claims failed for lack of a predicate. View "State of Cal. v. Encino Hospital Medical Center" on Justia Law

Michelle Caddell died from cervical cancer while in custody as a pretrial detainee in the Tulsa County Jail. Yolanda Lucas, as special administrator of decedent Caddell’s estate, initiated this case under 42 U.S.C. § 1983 bringing claims of deliberate indifference in violation of the Eighth and Fourteenth Amendments against Dr. Gary Myers and against Turn Key Health Clinics, LLC (“Turn Key”) and Sheriff Vic Regalado in his official capacity through municipal liability, violations of the Equal Protection clause against Turn Key and Sheriff Regalado, and negligence and wrongful death under Oklahoma state law against Dr. Myers and Turn Key. The three Defendants individually moved to dismiss all claims and the district court granted the motions. On appeal, Plaintiff challenged the district court’s determinations that she failed to plausibly allege: (1) deliberate indifference to serious medical needs against Dr. Myers; (2) municipal liability against Turn Key and Sheriff Regalado; and (3) violation of the Equal Protection clause against Turn Key and Sheriff Regalado. She also challenged the finding that Dr. Myers and Turn Key were entitled to immunity for the state law claims under the Oklahoma Governmental Tort Claims Act (“OGTCA”). The Tenth Circuit found it would need to determine the OGTCA's applicability to private corporations (and their employees) that contract with the state to provide medical services at the summary judgment stage if the factual record is sufficiently developed and the facts are uncontroverted. Accordingly, the Court reversed as premature the district court’s decision that Turn Key and Dr. Myers were immune under the OGTCA. The Court affirmed in all other respects. View "Lucas v. Turn Key Health Clinics, et al." on Justia Law

Employer Howard Center appealed a trial court order that confirmed an arbitration award in favor of grievant Daniel Peyser and AFSCME Local 1674. In May 2019, employer expressed concern over grievant’s billing practices, specifically, his submission of billing paperwork in May for services provided in April. Employer told grievant that it was considering disciplining him for “dishonesty and unethical action” concerning the backdated bills. Grievant brought two billing notes from patient records to show that other employees engaged in the same billing practices. Employer did not reprimand grievant for the billing practices. In August 2019, however, employer informed grievant that he breached employer’s confidentiality policy by sharing the billing notes with his union representative at the June meeting. Employer issued a written reprimand to grievant. The reprimand stated that sharing client records without redacting confidential information violated protocols and state and federal regulations, and that grievant knew or should have known of these standards. Employer also explained that it was required to report the breach to state and federal authorities and to those individuals whose records were disclosed. Grievant filed a grievance under the terms of his collective-bargaining agreement, arguing in part that employer lacked just cause to discipline him. In an October 2020 decision, the arbitrator sustained the grievance. Employer then filed an action in the civil division seeking to modify or vacate the arbitrator’s award, arguing in relevant part that the arbitrator manifestly disregarded the law in sustaining the grievance. Employer asked the Vermont Supreme Court to adopt “manifest disregard” of the law as a basis for setting aside the arbitration award and to conclude that the arbitrator violated that standard here. The Supreme Court did not decide whether to adopt the manifest-disregard standard because, assuming arguendo it applied, employer failed to show that its requirements were satisfied. The Court therefore affirmed. View "Howard Center v. AFSCME Local 1674, et al." on Justia Law

The First Circuit affirmed the judgment of the district court determining that Act 90, passed by the Legislative Assembly of Puerto Rico in 2019, was preempted by federal law, holding that the district court did not err.Act 90 requires that Medicare Advantage plans compensate Puerto Rico healthcare providers in Puerto Rico at the same rate as providers are compensated under traditional Medicare. Plaintiffs, several entities that managed Medicare Advantage plans, filed suit seeking a declaratory judgment and an injunction barring the "mandated price provision," arguing that the Medicare Advantage Act preempted the challenged provision and that provision was unconstitutional. The district court ruled in favor of Plaintiffs. The First Circuit affirmed, holding that Act 90's mandated price provision was preempted by federal law. View "Medicaid & Medicare Advantage Products Ass'n of Puerto Rico, Inc. v. Emanuelli-Hernandez" on Justia Law

Plaintiff Lancaster Hospital Corporation (Lancaster) operates an inpatient rehabilitation facility that provides services for Medicare beneficiaries. The Department of Health and Human Services (HHS) denied Plaintiff’s request for reimbursement because the provider failed to submit information in a form that could be audited. The district court granted summary judgment to HHS.   The Fourth Circuit affirmed. The court explained that Lancaster asserts that—even if some reductions were warranted—the Board erred by denying its entire 1997 reimbursement request. There appears no doubt Lancaster provided services to Medicare beneficiaries in 1997, and denying all reimbursement for that year may seem harsh. But the principle that people “must turn square corners when they deal with the Government” “has its greatest force when a private party seeks to spend the Government’s money.” However, the court explained that under Heckler v. Community Health Servs. of Crawford Cnty., Inc., “As a participant in the Medicare program,” Lancaster “had a duty to familiarize itself with the legal requirements for cost reimbursement,” including the need to provide cost data in a form “capable of being audited.” Thus, the Board’s decision to deny reimbursement for the fiscal year 1997 was neither arbitrary nor capricious and was supported by substantial evidence. View "Lancaster Hospital Corporation v. Xavier Becerra" on Justia Law

A.M. fatally shot her husband in May 2010 and was convicted of first-degree murder and a weapons offense. In March 2021, following diagnoses of end-stage multiple sclerosis by two physicians, the Commissioner of the Department of Corrections issued a Certificate of Eligibility for Compassionate Release for A.M. A.M. filed a petition with the court, which the State opposed. The State advised the court that A.M.’s children intended to testify against her release at a hearing, as did the victim’s mother. The trial court denied A.M.’s petition for release. The court found that A.M.’s remaining period of parole ineligibility did not bar compassionate release under the Compassionate Release Act (CRA); that A.M. had established by clear and convincing evidence that she had a “permanent physical incapacity” within the meaning of the Act; and that conditions of release “likely could be established” to assure that she “would not pose a risk to public safety.” The trial court, however, concluded that compassionate release was not mandatory when those conditions were met. The Appellate Division reversed, holding that once those factors are met, a trial court has no discretion to deny relief. In 1993, Eddie Oliver, now Al-Damany Kamu, shot and killed a detective in a courthouse to prevent him from testyfying in a criminal case. Defendant shot and wounded two other officers, attempted to kill a third official, and planned to kill the judge, He was convicted of first-degree murder and three counts of attempted murder. The Department of Corrections issued a Certificate of Eligibility for Compassionate Release for Kamau in November 2021. The State and the victims opposed release. Based on the text of the new statute and its legislative history, the New Jersey Supreme Court concluded the Compassionate Release Act afforded judges discretion to deny relief, in exceptional circumstances, even if the law’s medical and public safety conditions are satisfied. In individual cases, when the medical and public safety factors are met, courts can assess whether extraordinary aggravating factors exist that justify the denial of compassionate release. Absent any such circumstances, petitions for relief should be granted. The Court found the record in A.M.'s case did not present extraordinary aggravating circumstances. The Court therefore modified and affirmed the Appellate Division's judgment to release A.M. The appeal in Oliver/Kamu involved the kind of extraordinary aggravating circumstances that justified denying relief. The Court modified and affirmed the trial court's judgment denying defendant's petition for release. View "New Jersey v. A.M." on Justia Law

Lawsuits brought by governmental bodies and health clinics alleged that Quest, a wholesale pharmaceutical distributor, engaged in misconduct that contributed to a nationwide epidemic of opioid abuse. The plaintiffs plead violations of the RICO Act and state statutes, common law public nuisance, and negligence, seeking damages for “significant expenses for police, emergency, health, prosecution, corrections, rehabilitation, and other services.” Some complaints clarify that the claims “are not based upon or derivative of the rights of others” and that the plaintiffs “do not seek damages for death, physical injury to person, emotional distress, or physical damages to property[.]”Quest's insurance policies covered "damages because of 'bodily injury' or 'property damage'" and explain that “[d]amages because of ‘bodily injury’ include damages claimed by any person or organization for care, loss of services or death resulting at any time from the ‘bodily injury.’” “Bodily injury” is defined as “bodily injury, sickness or disease sustained by a person, including death resulting from any of these at any time.”The insurers sought declaratory judgments that they had no duty to defend or indemnify Quest. The district court granted the insurers summary judgment. The Sixth Circuit affirmed. Based on the plain language of the policies and their overall context and purpose, the court concluded that the Kentucky Supreme Court would find that the insurers have no duty to defend because the lawsuits do not seek damages “because of bodily injury” and claim only economic damages. View "Westfield National Insurance Co. v. Quest Pharmaceuticals, Inc." on Justia Law

The Supreme Court held that the Texas Insurance Code does not authorize a private cause of action by a physician against an insurer for payment of claims that accrued prior to 2020 and that Plaintiffs' claims for recovery in quantum merit and for unfair settlement practices failed as a matter of law.In each of the consolidated cases before the Supreme Court, Plaintiffs, groups of emergency medicine doctors outside of an insurer's provider network, brought suit against Defendant, the insurer, alleging that it did not pay them at the usual and customary rates for treating its insureds. Defendant moved for dismissal under Fed. R. Civ. P. 12(b)(6) for failure to state a claim. The district court granted the motion with respect to Plaintiff's implied contract and quantum merit claims and with respect to claims brought under the Emergency Care Statutes. On appeal, the court of appeals certified a question to the Supreme Court. The Supreme Court held (1) the Insurance Code does not create a private cause of action for claims under the Emergency Care Statutes; and (2) with respect to one case, the lower courts did not err in dismissing Plaintiffs' quantum merit and unfair settlement practices claims. View "Texas Medicine Resources, LLP v. Molina Healthcare of Texas, Inc." on Justia Law

The 1949 Federal Property and Administrative Services Act concerns the purchase of goods and services on behalf of the federal government, 40 U.S.C. 101. In November 2021, the Safer Federal Workforce Task Force, citing the Act, issued a “Guidance” mandating that employees of federal contractors in covered contracts with the federal government become fully vaccinated against COVID-19. Ohio, Kentucky, and Tennessee and Ohio sheriffs’ offices challenged the mandate. The district court enjoined its enforcement in the three states and denied the government’s request to stay the injunction pending appeal.The Sixth Circuit denied relief in January 2022 and, a year later, affirmed. The Property Act does not authorize the President to issue directives that simply “improve the efficiency of contractors and subcontractors.” The plaintiffs are likely to succeed in showing that the President exceeded his authority in issuing the mandate. The plaintiffs are likely to lose valuable government contracts and incur unrecoverable compliance costs if the mandate is not enjoined. The public interest “lies in a correct application” of the law. Because an injunction limited to the parties can adequately protect the plaintiffs’ interests while the case is pending, the district court abused its discretion in extending the preliminary injunction’s protection to non-party contractors in the plaintiff states. View "Commonwealth of Kentucky v. Biden" on Justia Law

The Washington State Health Care Authority (“HCA”) and the Swinomish Indian Tribal Community petition for review of a Center for Medicare and Medicaid Services (“CMS”) decision denying Washington’s request to amend Apple Health, the Washington State Medicaid plan (the “State Plan”). HCA petitioned CMS to amend the State Plan to include dental health aide therapists (“DHATs”) on the list of licensed providers who can be reimbursed through Medicaid. CMS rejected the Amended State Plan on the basis that it violates the Medicaid free choice of providers statute and regulation guaranteeing all Medicaid beneficiaries equal access to qualified healthcare professionals willing to treat them. Petitioners challenged this denial.   The Ninth Circuit granted the petition of review. The panel rejected CMS’s reasoning on the ground that the underlying Washington statute—Wash. Rev. Code Section 70.350.020—did not violate Section 1396(a)(23) because it merely authorized where and how DHATs can practice and did not in any way restrict Medicaid recipients’ ability to obtain service from DHATs relative to non-Medicaid recipients. CMS’s rejection of the Amended State Plan was “not in accordance with law.” 5 U.S.C. Section 706(2)(A). Accordingly, the panel granted the petition for review and remanded to the agency with instructions to approve the Amended State Plan. View "WASHINGTON STATE HEALTH CARE A, ET AL V. CENTERS FOR MEDICARE & MEDICAI, ET AL" on Justia Law