Justia Government & Administrative Law Opinion Summaries

Caring Hearts Personal Home Services, Inc. provided physical therapy and skilled nursing services to “homebound” Medicare patients. It sought reimbursement from Medicare for services provided. The definition of who qualified as "homebound" or what services qualified as "reasonable and necessary" was unclear, even to the Centers for Medicare & Medicaid Services (CMS). CMS has developed its own rules on both subjects that had been repeatedly revised and expanded over time. In an audit, CMS purported to find that Caring Hearts provided services to at least a handful of patients who didn’t qualify as “homebound” or for whom the services rendered weren’t “reasonable and necessary.” As a result, CMS ordered Caring Hearts to repay the government over $800,000. It was later found that in reaching its conclusions CMS applied the wrong law: the agency did not apply the regulations in force in 2008 when Caring Hearts provided the services in dispute. Instead, it applied considerably more onerous regulations the agency adopted years later, "[r]egulations that Caring Hearts couldn’t have known about at the time it provided its services." The Tenth Circuit found that Caring Hearts "[made] out a pretty good case that its services were entirely consistent with the law as it was at the time they were rendered" when CMS denied Caring Hearts' request for reconsideration. The Tenth Circuit reversed the district court's judgment affirming CMS' denial to Caring Hearts for reimbursement, and remanded for further proceedings. View "Caring Hearts v. Burwell" on Justia Law

A class of Tennessee residents who applied for Medicaid sought declaratory and injunctive relief, alleging that the delays they have experienced in receiving eligibility determinations on their applications violate 42 U.S.C. 1396a(a)(8) of the Medicaid statute, and that the state’s failure to provide a fair hearing on their delayed applications violates that statute and the Due Process Clause. Regulations implementing the statute provide that “the determination of eligibility for any applicant may not exceed” 90 days for those “who apply for Medicaid on the basis of disability” and 45 days for all other applicants. The district court certified a class and granted a preliminary injunction, which requires the state to grant a fair hearing on delayed applications to class members who request one. The Sixth Circuit affirmed the preliminary injunction, holding that the matter is not moot and that the federal government is not a required party. The court noted that the federal government submitted an amicus brief, supporting plaintiffs’ position. Despite the passage of the Affordable Care Act, states remain ultimately responsible for ensuring their Medicaid programs comply with federal law. View "Wilson v.Gordon" on Justia Law

The Texas Optometry Act prohibits commercial retailers of ophthalmic goods from attempting to control the practice of optometry; authorizes the Optometry Board and the Attorney General to sue a violator for a civil penalty; and provides that “[a] person injured as a result of a violation . . . is entitled to the remedies. In 1992, Wal-Mart opened “Vision Centers” in its Texas retail stores, selling ophthalmic goods. Wal-Mart leased office space to optometrists. A typical lease required the optometrist to keep the office open at least 45 hours per week or pay liquidated damages. In 1995, the Board advised Wal-Mart that the requirement violated the Act. Wal-Mart dropped the requirement and changed its lease form, allowing the optometrist to insert hours of operation. In 1998, the Board opined that any commercial lease referencing an optometrist’s hours violated the Act; in 2003, the Board notified Wal-Mart that it violated the Act by informing optometrists that customers were requesting longer hours. Optometrists sued, alleging that during lease negotiations, Wal-Mart indicated what hours they should include in the lease and that they were pressured to work longer hours. They did not claim actual harm. A jury awarded civil penalties and attorney fees. The Fifth Circuit certified the question of whether such civil penalties, when sought by a private person, are exemplary damages limited by the Texas Civil Practice and Remedies Code Chapter 41. The Texas Supreme Court responded in the affirmative, noting that “the certified questions assume, perhaps incorrectly, that the Act authorizes recovery of civil penalties by a private person, rather than only by the Board or the Attorney General.” View "Wal-Mart Stores, Inc. v. Forte" on Justia Law

This appeal arose out of a 42 U.S.C. 1983 action filed against DSHS by plaintiff. At issue is whether the Due Process Clause compels the state to perform a competency evaluation of pretrial detainees within seven days of a court order requiring evaluation. The district court addressed both initial competency evaluations and the mental health restoration services that follow a determination of incompetency to stand trial and concluded that the Due Process Clause of the Fourteenth Amendment requires that services for both categories must be provided within seven days of a court order, absent an individualized determination of clinical good cause. The district court entered a permanent injunction to this effect, although Washington appeals only that portion related to initial competency evaluations. The court agreed with the district court that DSHS must conduct competency evaluations within a reasonable time following a court’s order. The district court’s seven-day mandate, however, imposes a temporal obligation beyond what the Constitution requires. Therefore, the court vacated the injunction with respect to the seven-day requirement for in-jail competency evaluations and remanded to the district court to amend the injunction. View "Trueblood V. WSDSHS" on Justia Law

In response to a 2009 executive order announcing a ten percent reduction in state departments and agencies for the fiscal year ending June 30, 2010, the Iowa Department of Human Services (IDHS) promulgated temporary rules adjusting the reimbursement rates paid to Medicaid service providers. Thereafter, the legislature passed a law directing IDHS to continue for the next fiscal year the rate reductions as specified under the 2009 executive order. Accordingly, IDHS promulgated permanent rules implementing certain rate reductions. IDHS, however, inadvertently omitted a reduction for one component of the rate calculation for certain Medicaid service providers. Nevertheless, IDHS continued to reimburse those service providers at the reduced rates established under the temporary rules. In an administrative proceeding, Plaintiffs, several providers, challenged the rate calculation, arguing that, even if the “missing” rule was an oversight, IDHS could not reimburse them at the reduced rate without a rule authorizing it to do so. An administrative law judge granted summary judgment for IDHS, and the decision was affirmed on review. The district court reversed. The Supreme Court reversed, holding that the statute provides sufficient authority for IDHS to reimburse service providers at the reduced rates without a rule authorizing it to do so. View "Exceptional Persons, Inc. v. Iowa Dep’t of Human Servs." on Justia Law

Believing the purchase of orthopaedic prosthetic devices and other implants were eligible for a sales tax exemption, CareAlliance Health Services (the Hospital) sought a refund from South Carolina Department of Revenue (DOR). Following an audit, DOR denied the request as to orthopaedic prosthetic devices on the grounds they did not require a prescription to be sold and a prescription was not used in the purchase of the devices. The DOR also held other bone, muscle, and tissue implants were not exempt because they did not replace a missing part of the body, as required for the exemption. The Hospital filed for a contested case hearing. After discovery, both parties filed motions for summary judgment. Following a hearing on the motions, the ALC granted summary judgment in favor of the Hospital, finding orthopaedic prosthetic devices qualified for the exemption and other bone, muscle, and tissue implants replaced a missing part of the body. The DOR appealed, arguing the ALC erred in finding a prescription was required for the sale of an orthopaedic device between the Hospital and vendor because of federal regulations. The Supreme Court agreed and reversed: "The ALC's broad interpretation of the federal regulation is fundamentally at odds with the plain reading of the regulation and the strict construction afforded a tax exemption." Further, the Court reversed the ALC's finding that other bone, muscle and tissue implants replace a missing body part because it was not supported by substantial evidence in the record. The Court reversed the ALC and found the Hospital was not entitled to a tax exemption. View "CareAlliance Health Services v. SCDOR" on Justia Law

Wal-Mart petitions for review of the decision of the Commission finding that the company failed to comply with 29 C.F.R. 1910.132(d)(1), which requires the company to perform a hazard assessment of its distribution center. The court concluded that the regulation, the preamble, and the non-mandatory appendix fail to resolve the ambiguity as to whether Wal-Mart may use its Searcy hazard assessment as the hazard assessment for the allegedly identical New Braunfels location. In such circumstances, the court gives substantial deference to an agency’s interpretation of its own regulation. While section 1910.132(d)(1) may not require an employer to conduct a full-fledged hazard assessment of all identical workplaces, it is reasonable to interpret section 1910.132(d)(1) to require an employer to confirm that workplaces are indeed identical before a hazard assessment for one workplace can qualify as the hazard assessment for another location. Therefore, the court agreed with the Commission’s conclusion that the Secretary’s interpretation of section 1910.132(d)(1) is reasonable. However, because Wal-Mart lacked adequate notice of that interpretation, the court vacated the citation and the related penalty. View "Wal-Mart Distrib. Center v. OSHC" on Justia Law

The Alabama State Health Planning and Development Agency ("SHPDA") granted HealthSouth of Alabama, LLC ("HealthSouth") a certificate of need ("CON") allowing HealthSouth to operate 17 inpatient physical-rehabilitation beds in Shelby County. In a separate proceeding, SHPDA granted another CON to HealthSouth allowing it to operate an additional 17 inpatient physical-rehabilitation beds in Shelby County. Shelby Ridge Acquisition Corporation d/b/a Shelby Ridge Rehabilitation Hospital ("Shelby Ridge") opposed HealthSouth's CON applications, and, after SHPDA issued the CONs to HealthSouth, Shelby Ridge appealed SHPDA's decision. The circuit court reversed one of SHPDA's decisions but affirmed the other. HealthSouth, SHPDA, and Shelby Ridge appealed separately to the Court of Civil Appeals, which consolidated the appeals and concluded that SHPDA had erred by granting the CONs to HealthSouth. HealthSouth and SHPDA separately petitioned the Supreme Court for review, which was granted. While the appeals were pending, the parties resolved their disputes; the parties agreed that HealthSouth should have been allowed to build the planned 34-bed physical-rehabilitation hospital in Shelby County. The parties also agreed that the Court of Civil Appeals wrongly decided the appeals before it insofar as HealthSouth's CON applications were concerned. The Supreme Court agreed that the Court of Civil Appeals erred. "It is sufficient to note that the pivotal error of that court's opinion is the characterization as 'key' and determinative two of the many considerations to be evaluated and balanced by SHPDA in considering CON applications." The Supreme Court reversed the Court of Civil Appeals and rendered judgment in favor of HealthSouth and SHPDA. The Supreme Court also remanded the cases to the Court of Civil Appeals with instructions that that court remand the cases to the circuit court so the parties could implement the resolution they reached. View "Ex parte Alabama State Health Planning and Development Agency." on Justia Law

The plaintiffs in this case were providers and recipients of Medicaid services for individuals with intellectual and developmental disabilities who claimed that the defendant administrative agencies and their commissioners failed to follow the required procedures before reducing the reimbursement rates paid to the providers and limiting the services available to the recipients. The plaintiffs did not submit their claims to the agencies for administrative review, instead filing their lawsuit with the trial court. The trial court granted the defendants’ motion to dismiss the case for failure to exhaust administrative remedies, but the Court of Appeals reversed that ruling. The Georgia Supreme Court granted certiorari to to decide whether the Court of Appeals erred in holding that the defendants’ alleged failure to give the plaintiffs proper notice of adverse agency decisions excused the plaintiffs from the exhaustion requirement. The Supreme Court reversed, finding that the plaintiffs were required to raise their defective notice claims in the administrative review process in the first instance. View "Georgia Dept. of Behavioral Health Developmental Disabilities v. United Cerebral Palsy of Georgia, Inc." on Justia Law

Robert Mena was licensed to practice medicine and surgery in Idaho in 2003. In 2007, staff members at the hospital in Jerome where he had privileges reported behaviors that suggested to them that Dr. Mena might have been abusing drugs or alcohol. Dr. Mena was evaluated and tested negative for chemical dependency. But staff, still concerned about Dr. Mena's psychological status, opined that he was not then currently fit to practice medicine. After further evaluation, it was recommended that Dr. Mena curtail his work-weeks to 40 to 50 hours. The Idaho State Board of Medicine ("Board") also had begun an investigation regarding Dr. Mena's training and ability to perform certain medical procedures. The Board and Dr. Mena entered into a Stipulation and Order in 2009, in which he admitted that he had violated the Medical Practice Act by failing to provide health care that met the required standard and in which he agreed to specific conditions of probation and restrictions on his license to practice medicine. On September 26, 2011, the Board issued an order terminating the Stipulation and Order. That same day, the hospital in Jerome gave Dr. Mena written notification that it had granted him limited medical privileges on the condition that he obtain additional training, that he had failed to do so, and that his privileges were forfeited. A month later, the Board sent Dr. Mena a letter asking him to respond to the hospital's action. He eventually submitted a thirteen-page written response that was rambling with many obscure references, grammatical and syntax errors, and vague sentences. More evaluations were ordered. The Board issued its Final Order in early 2014, finding that Dr. Mena suffered from "some level of impairment," and it stated that "sanctions were necessary upon [Dr. Mena's] license." Dr. Mena filed a petition for judicial review to the district court, arguing: (1) the Board initiated proceedings pursuant to the Disabled Physician Act and then imposed sanctions that were not permitted by that Act; (2) the Board's order was not supported by substantial evidence; and (3) the hearing officer erred in holding that certain evidence was inadmissible. The district court upheld the Board's action, and Dr. Mena then appealed to the Idaho Supreme Court. The Supreme Court reversed and remanded, finding that Board's own evaluation of the evidence showed that there was insufficient evidence to support the Board's order. View "Mena v. Idaho Bd. of Medicine" on Justia Law