Justia Government & Administrative Law Opinion Summaries

The issue presented for the Oregon Supreme Court’s review was whether an adult foster care provider claiming unjust enrichment may recover the reasonable value of its services from a defendant who, through fraud, obtained a lower rate from the provider for the services. Plaintiff owned two adult foster homes for the elderly. Plaintiff had contracted with the Oregon Department of Human Services to provide services in a home-like setting to patients who qualified for Medicaid. For those patients, the rates charged would be those set by the department. Isabel Pritchard resided and received care in one of plaintiff’s adult foster homes until her death in November 2008. Because Prichard had been approved to receive Medicaid benefits, plaintiff charged Prichard the rate for Medicaid-qualified patients: approximately $2,000 per month, with approximately $1,200 of that being paid by the department. Plaintiff’s Medicaid rates were substantially below the rates paid by plaintiff’s “private pay” patients. Prichard’s application for Medicaid benefits, as with her other affairs, was handled by her son, Richard Gardner. Gardner had for years been transferring Prichard’s assets, mostly to himself (or using those funds for his personal benefit). Gardner’s misconduct was discovered by another of Prichard’s children: defendant Karen Nichols-Shields, who was appointed the personal representative for Prichard’s estate. In 2009, defendant contacted the police and reported her brother for theft. Ultimately, Gardner pleaded guilty to three counts of criminal mistreatment in the first degree. Gardner’s sentence included an obligation to pay a compensatory fine to Prichard’s estate, to which he complied. After defendant, in her capacity as personal representative, denied plaintiff Larisa’s Home Care, LLC’s claim against Prichard’s estate, plaintiff filed this action, essentially asserting Prichard had been qualified for Medicaid through fraud and that Prichard should have been charged as a private pay patient. The Oregon Supreme Court concluded that, generally, a defendant who obtains discounted services as a result of fraud is unjustly enriched to the extent of the reasonable value of the services. The Court therefore reversed the contrary holding by the Court of Appeals. Because the fraud here occurred in the context of a person being certified as eligible for Medicaid benefits, however, the Court remanded for the Court of Appeals to consider whether certain provisions of Medicaid law may specifically prohibit plaintiff from recovering in this action. View "Larisa's Home Care, LLC v. Nichols-Shields" on Justia Law

Women’s Surgical Center, LLC d/b/a Georgia Advanced Surgery Center for Women (the “Center”) planned to add a second operating room to its premises in order to create opportunities to form contracts with additional surgeons who could then use the Center in connection with their medical practices. However, any such change to the Center could only be legally accomplished if the Center sought and was granted a certificate of need (“CON”) by the Georgia Department of Community Health (the “Department”). Because the Center believed that it should not be subject to the CON requirements, it filed an action for declaratory and injunctive relief against the Department in an effort to have Georgia’s applicable CON law and the regulations authorizing it declared unconstitutional. The Department moved to dismiss the complaint, arguing, among other things, that the trial court lacked jurisdiction over the case because the Center failed to exhaust its administrative remedies before filing its lawsuit. The trial court denied the motion to dismiss, then both the Center and the Department filed motions for summary judgment with regard to the Center’s constitutional claims. The trial court rejected all of the Center’s constitutional challenges and granted summary judgment to the Department. In Case No. S17A1317, the Center appealed that ruling, and in Case No. S17X1318, the Department appealed the denial of its motion to dismiss. Finding no reversible error, the Georgia Supreme Court affirmed in both cases. View "Womens Surgical Center, LLC v. Berry" on Justia Law

When Arvada, Colorado police officers responded to a reported domestic disturbance in Terry Ross’s home, Ross went into a bedroom and shot himself. Officers radioed for an ambulance whose crew delivered him to the hospital. There, doctors treated Ross’s wounds as Arvada officers kept watch over him. When Ross, and later his estate, could not pay for his care, the hospital billed the City of Arvada nearly $30,000. The question presented by this case was essentially whether Arvada had to pay the tab. The trial court and court of appeals said yes; both read Colorado’s “Treatment while in custody” statute as entitling the hospital to relief. Relying on Poudre Valley Health Care Inc. v. City of Loveland, 85 P.3d 558 (Colo. App. 2003), the trial court decided the statute assigned police departments (or any agency that detains people) a duty to pay healthcare providers for treatment of those in custody. The court of appeals affirmed on essentially the same grounds. The Colorado Supreme Court, however, concluded the statute did not create any duty to a healthcare provider. Furthermore, the Court concluded that the hospital’s claim for unjust enrichment survived. Because that claim was contractual, the Court concluded the Colorado Governmental Immunity Act did not prohibit it. Therefore, the Court reversed the judgment of the court of appeals in part and remanded for further proceedings. View "City of Arvada ex rel. Arvada Police Department v. Denver Health" on Justia Law

The Supreme Judicial Court vacated the judgment of the superior court concluding that a provider’s participation in MaineCare constitutes a “license,” the revocation of which invokes the district court jurisdiction. The superior court declared that the district court, and not the Department of Health and Human Services, had exclusive original jurisdiction over the decision to terminate a doctor’s participation in, and reimbursement from, MaineCare and any other medical assistance programs in the state of Maine. The Supreme Judicial Court vacated the judgment entered in favor of the doctor and remanded the matter, holding that the Department’s decision to terminate the doctor’s participation in the MaineCare program did not fall within the licensing decisions over which the legislature gave the district court original and exclusive jurisdiction. View "Doane v. Department of Health & Human Services" on Justia Law

Alternative Medicine Maryland, LLC (AMM) sued the Natalie M. LaPrade Medical Cannabis Commission, its members, and the Department of Health and Mental Hygiene after AMM applied for, but did not receive, pre-approval for a medical cannabis grower license. AMM sought a declaratory judgment and preliminary and permanent injunctive relief, arguing that the Commission failed to follow applicable law with respect to the requirement to consider racial and ethnic diversity of potential medical cannabis grower licensees and requested that the Commission be required to reconnect the pre-approval process. Relevant to this appeal, the circuit court denied a motion to intervene filed by medical cannabis growers that had received pre-approvals for medical cannabis grower licenses, a coalition and trade association that advocate for the use of medical cannabis, and patients who would potentially receive medical cannabis as treatment for illnesses. The Supreme Court held (1) the growers were entitled to intervention as of right and permissive intervention; but (2) the circuit court did not err in denying intervention as of right or permissive intervention as to the patients and the trade association petitioners. View "Doe v. Alternative Medicine Maryland, LLC" on Justia Law

St. Vincent Health group acquired Randolph County Hospital and decided to replace the 80-year-old building. In 2002 the Hospital financed the project by borrowing $15.3 million from a fraternal corporation. Within a year, St. Vincent Health group was acquired by Ascension, the nation’s largest Roman Catholic health-care system. Ascension loaned the Hospital $15.6 million to refinance the loan. The Hospital sought reimbursement under 42 U.S.C. 1395f(b)(1), 1395x(v)(1)(A), and 42 C.F.R. 413.153, for “the necessary and proper costs of financing medical facilities.” Recognizing its problems with poor documentation, the Hospital withdrew its request that Medicare cover any expense before 2004 but requested compensation for 2004-2008, after Ascension had refinanced the loan in compliance with section 413.153(c)(2). The Provider Reimbursement Review Board ordered the 2004-2008 claims paid, finding that problems with the 2002 loan did not taint the refinancing. The Centers for Medicare and Medicaid Services reversed. The district court rejected reasoning concerning the initial loan but granted summary judgment, finding that the Hospital had not established that the Ascension loan refinanced that loan. The Seventh Circuit vacated, stating the “taint” theory is legally untenable and cannot be reasserted on remand, but the agency is free to request more or better documentation and to explore the significance of the difference in the principal amounts of the loans. View "St. Vincent Randolph Hospital, v. Price" on Justia Law

Rosewood is a skilled nursing facility, 42 U.S.C. 1395i-3(a), participating in Medicare and Medicaid as a provider. The Secretary of Health and Human Services, which enforces the statutory and regulatory provisions governing nursing homes operating in the Medicare/Medicaid network, assessed a civil monetary penalty against Rosewood on the grounds that it had failed to protect a resident from abuse, failed to timely report or to investigate thoroughly allegations of abuse, and failed to implement its internal policies on abuse, neglect, and misappropriation of property. The Centers for Medicare and Medicaid Services (CMS) determined that these deficiencies placed residents in “immediate jeopardy.” An Administrative Law Judge and the Department Appeals Board affirmed the $6,050 per day penalty imposed by CMS. The Seventh Circuit affirmed. Substantial evidence supports the Agency’s findings. The court noted three specific examples of noncompliance and concluded that there was a systemic failure to implement Rosewood’s policies aimed at conforming to federal regulations View "Rosewood Care Center of Swansea v. Price" on Justia Law

Prime Hospitals provide inpatient services under the Medicare program, submitting payment claims to private contractors, who make initial reimbursement determinations. Prime alleged that many short-stay claims were subject to post-payment review and denied. Prime appealed through the Medicare appeal process. Prime alleged short-stay claims audits were part of a larger initiative that substantially increased claim denials and that the Center for Medicare & Medicaid Services (CMS) was overwhelmed by the number of appeals. CMS began offering partial payment (68 percent) in exchange for dismissal of appeals. Prime alleged that it executed CMS's administrative settlement agreement so that CMS was contractually required to pay their 5,079 Medicare appeals ($23,205,245). CMS ultimately refused to allow the Prime to participate because it was aware of ongoing False Claims Act cases or investigations involving the facilities. Prime alleged that the settlement agreement did not authorize that exclusion. The district court denied a motion to dismiss Prime’s suit but transferred it to the Court of Federal Claims. The Federal Circuit affirmed in part. The breach of contract claim is fundamentally a suit to enforce a contract and does not arise under the Medicare Act, so the Claims Court has exclusive jurisdiction under the Tucker Act, 28 U.S.C. 1491. That court does not have jurisdiction, however, over Prime’s alternative claims seeking declaratory, injunctive, and mandamus relief from an alleged secret and illegal policy to prevent and delay Prime from exhausting administrative remedies. View "Alvarado Hospital, LLC v. Cochran" on Justia Law

The Hospitals challenged HHS's implementation of a Medicare outlier-payment program in the late 1990s and early 2000s. The Hospitals contend that HHS violated the Administrative Procedure Act (APA), 5 U.S.C. 551 et seq., by failing to identify and appropriately respond to flaws in its methodology that enabled certain "turbo-charging" hospitals to manipulate the system and receive excessive payments at the expense of non-turbo-charging hospitals, including the Hospitals. The DC Circuit held that District Hospital Partners, L.P. v. Burwell, 786 F.3d 46 (D.C. Cir. 2015), controlled to the extent that the Hospitals repeated challenges decided in that case. In regard to the remaining challenges, the court affirmed the district court's denials of the Hospitals' motions to supplement the record and to amend their complaint, and its decision that HHS acted reasonably in a manner consistent with the Medicare Act in fiscal years (FYs) 1997 through 2003, and 2007. However, because HHS inadequately explained aspects of the calculations for FYs 2004 through 2006, the court reversed summary judgment in that regard and remanded for further proceedings. View "Banner Health v. Price" on Justia Law

The Hospitals challenged HHS's implementation of a Medicare outlier-payment program in the late 1990s and early 2000s. The Hospitals contend that HHS violated the Administrative Procedure Act (APA), 5 U.S.C. 551 et seq., by failing to identify and appropriately respond to flaws in its methodology that enabled certain "turbo-charging" hospitals to manipulate the system and receive excessive payments at the expense of non-turbo-charging hospitals, including the Hospitals. The DC Circuit held that District Hospital Partners, L.P. v. Burwell, 786 F.3d 46 (D.C. Cir. 2015), controlled to the extent that the Hospitals repeated challenges decided in that case. In regard to the remaining challenges, the court affirmed the district court's denials of the Hospitals' motions to supplement the record and to amend their complaint, and its decision that HHS acted reasonably in a manner consistent with the Medicare Act in fiscal years (FYs) 1997 through 2003, and 2007. However, because HHS inadequately explained aspects of the calculations for FYs 2004 through 2006, the court reversed summary judgment in that regard and remanded for further proceedings. View "Banner Health v. Price" on Justia Law