Justia Government & Administrative Law Opinion Summaries

Beckley Appalachian Regional Hospital (Beckley ARH) was a voluntary provider of medical services through the Medicaid program pursuant to an agreement executed between it and the West Virginia Bureau for Medical Services (BMS). Beckley ARH filed a lawsuit against the West Virginia Department of Health and Human Resources and its secretary and the BMS and its commissioner (collectively, Respondents), seeking a remedy for inadequate Medicaid reimbursement rates. The circuit court dismissed the complaint for failure to state a claim upon which relief could be granted. The Supreme Court affirmed, holding that W. Va. Code 9-15-16 and 16-29B-20 do not provide for an express or implied private cause of action by a Medicaid provider for judicial review of reimbursement rates for medical services. View "Appalachian Reg'l Healthcare v. W. Va. Dep't of Health & Human Res." on Justia Law

Prinkey served in the Army, 1969 to 1970, including time in Vietnam. He was diagnosed with diabetes in 1996. Diabetes mellitus type II is presumed to be service connected if the veteran was exposed to Agent Orange, 38 U.S.C. 1116(a)(2)(H) (2002). In 2003, the VA received Prinkey’s claim for benefits on account of his diabetes, asserting exposure to Agent Orange. The VA Regional Office grantedservice connection for diabetes, evaluated at 20%, and lesser rated service connection for other disabilities secondary to diabetes. Prinkey sought to reopen his claim. During reexamination, the VA concluded that his diabetes more likely than not resulted from the surgery that removed most of his pancreas following years of alcohol abuse, not from his exposure to Agent Orange. Ultimately the Board of Veterans’ Appeals sustained severance of service connection for diabetes and related disabilities and denied entitlement to a total disability rating based on individual unemployability. The Veterans Court affirmed. The Federal Circuit affirmed. Under 38 C.F.R. 3.105(d) “service connection will be severed only where evidence establishes that it is clearly and unmistakably erroneous; the VA may consider medical evidence and diagnoses that postdate the original award of service connection. View "Prinkey v. Shinseki" on Justia Law

Appellee Steven Wilson is a licensed optometrist, providing eye care services in Lowndes County as Wilson Eye Center (“WEC”). Appellees Cynthia McMurray, Jodie E. Summers, and David Price are also licensed optometrists employed by WEC. Prior to 2010, Spectera, Inc. had entered provider contracts ("Patriot contracts") with Wilson and McMurray and they became members of Spectera's panel of eye care providers. Summers was already on Spectera's panel of eye care providers. Under the Patriot contract, Spectera would reimburse appellees for the materials Spectera insureds used from WEC's inventory by paying appellees a fee for their materials' costs and by having Spectera insureds remit a materials copayment to appellees. Spectera decided to terminate its Patriot contracts and replace them with independent participating provider (IPP) agreements. After the trial court temporarily enjoined Spectera from enforcing its IPP agreement, Spectera sought to remove appellees Wilson, Summers, and McMurray from its approved panel of providers. The trial court enjoined Spectera from taking such action. Although Price was not on Spectera's provider panel, he alleged Spectera violated Georgia law by denying him membership on its panel because of his refusal to sign the IPP agreement. Upon considering the parties' cross motions for summary judgment, the trial court granted issued a permanent injunction precluding Spectera from enforcing the restrictions contained in the IPP agreement as to "any other licensed eye care provider on [Spectera's] provider panel" or those who had applied for admittance to the panel. Spectera appealed the trial court's decision to the Court of Appeals which affirmed in part and reversed in part. Upon review of Spectera's appeal, the Supreme Court concluded a portion of the IPP agreement violated Georgia law, and therefore sustained the Court of Appeals in one respect. However, because the IPP agreement did create the type of impermissible discrimination between classes of licensed eye care providers contemplated by the applicable law, the Court of Appeals was incorrect in concluding that the IPP agreement violated that particular subsection of the applicable law. Furthermore, the termination of any outstanding contracts with appellees Wilson, McMurray, and Summers should have been based on the lawful terms stated in the contracts and not based on a permanent court injunction. Therefore, the Supreme Court affirmed in part, reversed in part and remanded the case for further proceedings. View "Spectera, Inc. v. Wilson" on Justia Law

Plaintiffs and their companies filed suit alleging that the contraceptive mandate in the Affordable Care Act, 42 U.S.C. 300gg-13(a)(4), violated their rights under the Religious Freedom Restoration Act (RFRA), 42 U.S.C. 2000bb et seq., the Free Exercise Clause, the Free Speech Clause, and the Administrative Procedure Act (APA), 5 U.S.C. 500 et seq. The court concluded that, even if the government had a compelling interest - from safeguarding the public health to protecting a woman's compelling interest in autonomy and promoting gender equality, the mandate was not the most restrictive means of furthering that interest. The court concluded that the district court erred in denying a preliminary injunction for plaintiffs on the grounds that their case was unlikely to succeed on the merits; the court reversed the district court's denial of a preliminary injunction for the individual owners; because the district court premised its decision entirely on a question of law, the court must remand for consideration of the other preliminary-injunction factors; and the court affirmed the district court's denial of preliminary injunction with respect to the companies. View "Gilardi, et al. v. HHS, et al." on Justia Law

The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, collectively, the Affordable Care Act require that most businesses employing 50 or more individuals provide female employees with health-insurance coverage that includes, at no cost to the employee, “such additional preventive care and screenings . . . as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.” 42 U.S.C. 300gg-13(a)(4). Those guidelines require plans to cover “[a]ll Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity.” Eden Foods, Inc., and Potter sought an injunction to prevent federal agencies from enforcing that mandate against them. They contend that offering such contraceptive services to the employees of Eden Foods would substantially burden the plaintiffs’ religious beliefs and contravene protections under the Religious Freedom Restoration Act, 42 U.S.C. 2000bb–2000bb-4 (RFRA). The district court denied relief. The Sixth Circuit affirmed. A for-profit corporation is not a “person” capable of religious exercise as intended by RFRA and individual shareholders/owners of a corporation have no standing to challenge provisions of laws that the corporation must obey. View "Eden Foods, Inc v. Sebelius" on Justia Law

The Office of the Medicaid Inspector General (OMIG) terminated a physician's participation in the Medicaid program on the basis of a Bureau of Professional Medical Conduct (BPMC) consent order, in which the physician pleaded no contest to charges of professional misconduct and agreed to probation. Supreme Court annulled the OMIG's determination. The Appellate Division affirmed, concluding (1) the agency acted arbitrarily and capriciously in barring the physician from treating Medicaid patients when the BPMC permitted him to continue to practice; and (2) the OMIG was required to conduct an independent investigation before excluding a physician from Medicaid on the basis of a BPMC consent order. The Court of Appeals affirmed but for another reason, holding (1) the OMIG is authorized to remove a physician from Medicaid in reliance solely on a consent order between the physician and the BMPC, regardless of whether BPMC chooses to suspend the physician's license or OMIG conducts an independent investigation; but (2) because OMIG did not explain why the BPMC consent order caused it to exclude the physician from the Medicaid program, the agency's determination was arbitrary and capricious. View "Koch v. Sheehan" on Justia Law

In a direct appeal, the issue before the Supreme Court in this case was the constitutionality of legislation mandating a one-time transfer of money from the Medical Care Availability and Reduction of Error Fund to Pennsylvania's General Fund. The Commonwealth faced a budget impasse for the 2009-10 fiscal year that lasted approximately 100 days. An interim budget was passed, and impasse was resolved when the Governor approved a supplemental appropriations bill, as well as implementing legislation making amendments to Pennsylvania's Fiscal Code. One of Act provisions designed to balance the budget directed that $100 million be transferred from the MCARE Fund to the General Fund. Appellees sought a declaration that: (1) the transfer of $100 million from the MCARE Fund to the General Fund extinguished vested rights or constituted an illegal taking in violation of the due process guarantees contained the Commonwealth and federal constitutions; and (2) the transfer violated the Uniformity Clause of the Pennsylvania Constitution. Concerned that the Commonwealth might effectuate the transfer and dissipate the funds, Appellees filed an application for preliminary injunctive relief (a temporary restraining order). After review, the Supreme Court concluded that the October 2009 amendment to the Fiscal Code transferring $100 million from the MCARE Fund to the General Fund implicated the providers' due process rights, but that the question of whether the legislation was finally unconstitutional requires further factual development. Accordingly, the Court reversed the Commonwealth Court's order granting summary relief. View "Geisinger Health System, et al v. Pennsylvania" on Justia Law

After the Department denied Memorial's application for a Certificate of Need to perform elective percutaneous coronary interventions (PCIs), Memorial filed suit alleging that the PCI regulations were an unreasonable restraint of trade in violation of the Sherman Act, 15 U.S.C. 1, and unreasonably discriminated against interstate commerce in violation of the dormant Commerce Clause and 42 U.S.C. 1983. The court concluded that the requirements did not violate the dormant Commerce Clause where the minimum procedure requirement did not burden interstate commerce and the minimum procedure requirement protected public safety. Accordingly, the court affirmed the district court's dismissal of all of Memorial's remaining claims. View "Yakima Valley Mem'l Hosp. v. Dep't of Health" on Justia Law

The U.S. Department of Health and Human Services approved a 2008 amendment to Pennsylvania’s state plan for administering its Medicaid program. Private nursing facilities that provide services to Medicaid recipients challenged the amendment as violating Title XIX of the Social Security Act, 42 U.S.C. 1396, by adjusting Pennsylvania’s method for determining Medicaid reimbursement rates to private nursing facilities for the 2008-09 fiscal year without considering quality of care, which they claim violates 42 U.S.C. 1396a(a)(30)(A) and without satisfying the public process requirements of 42 U.S.C. 1396a(a)(13)(A). The district court rejected the claims on summary judgment. The Third Circuit affirmed in part, finding the state immune from the requested relief under the Eleventh Amendment. The district court erred in granting summary judgment to the federal defendants. By approving the amendment without any assurance that the amended plan would produce payments that are consistent with quality of care, HHS acted arbitrarily. View "Christ the King Manor, Inc. v. Sec'y, U.S. Dep't of Health & Human Servs." on Justia Law

The issue before the Supreme Court in this case centered on whether defendant professional corporations and a limited liability company were "health care providers" as defined by the state Medical Malpractice Act so as to be able to receive the Act's benefits. The Court of Appeals determined that though Defendants did not literally meet the Act's definition of "health care provider," it nonetheless held that Defendants were health care providers under the Act because a strict adherence to the plain language of the definition would conflict with legislative intent. Although the Court of Appeals reached the same conclusion, the Supreme Court disagreed with the Court's determination that the definition of "health care provider" literally excludes Defendants. The Supreme Court concluded that several provisions in the Act indicated that the Legislature intended professional medical organizations like Defendants to be covered by the Act. Accordingly, the Court affirmed the Court of Appeals but on different grounds. View "Baker v. Hedstrom" on Justia Law