Justia Government & Administrative Law Opinion Summaries

A group of healthcare and air-ambulance providers challenged certain agency rules regarding the No Surprises Act, which aims to protect patients from unexpected medical bills. The key issues involved the calculation of the "qualifying payment amount" (QPA), deadlines for insurers to respond to provider bills, and disclosure requirements for insurers.The United States District Court for the Eastern District of Texas reviewed the case and held several provisions of the rules unlawful, vacating them. The court found that the rules conflicted with the Act's terms and were arbitrary and capricious. The defendant agencies appealed the decision regarding certain provisions, while the plaintiffs cross-appealed the court's upholding of the disclosure requirements.The United States Court of Appeals for the Fifth Circuit reviewed the case. The court reversed the district court's vacatur of the QPA calculation provisions, holding that the rules did not conflict with the Act and were not arbitrary and capricious. The court affirmed the district court's vacatur of the deadline provision, agreeing that it conflicted with the Act's unambiguous terms. The court also affirmed the district court's decision upholding the disclosure requirements, finding them reasonable and adequately explained.In summary, the Fifth Circuit reversed the district court's decision on the QPA calculation provisions, affirmed the vacatur of the deadline provision, and upheld the disclosure requirements. The court concluded that the proper remedy for the unlawful deadline provision was vacatur, not remand, and rejected the idea of party-specific vacatur. View "Texas Medical Association v. Health and Human Services" on Justia Law

The case involves Amaka Oji and Oji Fit World, LLC (OFW), who were approved as Medicaid providers by the D.C. Department of Health Care Finance (DHCF) in 2011. Between 2012 and 2015, they submitted over 24,000 claims for reimbursement for wellness services provided to Medicaid beneficiaries. Investigations by DHCF, the Office of the Inspector General for the Centers for Medicare and Medicaid Services, and the FBI revealed that Oji and OFW regularly overbilled Medicaid, often charging for a full hour of service regardless of the actual time spent or whether the service was provided at all.The District of Columbia filed a lawsuit in April 2021 under the D.C. False Claims Act and the common law doctrine of unjust enrichment. The Superior Court of the District of Columbia granted summary judgment in favor of the District, finding that Oji and OFW had submitted false claims and falsified records. The court awarded the District $1,001,362.50 in treble damages and $497,000 in civil penalties. Oji and OFW's various procedural defenses, including claims of laches and statute of limitations, were deemed waived due to their failure to raise them in a timely manner.The District of Columbia Court of Appeals reviewed the case and affirmed the summary judgment order. However, the court remanded the case for further consideration of the damages and penalties. The appellate court found that the Superior Court had not provided sufficient explanation or analysis for the awarded amounts, making it difficult to review the decision. The appellate court emphasized the need for the trial court to explain its reasoning in detail to permit adequate appellate review. View "Oji Fit World, LLC v. District of Columbia" on Justia Law

The case involves the People of the State of California, represented by the San Diego City Attorney, who filed a complaint against Kaiser Foundation Health Plan, Inc. The complaint alleged that Kaiser violated the unfair competition law (UCL) and false advertising law (FAL) by failing to maintain and update accurate health plan provider directories (PDs) as required by California Health and Safety Code section 1367.27. The People claimed that Kaiser’s inaccuracies in PDs misled consumers and harmed competitors.The Superior Court of San Diego County granted Kaiser’s motion for summary judgment, exercising its discretion to abstain from adjudicating the action. The court reasoned that the legislative framework did not impose an accuracy requirement but rather outlined procedural steps for maintaining PDs. The court concluded that adjudicating the People’s claims would require it to assume regulatory functions and interfere with policy judgments already made by the Legislature and the Department of Managed Health Care (DMHC).The Court of Appeal, Fourth Appellate District, Division One, State of California, reviewed the case and concluded that the trial court abused its discretion by applying the doctrine of judicial abstention. The appellate court found that section 1367.27 sets forth clear mandates for PD accuracy, which the trial court could enforce through its ordinary judicial functions. The appellate court held that the People’s enforcement of these statutory requirements would not interfere with the DMHC’s regulatory functions and that the trial court’s abstention was based on a mistaken view of the law. Consequently, the appellate court reversed the judgment and remanded the matter with directions to deny Kaiser’s motion for summary judgment. View "P. ex rel. Elliott v. Kaiser Foundation Health Plan" on Justia Law

A group of skilled nursing facilities in New York and Rhode Island challenged a rule promulgated by the U.S. Department of Health and Human Services (HHS). The rule allowed certain inspections of these facilities without the presence of a registered nurse, which the plaintiffs argued contradicted the Medicaid Act's requirement for a registered nurse to be part of the survey teams. The dispute arose after an incident at Avon Nursing and Rehabilitation, where a resident was injured, leading to an inspection by a team that did not include a registered nurse. The plaintiffs contended that the rule violated the statutory requirement.The United States District Court for the Southern District of New York granted summary judgment in favor of the government. The court concluded that the Medicaid Act's registered nurse requirement applied only to surveys conducted under 42 U.S.C. § 1396r(g)(2) and not to activities under 42 U.S.C. § 1396r(g)(4), which were the subject of the challenged rule. The court also determined that even if the statute were ambiguous, the agency's interpretation was reasonable and entitled to deference under Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc.The United States Court of Appeals for the Second Circuit reviewed the case and affirmed the district court's judgment. The appellate court held that the registered nurse requirement did not extend to complaint investigations and other enforcement activities under 42 U.S.C. § 1396r(g)(4). The court reasoned that the term "survey" in the statute referred specifically to annual standard surveys, extended surveys, and validation surveys, and not to the investigatory activities described in § 1396r(g)(4). Consequently, the rule allowing inspections without a registered nurse did not contradict the Medicaid Act. View "Avon Nursing & Rehabilitation v. Becerra" on Justia Law

The case involves Lucas Sirois and Alisa Sirois, who were indicted for conspiracy to distribute and possess with intent to distribute marijuana under the Controlled Substances Act (CSA). They sought to enjoin the Department of Justice (DOJ) from prosecuting them, arguing that their conduct was in substantial compliance with the Maine Medical Use of Cannabis Act, which allows for the use, distribution, possession, and cultivation of medical marijuana under state law. The defendants claimed that the DOJ's prosecution violated the Rohrabacher-Farr Amendment, which prohibits the DOJ from using funds to prevent states from implementing their medical marijuana laws.The United States District Court for the District of Maine denied the defendants' request for injunctive relief. The court held a hearing where the government presented evidence that the defendants' operations, particularly a grow operation known as the "Shoe Shop," violated Maine's medical marijuana laws by operating as a collective and engaging in black-market sales. The court found that the government had met its burden of production, showing a substantial evidentiary basis for the prosecution. However, the defendants failed to meet their burden of persuasion to demonstrate that the prosecution lacked a substantial evidentiary basis or was arbitrary or irrational.The United States Court of Appeals for the First Circuit reviewed the case and affirmed the District Court's decision. The appellate court held that the defendants did not show by a preponderance of the evidence that they were in substantial compliance with Maine's medical marijuana laws. The court noted significant evidence that the Shoe Shop operated as a collective and that Lucas Sirois engaged in black-market sales. The court concluded that the defendants failed to demonstrate that the DOJ's prosecution would prevent Maine from giving practical effect to its medical marijuana laws, as required under the Rohrabacher-Farr Amendment. Therefore, the denial of the motion to enjoin the prosecution was affirmed. View "United States v. Sirois" on Justia Law

K.M., an adult with multiple disabilities, including autism and a seizure disorder, has been receiving Medicaid-funded developmental disabilities services for over twenty years. These services, provided by Washington County Mental Health Services (WCMHS), were supposed to include more than thirty hours of community support each week. However, since March 2020, K.M. has only received two to five hours of support weekly, leading to negative health effects.K.M. petitioned the Human Services Board to order the Department of Disabilities, Aging, and Independent Living (DAIL) to provide the full services he is entitled to. The Board dismissed his petition, stating it failed to specify the action required for compliance and that an order to provide services without available staff was too vague. The Board also interpreted K.M.'s request as seeking a broader policy change, which it deemed outside its authority, citing Husrefovich v. Department of Aging & Independent Living.The Vermont Supreme Court reviewed the case and reversed the Board's dismissal. The Court held that the Board has the statutory authority to order DAIL to provide the services K.M. is entitled to under federal and state law. The Court clarified that while the Board cannot issue broad policy injunctions, it can provide specific relief to individuals. The Court found K.M.'s request for services clear and specific enough to inform DAIL of the required action. The case was remanded to the Board for further proceedings consistent with this opinion. View "In re Appeal of K.M." on Justia Law

The case involves a challenge to Montana House Bill 702 (HB 702), which prohibits discrimination based on vaccination status. Plaintiffs, including health care providers and individuals with compromised immune systems, argued that HB 702 is preempted by the Americans with Disabilities Act (ADA) and the Occupational Health and Safety Act (OSH Act) and violates the Equal Protection Clause of the Fourteenth Amendment. They sought to invalidate HB 702 in all health care settings, claiming it prevents employers from knowing employees' vaccination status, thus hindering ADA-required accommodations and OSH Act compliance.The United States District Court for the District of Montana ruled in favor of the plaintiffs, holding that HB 702 is preempted by the ADA and the OSH Act and violates the Equal Protection Clause. The court issued a permanent injunction against the enforcement of HB 702 in health care settings, reasoning that the law conflicts with federal requirements for reasonable accommodations and workplace safety.The United States Court of Appeals for the Ninth Circuit reversed the district court's decision and vacated the injunction. The Ninth Circuit held that neither the ADA nor the OSH Act facially preempts HB 702 in health care settings. The court found that the plaintiffs did not demonstrate a genuine conflict between HB 702 and the ADA or OSH Act in any specific case, much less in all health care settings. The court also held that HB 702 does not violate the Equal Protection Clause, as the classification and differential treatment of facilities could rationally reflect Montana's interest in balancing personal privacy and public health.The Ninth Circuit reserved judgment on whether the ADA and the OSH Act could preempt HB 702 on a narrower, as-applied basis in future cases. The court deemed moot the portion of the district court's order related to interim CMS regulations, as those regulations have been rescinded. The court concluded that HB 702 is not facially invalid under the ADA, OSH Act, or Equal Protection Clause and vacated the district court's injunction in full. View "MONTANA MEDICAL ASSOCIATION V. KNUDSEN" on Justia Law

Carl McDaniel, a Wisconsin prisoner with multiple serious medical conditions, sued the Wisconsin Department of Corrections under the ADA and the Rehabilitation Act, claiming the Department violated his rights by denying him a cell in a no-stairs unit, a single-occupancy cell, and a bed without a top bunk. He also brought an Eighth Amendment claim against Dr. Salam Syed, alleging deliberate indifference to his medical needs. The district court granted summary judgment for the Department on all claims and for Dr. Syed on the Eighth Amendment claim. McDaniel appealed.The United States District Court for the Eastern District of Wisconsin initially handled the case. McDaniel, representing himself, submitted evidence that he missed approximately 600 meals in one year due to the pain and difficulty of navigating stairs to access meals and medications. The district court, however, largely discounted McDaniel’s factual statements and granted summary judgment for the defendants, concluding that McDaniel’s cell assignment was reasonable and that his medical treatment did not violate the Eighth Amendment.The United States Court of Appeals for the Seventh Circuit reviewed the case. The court affirmed the summary judgment for the Department on the claims for a single-occupancy cell and no top bunk, as well as the Eighth Amendment claim against Dr. Syed. However, it reversed the summary judgment on the refusal to assign McDaniel to a no-stairs unit. The court found that McDaniel presented sufficient evidence that the denial of a no-stairs unit effectively denied him access to meals and medications, which could be seen as an intentional violation of the ADA and the Rehabilitation Act. The court also held that McDaniel’s ADA and Rehabilitation Act claims for compensatory damages survived his release from prison and his death.The Seventh Circuit concluded that a reasonable jury could find that the denial of a no-stairs unit amounted to an intentional violation of McDaniel’s rights under the ADA and the Rehabilitation Act, and that the Department was not entitled to sovereign immunity. The case was remanded for further proceedings consistent with this opinion. View "McDaniel v. Syed" on Justia Law

Elizabeth Holt, a former insurance agent for Medicare Medicaid Advisors, Inc. (MMA), alleged that MMA and several insurance carriers (Aetna, Humana, and UnitedHealthcare) violated the False Claims Act (FCA). Holt claimed that MMA engaged in fraudulent practices, including falsifying agent certifications and violating Medicare marketing regulations, which led to the submission of false claims to the Centers for Medicare and Medicaid Services (CMS).The United States District Court for the Western District of Missouri dismissed Holt's complaint. The court found that no claims were submitted to the government, the alleged regulatory violations were not material to CMS’s contract with the carriers, and the complaint did not meet the particularity standard required by Federal Rule of Civil Procedure 9(b). The court also denied Holt's motion for reconsideration, which introduced a fraudulent inducement theory and requested leave to amend the complaint.The United States Court of Appeals for the Eighth Circuit reviewed the case. The court affirmed the district court's dismissal, agreeing that Holt's allegations did not meet the materiality requirement under the FCA. The court applied the materiality standard from Universal Health Services, Inc. v. United States ex rel. Escobar, considering factors such as whether the government designated compliance as a condition of payment, whether the violations were minor or substantial, and whether the government continued to pay claims despite knowing of the violations. The court found that the alleged violations did not go to the essence of CMS’s contract with the carriers and were not material to the government's payment decisions.The Eighth Circuit also upheld the district court's denial of Holt's motion for reconsideration and request to amend the complaint, concluding that adding a fraudulent inducement claim would be futile given the immateriality of the alleged violations. View "United States ex rel. Holt v. Medicare Medicaid Advisors" on Justia Law

Lake Region Healthcare Corporation operates a hospital in Minnesota and experienced a significant decrease in Medicare inpatient discharges in 2013, qualifying it for a volume-decrease adjustment (VDA). The hospital sought an adjustment of $1,947,967 using a method that estimates the portion of Medicare payments attributable to fixed costs. A Medicare contractor denied the adjustment, applying a method that treats all Medicare payments as compensation for fixed costs, resulting in no adjustment. The Provider Reimbursement Review Board (PRRB) reversed the contractor's decision, but the Centers for Medicare & Medicaid Services (CMS) reinstated it.The United States District Court for the District of Columbia ruled in favor of the government, deferring to CMS's method under Chevron deference. The court found that the statute did not specify how to calculate the VDA and that CMS's method was a reasonable interpretation, even if not the best one. The court concluded that CMS's approach was consistent with the statutory requirement to compensate only for fixed costs.The United States Court of Appeals for the District of Columbia Circuit reviewed the case de novo. The court held that CMS's method of attributing all Medicare payments to fixed costs did not comply with the statutory requirement to fully compensate hospitals for their fixed costs. The court noted that Medicare payments cover both fixed and variable costs and that CMS's method overstates the amount of reimbursed fixed costs, thus understating unreimbursed fixed costs. The court found that reasonable proxies exist to estimate the fixed-cost component of Medicare payments and that CMS's method was not a reasonable approximation of full compensation for fixed costs.The court reversed the district court's decision, granted summary judgment to Lake Region, and remanded the case to the agency for further proceedings consistent with the opinion. View "Lake Region Healthcare Corporation v. Becerra" on Justia Law