Justia Government & Administrative Law Opinion Summaries

Medi–Cal, California’s program under the joint federal-state Medicaid program (Welf. & Inst. Code 14000), provides health care services to certain low-income individuals and families, including the aged, blind, disabled, pregnant women, and others. (42 U.S.C. 1396). Beginning in 2013-2014, there were delays in the determination of applications for Medi-Cal benefits, sometimes with severe consequences for applicants who did not obtain needed medical care. Applicants and an advocacy organization sued the California Department of Health Care Services (DHCS). The court ordered DHCS to make Medi-Cal eligibility determinations within 45 days unless certain exceptions applied. The court of appeal reversed. The trial court did not abuse its discretion by declining to abstain but California law does not impose on DHCS a duty to make all Medi-Cal eligibility determinations within 45 days. There is an obligation to determine Medi-Cal eligibility within 45 days under federal regulation 32 CFR 435.912(c)(3)(ii), but that obligation is subject to exceptions so that the underlying obligation is not sufficiently clear and plain to be enforceable in mandate. It was not clear whether DHCS was out of compliance with an overall performance benchmark of processing 90% of applications within 45 days; absent such evidence, it was error to issue writ relief applicable across-the-board. View "Rivera v. Kent" on Justia Law

Hoag, a Newport Beach acute care hospital whose patients include beneficiaries of California’s Medi-Cal program, was audited by the California Department of Health Care Services. Hoag’s cost report for fiscal year 2009 included $2,413,623 in audit reimbursement reductions mandated by Assembly Bill (AB) 5 and AB 1183. Hoag filed an administrative appeal that was a blanket challenge to the legality of those assembly bills and the legality of the reimbursement reductions based upon them. Over 18 months later, Hoag submitted a second administrative appeal regarding an alleged $620,903 calculation error that it requested be “incorporated” into the open administrative appeal. Hoag alleged that if its global challenge failed, the $2,413,623 reduction should not include $620,903 stemming from an erroneous calculation of Medi-Cal days subject to the reductions required by the assembly bills. The Department’s Office of Administrative Hearings and Appeals dismissed the administrative appeal of the alleged calculation error as untimely. The court of appeal affirmed. Hoag’s legal challenge to the Medi-Cal audit reduction is a separate issue from its challenge to the alleged calculation error and was, therefore, untimely. View "Hoag Memorial Hospital Presbyterian v. Kent" on Justia Law

Two Mississippi hospitals filed suit alleging that the government miscalculated their Disproportionate Share Hospital (DSH) payments. In this case, the district court gave substantial deference to the interpretation of HHS, which read that the relevant statute and regulation to exclude from the numerator Mississippi's uncompensated care pool (UCCP) patient days.However, the Fifth Circuit held that HHS's position was foreclosed by the text and structure of the relevant provisions. Therefore, HHS's decision to exclude UCCP patient days from the Medicaid fraction's numerator was not in accordance with law. Accordingly, the court reversed and remanded for further proceedings. View "Forrest General Hospital v. Azar" on Justia Law

The Medicare statute precludes judicial review of estimates used to make certain payments to hospitals for treating low-income patients. At issue was whether this preclusion provision barred challenges to the methodology used to make the estimates.The DC Circuit held that it could not review the Secretary's method of estimation without also reviewing the estimate. Therefore, the two were inextricably intertwined and 42 U.S.C. 1395ww(r)(3)(A) precludes review of both. The court held that Florida Health Sciences Center, Inc. v. Secretary of HHS, 830 F.3d 515 (D.C. Cir. 2016), -- not ParkView Medical Associates v. Shalala, 158 F.3d 146 (D.C. Cir. 1998) -- was controlling in this case. In Florida Health, the court held that section 1395ww(r)(3) barred review because the plaintiff was simply trying to undo the Secretary's estimate of the hospital's uncompensated care by recasting its challenge to the Secretary's choice of data as an attack on the general rules leading to her estimate. Here, DCH was simply trying to undo the Secretary's estimate of its uncompensated care by recasting its challenge to that estimate as an attack on the underlying methodology. View "DCH Regional Medical Center v. Azar" on Justia Law

The Supreme Court reversed the decision of the Commissioner of Human Services determining that RS Eden, a supervised living facility where J.W. received treatment before voluntarily leaving and dying of a drug overdose five days later, was responsible for maltreatment of J.W. by neglect, holding that the Commission's decision was not supported by substantial evidence.RS Eden appealed the maltreatment determination to the court of appeals, which affirmed. The Supreme Court reversed, holding that that Commissioner's finding of maltreatment for neglect for RS Eden's failure to obtain a waiver or to confer with a prescribing physicians was not supported by substantial evidence because RS Eden complied with the rules regarding the disposition of controlled substances and took reasonable steps to protect its client. View "In re Appeal by RS Eden" on Justia Law

The Supreme Court affirmed the order of the district court affirming the decision of the Nebraska Department of Health and Human Services (DHHS) terminating Appellant's status as a Medicaid service provider, holding that the district court's affirmance of the sanction imposed by DHHS was not arbitrary, capricious, or unreasonable.Based on Appellant's failures to adhere to the standards for participation in Medicaid, DHHS terminated Appellant's provider agreements for good cause and then informed Appellant of her permanent exclusion from the Medicaid program. The DHHS director of the Division of Medicaid and Long-Term Care ruled that DHHS' decision to terminate Appellant as a Medicaid service provider was proper. The district court affirmed. The Supreme Court affirmed, holding (1) the court's finding that Appellant billed for overlapping services was based on competent evidence; and (2) DHHS' sanction to permanently exclude Appellant from the Medicaid program was not arbitrary or capricious. View "Tran v. State" on Justia Law

Genesis Hospice LLC provided outpatient hospice care to Medicaid beneficiaries in the Mississippi Delta. Claims Genesis submitted outside the norm, prompting a Mississippi Division of Medicaid audit. A statistical sample of 75 of the 808 billed claims were reviewed, and of that 75, 68 claims were not substantiated by the patients’ records and thus not eligible for payment. The auditing physicians specifically found that the patient records for the 68 rejected claims lacked sufficient documentation to support the given terminal-illness diagnosis and/or lacked documentation of disease progression. Medicaid’s statistician extrapolated that 68 of 75 unsupported claims represented a total overpayment of $1,941,285 for the 808 claims Genesis billed during the relevant time period. And Medicaid demanded Genesis repay this amount. Medicaid’s decision has been affirmed in an administrative appeal before Medicaid and by the Hinds County Chancery Court, sitting as an appellate court. On further appeal to the Mississippi Supreme Court, Genesis essentially argued Medicaid unfairly imposed documentation requirements not found in the federal or state Medicaid regulations. Genesis insisted the only requirement was a physician’s certification that in his or her subjective clinical judgment the patient was terminally ill, which Genesis provided. The Supreme Court found the regulations were clear: a physician’s certification of terminal illness is indeed required, but so is documentation that substantiates the physician’s certification. Because Genesis’ records failed to support 90 percent of its hospice claims, Medicaid had the administrative discretion to demand these unsupported claims be repaid. Therefore, the Supreme Court affirmed. View "Genesis Hospice Care, LLC v. Mississippi Division of Medicaid" on Justia Law

The Alaska Department of Health and Social Services required most healthcare facilities to document the need for proposed services before the state approves construction of a new facility. The agency determined that an ambulatory surgical facility seeking to relocate from Anchorage to Wasilla did not need to submit such documentation because it was moving within the same community as defined by the relevant statute. Competing medical facilities in the Matanuska-Susitna Borough objected to the determination, arguing that Anchorage and Wasilla were not the “same community” and that the proposed relocation required the usual certification of need. Because Anchorage and Wasilla were not the same community as contemplated by the statute, the Alaska Supreme Court reversed the determination that the facility was exempt from the required certification process. View "Alaska Spine Center, LLC v. Mat-Su Valley Medical Center, LLC" on Justia Law

Blue Valley Hospital, Inc., (“BVH”) appealed a district court’s dismissal of its action for lack of subject matter jurisdiction. The Department of Health and Human Services (“HHS”) and the Centers for Medicare and Medicaid Services (“CMS”) terminated BVH’s Medicare certification. The next day, BVH sought an administrative appeal before the HHS Departmental Appeals Board and brought this action. In this action, BVH sought an injunction to stay the termination of its Medicare certification and provider contracts pending its administrative appeal. The district court dismissed, holding the Medicare Act required BVH exhaust its administrative appeals before subject matter jurisdiction vested in the district court. BVH acknowledged that it did not exhaust administrative appeals with the Secretary of HHS prior to bringing this action, but argued: (1) the district court had federal question jurisdiction arising from BVH’s constitutional due process claim; (2) BVH’s due process claim presents a colorable and collateral constitutional claim for which jurisdictional exhaustion requirements are waived under Mathews v. Eldridge, 424 U.S. 319 (1976); and (3) the exhaustion requirements foreclosed the possibility of any judicial review and thus cannot deny jurisdiction under Bowen v. Michigan Academy of Family Physicians, 476 U.S. 667 (1986). The Tenth Circuit disagreed and affirmed dismissal. View "Blue Valley Hospital v. Azar" on Justia Law

The district court found that a woman, "Linda M.," charged with several misdemeanors was incompetent to stand trial and committed her to a state hospital. The hospital later brought petitions in the superior court for civil commitment and involuntary medication. Linda moved to dismiss or stay the proceedings, contending that the superior court was an improper forum because of the criminal case pending in the district court. The superior court denied the motion, asserted its jurisdiction to hear the case, and granted the hospital’s petition for authority to administer medication. Linda appealed. The Alaska Supreme Court held the superior court properly asserted its jurisdiction over the civil commitment and involuntary medication petitions and that the superior court did not err in finding that involuntary medication was in Linda's best interests. View "In Re Hospitalization of Linda M." on Justia Law