Justia Health Law Opinion Summaries

In a suit under the False Claims Act (FCA), Proctor alleged that Safeway knowingly submitted false claims to government health programs when it reported its “retail” price for certain drugs as its “usual and customary” price, although many customers paid less than the retail price because of discount and price-matching programs. The district court granted Safeway summary judgment, concluding that Safeway’s pricing practices were “objectively reasonable” and no “authoritative guidance” cautioned against its interpretation of Medicare and Medicaid regulations.While the case was pending, the Seventh Circuit held that a defendant does not act with reckless disregard as long as its interpretation of the relevant statute or regulation was objectively reasonable and no authoritative guidance warned the defendant away from that interpretation. Failure to satisfy that standard for reckless disregard precludes liability under FCA’s actual knowledge and deliberate indifference provisions, which concern higher degrees of culpability.The Seventh Circuit then affirmed summary judgment in favor of Safeway. A footnote in a Centers for Medicare and Medicaid (CMS) manual does not constitute “authoritative guidance.” CMS can (and did) revise the manual at any time, and a single footnote in a lengthy manual does not support treble damages liability in this case. The other sources of guidance Proctor identified are unpersuasive because they do not come from the agency. View "Proctor v. Safeway, Inc." on Justia Law

Relators brought qui tam claims against dozens of defendants alleging healthcare fraud against the federal government in April 2017. H.I.G. Capital, LLC and H.I.G. Surgery Centers, LLC (“H.I.G.”) were among the defendants. Plaintiffs amended their complaint in January 2019.Previously, another group of relators filed qui tam claims against several of the same defendants; however, they did not name H.I.G. in their initial complaint. The federal government intervened, resulting in a $41 million settlement which included the defendants and both sets of relators. The settlement agreement released H.I.G. insofar as any independent conduct outside their status as investors in or owners of the defendants included in the settlement. Relators then amended their complaint a second time, narrowing their allegations to focus only on H.I.G.The district court granted H.I.G.’s motion to dismiss based on the first-to-file rule. The district court determined that, because the settled claim was pending at the time Relators filed their initial complaint, Relators’ complaint was barred if the actions were related. The district court found the cases were related and dismissed Relators’ claims.The Eleventh Circuit affirmed. Relators filed their complaints while the action that was eventually settled was pending. Thus, Relators’ case must be dismissed if the actions were related. The court then adopted the “same material elements” test relied upon by other circuit courts. Finding that the two cases contained the same material elements of fraud, the court concluded the district court properly dismissed Relators’ claims. View "Sheldon Cho, et al v. H.I.G. Capital, LLC, et al" on Justia Law

In 2012, United Healthcare of Mississippi (United) entered into provider agreements with Mississippi’s fourteen Community Mental Health Centers (CMHCs) to provide Medicaid services under the Division of Medicaid’s (DOM’s) managed care program. From 2012 until 2019, United paid the CMHCs an agreed upon amount for Medicaid services - 100 percent of the medicaid fee schedule rates. In July 2019, United unilaterally imposed a 5 percent rate cut, retroactive to January 1, 2019, and later demanded that the CMHCs refund 5 percent of all payments made from July 1, 2018, through December 31, 2018, all of which totaled more than $1 million. The CMCHs demanded that United immediately cease and desist from the 5 percent rate cut and recoupments. When United refused, the CMHCs filed a Complaint for Damages and Injunctive Relief, specifically requesting, inter alia, a preliminary injunction. United responded with a motion to compel arbitration and to stay the proceedings. After a two-day evidentiary hearing, the circuit court denied United’s motion to compel arbitration, granted the CMHCs’ request for injunctive relief, and issued a preliminary injunction. The limited issues presented to the Mississippi Supreme Court were whether the trial court properly enjoined United from imposing a 5 percent rate cut and whether the trial court erred by denying arbitration. After review, the Supreme Court affirmed the trial court’s decision to grant a preliminary injunction and to deny the motion to compel arbitration. View "United Healthcare of Mississippi Inc. et al. v. Mississippi's Community Mental Health Commissions, et al." on Justia Law

The Supreme Court affirmed the judgment of the circuit court determining that James Bruggeman was a vulnerable adult and finding by a preponderance of the evidence that Jennifer Ramos neglected and financially exploited Bruggeman while she was a caretaker and was entrusted with his property, holding that there was no error.Specifically, the Supreme Court held that the circuit court (1) did not abuse its discretion when it quashed the subpoena for Bruggeman to testify; (2) did not err in determining that Bruggeman was a vulnerable adult under S.D. Codified Laws 21-65-1(15); (3) did not err when it found that Bruggeman was the victim of financial exploitation; and (4) did not err when it ordered Ramos to pay Black Hills Advocate’s attorney fees. View "Bruggeman v. Ramos" on Justia Law

The Supreme Court affirmed the judgment of the court of appeals affirming the decision of the circuit court to overturn a final order of the Secretary of the Cabinet for Health and Family Services dismissing an administrative action against Appalachian Hospice Care, Inc., holding that there was no error.At issue on appeal was whether the Secretary erred in concluding that a non-lawyer's request for an administrative hearing on behalf of a corporate entity constitutes the unauthorized practice of law requiring dismissal of the administrative action. The lower courts answered the question in the negative. The Supreme Court affirmed, holding that there was no unauthorized practice of law in this case. View "Cabinet for Health & Family Services v. Appalachian Hospice Care, Inc." on Justia Law

The Supreme Court affirmed the order of the circuit court denying Petitioner's motion to compel arbitration, holding that the circuit court did not err.Respondents Louise McGraw and Charlotte Rodgers, by and through their daughters, Nancy Reuschel and Loretta Holcomb, filed a complaint against Petitioner, Chancellor Senior Management, Ltd., arguing that Petitioner defrauded their mothers by making misrepresentations and misleading statements and concealing material facts, in violation of the West Virginia Consumer Credit and Protection Act (WVCCPA). See W. Va. Code 46A-1-101 to -8-102. Petitioner filed a motion to compel arbitration based on an arbitration provision set forth in the residency agreement Reuschel and Holcomb signed on behalf of their motions. The circuit court denied the motion, concluding that the agreement could not be enforced as written. The Supreme Court affirmed, holding that the circuit court did not err in determining that the arbitration agreement could not be enforced as written because it did not "comply with its own stated standards." View "Chancellor Senior Management, Ltd. v. McGraw" on Justia Law

Englewood, a non-profit corporation with a single community hospital in Bergen County, New Jersey, provides primary, secondary, and some non-complex tertiary services to patients. It lacks the expertise, regulatory approvals, and facilities to provide more complex tertiary and quaternary services. Hackensack, New Jersey's largest hospital system, has multiple academic medical centers, community hospitals, specialty hospitals, a medical school, and a research institution, including two hospitals in Bergen County.The Federal Trade Commission opposes a merger between Englewood and Hackensack and filed an administrative complaint citing the Clayton Act, 15 U.S.C. 18. To prevent the parties from merging before the administrative adjudication, the FTC filed suit under Section 13(b) of the Federal Trade Commission Act. The Third Circuit affirmed the entry of a preliminary injunction. The FTC established that there is a reasonable probability that the merger will substantially impair competition. The court upheld the district court’s acceptance of the FTC’s proposed relevant geographic market defined by all hospitals used by commercially insured patients residing in Bergen County; price discrimination is not a prerequisite for a patient-based market. The district court did not err in finding that there would be a significant price impact and any benefits that would result from the merger did not offset anticompetitive concerns. View "Federal Trade Commission v. Hackensack Meridian Health Inc" on Justia Law

Under the “individual mandate” within the Patient Protection and Affordable Care Act of 2010, non-exempt individuals must either maintain a minimum level of health insurance or pay a “penalty,” 26 U.S.C. 5000A, the “shared responsibility payment” (SRP). The McPhersons did not maintain health insurance for part of 2017, and Juntoff did not maintain health insurance in any month in 2018. They did not pay their SRP obligations. In each of their Chapter 13 bankruptcy cases, the IRS filed proofs of claim and sought priority treatment as an “excise/income tax”: for Juntoff, $1,042.39, and for the McPhersons, $1,564.The bankruptcy court confirmed their plans, declining to give the IRS claims priority as a tax measured by income. The Bankruptcy Appellate Panel reversed. DIstinguishing the Sebelius decision in which the Supreme Court determined that the SRP constituted a “penalty” for purposes of an Anti-Injunction Act analysis and a “tax” under a constitutionality analysis, the Panel concluded that the SRP is not a penalty but a tax measured by income. It is “calculated as a percentage of household income, subject to a floor based on a specified dollar amount and a ceiling based on the average annual premium the individual would have to pay for qualifying private health insurance.” View "In re: Juntoff" on Justia Law

A putative class of medical providers sued, alleging a conspiracy to drive up the prices of syringes and safety IV catheters (Products). Their first complaint, alleging a hub‐and‐spokes conspiracy ( Sherman Act, 15 U.S.C. 1) between manufacturer, BD, group purchasing organizations, and four distributors, was dismissed because the Providers failed to allege that the distributors coordinated with each other in furtherance of the conspiracy. In an amended complaint, the Providers abandoned their horizontal conspiracy allegations and alleged two vertical conspiracies, one between BD and McKesson and another between BD and Cardinal Health.The district court dismissed, noting that because the named plaintiffs do not purchase the Products directly from Cardinal, they lack “antitrust standing” to sue Cardinal. The Seventh Circuit affirmed. . The Providers cannot sue Cardinal under Article III because their injury is not fairly traceable to Cardinal’s conduct; precedent precludes the suit because they do not purchase the Products from either member of the BD‐Cardinal conspiracy. The Providers did not plausibly establish that vertical conspiracies involving just two distributors and BD could influence the prices that the Providers pay, regardless of which distributor they purchase from, and regardless of the fact that there are at least four major distributors. View "Marion Diagnostic Center, LLC v. Becton Dickinson & Co." on Justia Law

The Fifth Circuit affirmed the district court's grant of summary judgment in favor of the HHS Defendants in an action challenging HHS's risk-adjustment program, implemented under the Patient Protection and Affordable Care Act (ACA), and repromulgation of the 2017 and 2018 rules. In this case, Vista Health Plan, a health insurance company in Texas, was assessed risk-adjustment fees that exceeded its premium revenue, causing the company to cease operations.After determining that it has jurisdiction over the appeal, the court concluded that the 2017 and 2018 Final Rules adopted by HHS were not impermissibly retroactive under Landgraf v. USI Film Prods., 511 U.S. 244, 268 (1994). The court also concluded that HHS's failure to follow the Administrative Procedure Act's notice-and-comment procedures in its repromulgation of the 2017 Final Rule was at worst harmless error. Rather, the new rule actually maintained the settled expectations of insurers covered by the previous version of the rule. Finally, the court concluded that Vista's other issues on appeal regarding the administrative record before the district court, Chevron deference as to HHS's interpretation of the governing law, and the district court's "sua sponte" summary judgment on Vista's regulatory taking claim lack merit. View "Vista Health Plan, Inc. v. United States Department of Health and Human Services" on Justia Law