Justia Health Law Opinion Summaries

Dr. Paulus was prosecuted for healthcare fraud. Government consultants reviewed 496 of Paulus’s procedures and concluded that 146 (about 30%) were unnecessary. King’s Daughters Medical Center (KDMC) consultants also reviewed a random selection of Paulus’ procedures. Three experts at trial concluded that Paulus overstated his patients’ arterial blockage and inserted medically unnecessary stents. A jury convicted Paulus. After remand, before sentencing, the government disclosed to Paulus for the first time the “Shields Letter,” stating that when KDMC faced previous legal trouble, it hired independent experts to review 1,049 of Paulus’s cases; they flagged about 7% of his procedures as unnecessary. The defense viewed this evidence as exculpatory and consistent with diagnostic differences of opinion. Before trial, the district court had held that the information was inadmissible and that the parties “[we]re not to disclose” any information about the KDMC Review to Paulus.The Sixth Circuit vacated Paulus’s convictions and remanded, finding that the Shields Letter was material to Paulus’s defense and that failure to disclose it violated Paulus’s “Brady” rights. On remand, the government subpoenaed KDMC for additional information regarding the study referenced in the Shields Letter. KDMC objected, citing the attorney-client, work-product, and settlement privileges. The government filed a motion to compel, which was granted. KDMC sought a writ of mandamus. The Sixth Circuit denied KDMC’s petition. KDMC’s disclosure of some information regarding its experts’ study waived its privilege over the related, undisclosed information now being sought. View "In re: King's Daughters Health System, Inc." on Justia Law

Plaintiff, a hospice provider, challenges the Centers for Medicare and Medicaid Services (“CMS”) methodology, contending that it violates both the Medicare statute and the Budget Control Act and that CMS did not follow the required administrative procedures for adopting it.According to Plaintiff, the sequestration methodology violated the statute and the regulation by adding back the sequestration reduction withheld from the preliminary disbursements into the equation, such that — for overpayment purposes — funds the providers did not actually receive were being counted against them. Plaintiff contends that CMS was required to use the net payments methodology instead of the sequestration methodology.The court held that the regulations and guidance do not support Plaintiff’s contention that the statute unambiguously requires the net payments methodology. Reasoning that section 1395f(i)(2)(A) does not mandate any one methodology for applying the aggregate cap. Further, the plain meaning of the statute gives no instruction as to how overpayments should be calculated, the court concludes the statute is “silent . . . with respect to the specific issue” of what methodology CMS must use in applying the aggregate cap. Further, because the Secretary’s chosen methodology comports with the statutory text, purpose, and operation, Plaintiff has not shown that the Board’s decision was “arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law.” Thus, the court affirmed the district court’s grant of summary judgment to the Secretary and denial of summary judgment to Plaintiff. View "Gentiva Health Services, Inc. v. Becerra" on Justia Law

Plaintiff sued Adventist Health System/West and Hanford Community Hospital (collectively, Hospital), for a violation of the Consumer Legal Remedies Act (CLRA; Civ. Code, Sec. 1750 et seq.) and declaratory relief.Plaintiff received emergency treatment and services at Hospital’s emergency room in Hanford. The emergency room did not contain a posted notice or warning that a substantial EMS Fee would be added to Plaintiff’s bill on top of the individual charges for each item of treatment and services provided to her. Plaintiff alleged Hospital engaged in a deceptive practice when it did not disclose its intent to charge her a substantial emergency room EMS Fee.Hospital moved for judgment on the pleadings, which the trial court granted. The court found that although Plaintiff’s pleading adequately alleges Hospital failed to disclose facts that were known exclusively by Hospital and were not reasonably accessible to Plaintiff, the court concluded Plaintiff’s conclusory allegation that she relied on the failure to disclose the EMS Fee and thereafter received treatment at the Hospital does not plead the element of reliance with sufficient particularity.In an unpublished part of the opinion, the court concluded Plaintiff has not carried her burden of demonstrating the trial court erred when it denied her leave to file a third amended complaint. Thus, the court affirmed the judgment. View "Torres v. Adventist Health System/West" on Justia Law

The Supreme Court reversed the order of the circuit court enjoining the enforcement of the Bentonville School District's mask policy in favor of Plaintiffs, parents of school children, holding that the the circuit court abused its discretion in granting Plaintiffs' motion for a temporary restraining order (TRO).In granting the TRO, the circuit court concluded that the school policy at issue violated Plaintiffs' right under Ark. Const. art. II, 21 and 29 to care for their children and that the District lacked the authority to issue the mask policy. The Supreme Court reversed, holding that (1) the circuit court abused its discretion in finding that the policy violated Plaintiffs' constitutional rights and was enacted without proper authority; and (2) Plaintiffs failed to show that irreparable harm would result in the absence of a TRO. View "Bentonville School District v. Sitton" on Justia Law

Plaintiff filed a lawsuit in state court, alleging state law claims arising from SelectHealth’s administration of her deceased husband’s Medicare Advantage ("MA") plan and his death. SelectHealth removed the action to federal court on the basis of diversity jurisdiction.The court first considered whether Plaintiff’s claims must be exhausted through the Medicare Act’s administrative review scheme. The court concluded that Plaintiff’s claims were not subject to the SSA’s exhaustion requirement because the dispute was not whether Plaintiff’s husband received a favorable outcome from the internal benefits determination process but rather whether he should have received the services earlier.Next, the court held that Plaintiff’s claim that SelectHealth breached a duty to process her husband’s October 7, 2016 appeal was expressly preempted. The court reasoned that the Medicare Act preempted those claims, regardless of whether they would be inconsistent with federal regulations. The court also held that the Medicare Act also preempted Plaintiff’s claims based on SelectHealth’s alleged breach of duty to investigate properly her husband’s August 23, 2016 preauthorization request for consultation and testing at the Medical Center in Phoenix, Arizona.The court concluded that a state law claim based on a duty to process claims for benefit in a timely manner is preempted by the Part C regulations that set forth the timeframes for initial determinations and reconsideration decisions. The court affirmed the district court’s summary judgment in favor of SelectHealth because the Medicare Act’s express preemption provision barred her claims. View "NAOMI AYLWARD V. SELECTHEALTH, INC." on Justia Law

Johnson & Johnson, Ethicon, Inc., and Ethicon US, LLC (collectively, Ethicon) appealed after a trial court levied nearly $344 million in civil penalties against Ethicon for willfully circulating misleading medical device instructions and marketing communications that misstated, minimized, and/or omitted the health risks of Ethicon’s surgically-implantable transvaginal pelvic mesh products. The court found Ethicon committed 153,351 violations of the Unfair Competition Law (UCL), and 121,844 violations of the False Advertising Law (FAL). The court imposed a $1,250 civil penalty for each violation. The Court of Appeal concluded the trial court erred in just one respect: in addition to penalizing Ethicon for its medical device instructions and printed marketing communications, the court penalized Ethicon for its oral marketing communications, specifically, for deceptive statements Ethicon purportedly made during one-on-one conversations with doctors, at Ethicon-sponsored lunch events, and at health fair events. However, there was no evidence of what Ethicon’s employees and agents actually said in any of these oral marketing communications. Therefore, the Court of Appeal concluded substantial evidence did not support the trial court’s factual finding that Ethicon’s oral marketing communications were likely to deceive doctors. Judgment was amended to strike the nearly $42 million in civil penalties that were imposed for these communications. View "California v. Johnson & Johnson" on Justia Law

Global Rescue Jets, which does business as Jet Rescue, billed Kaiser at Jet Rescue’s usual and customary rates. Kaiser paid only a fraction of the billed amount, however, because in its view Jet Rescue’s services were covered by Medicare and thus subject to payment at the much lower Medicare-approved rates. Jet Rescue brought this action against Kaiser to recover the additional sums Kaiser allegedly owes. Jet Rescue argues that it was not required to exhaust administrative remedies before filing suit and that the exhaustion requirement should have been excused in any eventThe circuit court affirmed the district court’s dismissal, reasoning original Medicare beneficiaries must exhaust their administrative remedies before seeking judicial review of a claim for benefits. The panel also rejected Jet Rescue’s contention that the exhaustion requirement should be excused. The panel held that the exhaustion requirement may be excused if three conditions are satisfied: (1) the plaintiff’s claim is wholly collateral to a claim for Medicare benefits; (2) the plaintiff has made a colorable showing of irreparable harm; and (3) exhaustion would be futile. The panel concluded that Jet Rescue failed to meet the first and third requirements. Thus, the circuit court rejected both arguments and affirmed the district court’s judgment. View "GLOBAL RESCUE JETS, LLC V. KAISER FOUNDATION HEALTH PLAN" on Justia Law

Appellant, a California critical access hospital, sought Medicare reimbursement for the cost of keeping specialty doctors on call. Under the federal Emergency Medical Treatment and Active Labor Act, hospitals providing emergency room service must stabilize patients before releasing them or transferring them to another hospital. Additionally, California law requires all hospitals to perform certain procedures, including surgery. Appellant claims that it cannot comply with both state and federal law unless it can pay on-call compensation to specialists in surgery, obstetrics, pediatrics, and cardiology.Affirming the district court’s ruling, the D.C. Circuit held that Appellant is not entitled to Medicare reimbursement for the cost of keeping various specialty doctors on call. Appellant’s federal obligation to stabilize patients before release does not necessarily imply the need for various specialists. Thus, the Provider Reimbursement Review Board (“the Board”) reasonably concluded that Appellant had the ability to stabilize patients with existing emergency room physicians and that specialists were not required to be on call.Regarding Appellant’s state obligations, the Board’s conclusion that Appellant could satisfy the requirements by keeping a physician with surgical training on-site was reasonable. View "St. Helena Clear Lake Hospital v. Xavier Becerra" on Justia Law

Under Michigan abortion law, a minor may bypass the parental-consent requirement by obtaining a court order granting the right to self-consent (for mature minors) or judicial consent (for “best interests” minors). When the plaintiff sought to apply for judicial bypass, the defendant hadn’t heard of the process and told the plaintiff to come back later. Plaintiff sued the defendant in her individual and official capacities under 42 U.S.C. § 1983, alleging that defendant’s refusal to allow her to apply for a judicial bypass without parental notification violated her Fourteenth Amendment rights. The district court denied the motion when the defendant moved for summary judgment, invoking quasi-judicial and qualified immunity.Before the Eighth Circuit, the defendant claimed she acted at the direction of the Associate Circuit Judge (“Judge”). The Judge testified that he did not recall telling the defendant not to accept the application without parental consent. The circuit court concluded there was a genuine issue of material fact regarding the Judge’s practice of giving pre-filing directions. Further, the is a clearly established right to apply for a judicial bypass. Thus the circuit court declined to address the defendant’s other arguments regarding qualified immunity. View "Jane Doe v. Michelle Chapman" on Justia Law

The Supreme Court reversed the judgment of the trial court denying ResCare Health Service's request for a declaratory judgment, holding that ResCare sufficiently pleaded its declaratory judgment request.ResCare, which operates intermediate care facilities in Indiana for individuals with intellectual disabilities, petitioned for administrative reconsideration after an auditor with the Indiana Family & Social Services Administration’s Office of Medicaid Policy and Planning (FSSA) adjusted cost reports to prevent ResCare from recovering costs for over-the-counter medicines under Medicaid. An ALJ granted summary judgment for ResCare. The trial court affirmed the agency's final decision. The Supreme Court reversed, holding (1) ResCare did not need to file a separate complaint for a declaratory judgment; (2) ResCare sufficiently pleaded its declaratory judgment claim; and (3) ResCare's patients did not have to be joined to the litigation before the declaratory judgment request could be considered. View "ResCare Health Services Inc. v. Indiana Family & Social Services Administration" on Justia Law