Justia Government & Administrative Law Opinion Summaries

Several skilled nursing facilities challenged the State Department of Health Care Services and its director, Michelle Baass, over the formula used to calculate Medi-Cal reimbursement overpayments. The plaintiffs argued that the Department's method, which was based on the amount Medicare paid for ancillary services rather than the amount Medi-Cal overpaid, violated a ministerial duty and constituted an underground regulation.The trial court sustained the Department's demurrer without leave to amend, concluding that the plaintiffs' claim was not cognizable in a traditional writ of mandate proceeding. The court also found that the plaintiffs failed to state a claim that the Department violated a ministerial duty or adopted an underground regulation. Additionally, the trial court denied the plaintiffs' motion to compel discovery of certain documents, deeming them privileged.The California Court of Appeal, Third Appellate District, reviewed the case. The court determined that some of the plaintiffs' claims were indeed cognizable in a traditional writ of mandate proceeding and that the petition stated a claim for relief regarding the Department's use of an underground regulation when calculating Medi-Cal reimbursement overpayments. However, the court found that the plaintiffs did not provide an adequate record to review whether the trial court erred in denying their motion to compel discovery.The appellate court reversed the judgment of dismissal and affirmed the trial court's order denying the plaintiffs' motion to compel. The case was remanded to the trial court with instructions to vacate its order sustaining the Department's demurrer without leave to amend and to enter a new order overruling the demurrer. The plaintiffs were awarded their costs on appeal. View "California Healthcare & Rehabilitation Center v. Baass" on Justia Law

The case involves the U.S. Centers for Medicare & Medicaid Services (CMS) approving the New York State Department of Health’s (NYSDOH) application to distribute $361.25 million to certain managed care organizations. These organizations were to direct the funds to the top one-third of revenue-generating licensed home care services agencies (LHCSAs) in New York’s four rate regions, provided they agreed to use the funding in a specified manner. The plaintiffs, who are LHCSAs that did not meet the revenue threshold, argued that the approval was unlawful under federal law and regulations because the class of eligible agencies was improperly defined and the application was not assessed for actuarial soundness before approval.The district court dismissed the amended complaint against the State Appellees for failing to adequately allege a cause of action under Ex parte Young and granted summary judgment to the Federal Appellees. The court concluded that the approval of the State’s application did not violate the Administrative Procedure Act (APA) and denied the plaintiffs’ motion to admit extra-record evidence.The United States Court of Appeals for the Second Circuit reviewed the case and agreed with the district court’s decision. The court held that CMS’s approval of NYSDOH’s application complied with federal law. It found that the provider class was properly defined under 42 C.F.R. § 438.6(c)(2)(ii)(B) and that CMS was not required to assess actuarial soundness during the pre-approval process. The court also concluded that CMS did not act arbitrarily or capriciously in approving the application and that the district court did not abuse its discretion in excluding the extra-record evidence. Consequently, the Second Circuit affirmed the judgment of the district court. View "Safe Haven Home Care, Inc. v. United States Department of Health and Human" on Justia Law

In November 2021, Lincoln Medical administered a COVID-19 vaccine to the five-year-old child of Jeremiah Hogan and Siara Jean Harrington at a school clinic without obtaining parental consent. Hogan filed a notice of claim in the Superior Court against the doctor, Lincoln Medical Partners, and MaineHealth, Inc., alleging various torts including professional negligence, battery, and false imprisonment on behalf of the child, and emotional distress and tortious interference with parental rights on behalf of the parents.The Superior Court appointed a chair for the prelitigation screening panel, and Lincoln Medical moved to dismiss the notice of claim, citing immunity under the federal Public Readiness and Emergency Preparedness (PREP) Act. The court granted the motion to dismiss, interpreting the PREP Act to provide immunity to the defendants with no applicable exceptions. Hogan appealed the decision.The Maine Supreme Judicial Court reviewed the case and affirmed the Superior Court's judgment. The court held that the PREP Act provides broad immunity to covered persons, including individuals and corporations, from suits related to the administration of covered countermeasures, such as the COVID-19 vaccine. The court found that the federal statute preempts state law that would otherwise allow Hogan to sue, as the claims were directly related to the administration of the vaccine. The court concluded that the defendants were immune from Hogan’s claims under the PREP Act, and the state tort claims were preempted by federal law. View "Hogan v. Lincoln Medical Partners" on Justia Law

A hospital in Siskiyou County, California, filed a lawsuit against the County of Siskiyou and other defendants, challenging the practice of bringing individuals with psychiatric emergencies to its emergency department under the Lanterman-Petris-Short (LPS) Act. The hospital argued that it was not equipped or licensed to provide the necessary psychiatric care and sought to prevent the county from bringing such patients to its facility unless they had a physical emergency condition. The hospital also sought reimbursement for the costs associated with holding these patients.The Siskiyou County Superior Court denied the hospital's motion for a preliminary injunction, which sought to stop the county from bringing psychiatric patients to its emergency department. The court found that the hospital had not demonstrated a likelihood of success on the merits and that the burden on the county and the potential harm to the patients outweighed the hospital's concerns.The hospital's complaint included several causes of action, including violations of Medicaid laws, disability discrimination laws, mental health parity laws, and section 17000 of the Welfare and Institutions Code. The hospital also alleged breach of an implied-in-fact contract for the costs incurred in providing post-stabilization services to psychiatric patients. The trial court sustained demurrers to the complaint without leave to amend, finding that the hospital failed to identify any clear legal mandate that the county or the Department of Health Care Services had violated.The California Court of Appeal, Third Appellate District, affirmed the trial court's judgment of dismissal. The appellate court concluded that the hospital had not identified any mandatory and ministerial duty that the county or the department had violated, which is necessary to obtain a writ of mandate. The court also found that the hospital's breach of contract claim failed because there were no allegations of mutual consent to an implied contract. Consequently, the hospital's appeal from the denial of its motion for a preliminary injunction was dismissed as moot. View "Siskiyou Hospital v. County of Siskiyou" on Justia Law

Michael Chapman, an Alabama inmate, sued prison officials and staff for deliberate indifference to his medical needs, violating the Eighth Amendment. Chapman alleged that an untreated ear infection led to severe injuries, including mastoiditis, a ruptured eardrum, and a brain abscess. He also claimed that the prison's refusal to perform cataract surgery on his right eye constituted deliberate indifference. The district court granted summary judgment for all defendants except the prison’s medical contractor, which had filed for bankruptcy.The United States District Court for the Middle District of Alabama found Chapman’s claim against nurse Charlie Waugh time-barred and ruled against Chapman on other claims, including his request for injunctive relief against Commissioner John Hamm, citing sovereign immunity. The court also concluded that Chapman’s claims against other defendants failed on the merits and dismissed his state-law claims without prejudice.The United States Court of Appeals for the Eleventh Circuit reviewed the case. The court reversed the district court’s determination that Chapman’s claim against Waugh was time-barred, finding that Chapman’s cause of action accrued within the limitations period. The court vacated the district court’s judgment for Waugh and remanded for reconsideration in light of the recent en banc decision in Wade, which clarified the standard for deliberate indifference claims. The court also vacated the judgment for Hamm on Chapman’s cataract-related claim for injunctive relief, as sovereign immunity does not bar such claims. Additionally, the court vacated the summary judgment for all other defendants due to procedural errors, including inadequate notice and time for Chapman to respond, and remanded for further consideration. View "Chapman v. Dunn" on Justia Law

A medical doctor, employed by San Bernardino Medical Group and working for OptumCare Medical Group, faced a summary suspension of his clinical privileges by PrimeCare Medical Network, Inc. after a patient complaint. The patient alleged that the doctor hit her hand during an office visit, which the doctor admitted to in his notes, explaining it was to stop her from arguing. The next day, PrimeCare’s Chief Medical Officer (CMO) summarily suspended the doctor’s privileges, citing imminent danger to patient health.The Corporate Quality Improvement Committee (CQIC) upheld the suspension pending the doctor’s completion of an anger management course. The doctor requested a formal hearing, and PrimeCare’s Judicial Hearing Committee (JHC) found that the summary suspension was not warranted, as the incident was isolated and did not demonstrate imminent danger. The JHC recommended anger management and a chaperone for the doctor but did not find the suspension justified.PrimeCare’s Board of Directors reviewed the JHC’s decision, arguing it was inconsistent with the applicable burden of proof. The Board conducted an independent review, disagreed with the JHC’s findings, and reinstated the suspension, concluding that the doctor’s actions and subsequent comments posed an imminent threat to patients.The doctor filed a petition for writ of administrative mandamus, which the Superior Court of San Bernardino County granted. The court ruled that the Board exceeded its jurisdiction and committed a prejudicial abuse of discretion by independently reviewing and reversing the JHC’s decision. The court ordered the Board to adopt the JHC’s decision, reinstate the doctor’s privileges, and report the reinstatement to relevant entities.The California Court of Appeal, Fourth Appellate District, affirmed the trial court’s judgment, agreeing that the Board’s actions were unauthorized and inconsistent with the statutory requirement that peer review be performed by licentiates. View "Lin v. Board of Directors of PrimeCare Medical Network" on Justia Law

The case involves the United States government alleging that Regeneron Pharmaceuticals violated the Anti-Kickback Statute (AKS) by covering copayments for patients prescribed Eylea, a drug used to treat wet age-related macular degeneration. The government contends that this action induced doctors to prescribe Eylea, leading to Medicare claims that were "false or fraudulent" under the False Claims Act (FCA) because they "resulted from" the AKS violation.The United States District Court for the District of Massachusetts reviewed the case and agreed with Regeneron's interpretation that the phrase "resulting from" in the 2010 amendment to the AKS requires a but-for causation standard. This means that the government must prove that the AKS violation was the actual cause of the Medicare claims. The district court noted the conflict in case law and sought interlocutory review, which was granted.The United States Court of Appeals for the First Circuit affirmed the district court's ruling. The court held that the phrase "resulting from" in the 2010 amendment to the AKS imposes a but-for causation requirement. The court reasoned that the ordinary meaning of "resulting from" requires actual causality, typically in the form of but-for causation, unless there are textual or contextual indications to the contrary. The court found no such indications in the 2010 amendment or its legislative history. Therefore, to establish falsity under the FCA based on an AKS violation, the government must prove that the kickback was a but-for cause of the submitted claim. View "United States v. Regeneron Pharmaceuticals, Inc." on Justia Law

A medical institute and its co-director sought to provide patients with psilocybin, a schedule I controlled substance, for therapeutic use. They requested the Drug Enforcement Administration (DEA) to exempt the co-director from registration under the Controlled Substances Act (CSA) or to waive the registration requirement. The DEA declined both requests, leading the petitioners to seek judicial review.Previously, the petitioners had asked the DEA for guidance on accommodating the Right to Try Act (RTT Act) for psilocybin use. The DEA responded that the RTT Act did not waive CSA requirements, and the petitioners' initial judicial review was dismissed for lack of jurisdiction. The petitioners then made a concrete request to the DEA for exemption or waiver, which the DEA again denied, prompting the current appeal.The United States Court of Appeals for the Ninth Circuit reviewed the case. The court held that it had jurisdiction under 21 U.S.C. § 877 to review the DEA's final decision. The court found that the DEA's denial was not arbitrary and capricious. The DEA provided a reasonable explanation, stating that the RTT Act did not exempt the CSA's requirements and that the proposed use of psilocybin was inconsistent with public health and safety. The DEA also noted that the petitioners did not provide sufficient details for the proposed regulation. The court denied the petition for review, affirming the DEA's decision. View "ADVANCED INTEGRATIVE MEDICAL SCIENCE INSTITUTE, PLLC V. UNITED STATES DRUG ENFORCEMENT ADMIN" on Justia Law

A personal care assistant (PCA) in a Medicaid program was investigated for submitting inaccurate records of services provided. The investigation substantiated the allegations, and a committee within the overseeing agency decided to terminate her from the program. The PCA was notified and informed of her right to appeal. An administrative law judge (ALJ) recommended adopting the committee’s determination, which the agency did. The PCA appealed to the superior court, which affirmed the agency’s decision. The PCA then appealed, raising several issues.The superior court found the PCA’s Open Meetings Act claim untimely and concluded that the Administrative Procedures Act (APA) did not apply because the sanction procedures were interpretations of existing regulations. It also determined that the PCA had no property interest in future reimbursements from the program and that her liberty interest in her reputation was not implicated. The court found substantial evidence supported the agency’s findings and the termination sanction.The Supreme Court of Alaska reviewed the case. It concluded that the PCA’s Open Meetings Act claim was untimely and that the APA did not require the Department to promulgate new regulations for the sanctions committee. The court also found that the PCA had a protected liberty interest in her reputation but determined that she received due process through the hearing before the ALJ. The court held that substantial evidence supported the Department’s findings and that the sanctions imposed were reasonable. The Supreme Court of Alaska affirmed the superior court’s decision upholding the agency’s termination of the PCA. View "Thomason v. State" on Justia Law

Lisa Wheeler, a physician assistant and former Assistant Medical Director at Acadia Healthcare Company’s Asheville, North Carolina clinic, filed a complaint alleging that Acadia falsified medical records to claim payments from government healthcare programs. Wheeler claimed that Acadia, which provided methadone-assisted treatment for opioid use disorder, failed to provide required therapy and counseling services, instead fabricating therapy notes to submit fraudulent claims to Medicare, Medicaid, and other government programs.The United States District Court for the Western District of North Carolina dismissed Wheeler’s amended complaint, concluding that she failed to adequately plead that Acadia’s false claims were material or submitted to the government. The court found that Wheeler did not sufficiently allege that Acadia’s failure to provide therapy was material to the government’s payment decisions or that false claims were actually submitted to the government.The United States Court of Appeals for the Fourth Circuit reviewed the case and reversed the district court’s decision. The Fourth Circuit held that Wheeler adequately pled her claims of presentment, false statement, false certification, and fraudulent inducement under the False Claims Act. The court found that Wheeler’s allegations of falsified therapy notes and non-compliance with federal opioid treatment standards were material to the government’s payment decisions. The court also concluded that Wheeler sufficiently alleged that Acadia submitted false claims to government healthcare programs and that the fraudulent conduct was central to the government’s decision to pay.Additionally, the Fourth Circuit held that Wheeler adequately pled her reverse false claim, finding that the stipulated penalties in Acadia’s Corporate Integrity Agreement with the government constituted an obligation under the False Claims Act. The court remanded the case for further proceedings consistent with its opinion. View "United States ex rel. Wheeler v. Acadia Healthcare Company, Inc." on Justia Law