Justia Government & Administrative Law Opinion Summaries

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

The Eleventh Circuit affirmed the district court's dismissal of the Hospitals' suit to recover recoupments. At issue was whether, under the Medicare Act, 42 U.S.C. 1395w-21 to 1395w-29, the Hospitals must exhaust their administrative remedies before bringing suit for underpayment by the Medicare Advantage Organization (MAO) that manages enrollee benefits. The court held that the Hospitals, who were challenging CIP's recoupment decision, were parties to an "organization determination" who were subject to the administrative exhaustion requirements of the Medicare Act. The court noted that although it was sympathetic to the concern HHS has expressed in amicus briefs, the language of the Medicare Act and its implementing regulations was clear that billing disputes between MAOs and noncontract provider assignees qualify as "organization determinations" and were thus subject to the Act's exhaustion requirement. View "Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Co." on Justia Law

The Eleventh Circuit affirmed the district court's dismissal of the Hospitals' suit to recover recoupments. At issue was whether, under the Medicare Act, 42 U.S.C. 1395w-21 to 1395w-29, the Hospitals must exhaust their administrative remedies before bringing suit for underpayment by the Medicare Advantage Organization (MAO) that manages enrollee benefits. The court held that the Hospitals, who were challenging CIP's recoupment decision, were parties to an "organization determination" who were subject to the administrative exhaustion requirements of the Medicare Act. The court noted that although it was sympathetic to the concern HHS has expressed in amicus briefs, the language of the Medicare Act and its implementing regulations was clear that billing disputes between MAOs and noncontract provider assignees qualify as "organization determinations" and were thus subject to the Act's exhaustion requirement. View "Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Co." on Justia Law

Healthcare Providers sought a mandamus order to force the HHS Secretary to clear the administrative appeals backlog and adhere to the Medicare statute's timeframe to complete the process. The district court subsequently determined that mandamus was appropriate and adopted Healthcare Provider's proposed timetable when the Secretary refused to engage with the premise of setting a timetable at all and proposed no alternative targets. The DC Circuit held that, notwithstanding the district court's earnest efforts to make do with what the parties presented, the failure to seriously test the Secretary's assertion of impossibility and to make a concomitant finding of possibility was an abuse of discretion. Accordingly, the court vacated the mandamus order and the order denying reconsideration, and remanded to the district court to evaluate the merits of the Secretary's claim that unlawful compliance would be impossible. View "American Hospital Assoc. v. Price" on Justia Law

Plaintiffs purchased Illinois nursing homes and obtained new state licenses and federal Medicare provider numbers. Most of the residents in the 10 homes qualify for Medicaid assistance. The Illinois Department of Healthcare and Family Services (IDHFS) administers Medicaid funds under 42 U.S.C. 1396-1396w-5, reimbursing nursing homes for Medicaid-eligible expenses on a per diem basis. The rate must be calculated annually based on the facility's costs. When ownership of a home changes, state law requires IDHFS to calculate a new rate based on the new owner’s report of costs during at least the first six months of operation. The Medicaid Act requires states to use a public process, with notice and an opportunity to comment, in determining payment rates. The owners allege that IDHFS failed to: recalculate their reimbursement rates; provide an adequate notice-and-comment process; and comply with the state plan, costing them $12 million in unreimbursed costs. The Seventh Circuit affirmed denial of a motion to dismiss. Section 1396a(a)(13)(A) confers a right that is presumably enforceable under 42 U.S.C. 1983; it benefits the owners and is not so amorphous that its enforcement would strain judicial competence. While the Eleventh Amendment may bar some of the requested relief, if it appears that owners have been underpaid, that does not deprive the court of jurisdiction over the case as a whole. View "BT Bourbonnais Care, LLC v. Norwood" on Justia Law

Texas Neighborhood Services received Head Start grant money to provide childcare services to low-income families in Texas. The Department subsequently required Neighborhood Services to repay $1.3 million in federal funds it awarded to staff in the form of performance bonuses. The Department argued that the payments were unreasonable and inadequately documented and the Appeals Board agreed. The DC Circuit affirmed the district court's rejection of Neighborhood Services' challenge under the Administrative Procedures Act. In this case, Neighborhood Services failed to produce documentation sufficient to show that it was awarding performances in accordance with the Office of Management and Budget's Circular A-122, which explains when and how the government will reimburse federal grantees, including organizations receiving Head Start money, for different types of expenses. View "Texas Neighborhood Services v. HHS" on Justia Law

The Ninth Circuit held that the Secretary erred in approving a state plan amendment (SPA) pursuant to 42 U.S.C. 1396(a)(30)(A), without requiring any evidence regarding the extent that such care and services were available to the general population in the geographic area. In this case, the Secretary's approval of the SPA absent considerations of some form of comparative-access data was arbitrary and capricious. Accordingly, the court reversed the district court's grant of summary judgment in favor of the Secretary and remanded. View "Hoag Memorial Hospital Presbyterian v. Price" on Justia Law

In several cases consolidated for review, the issue common to all was whether the Michigan Department of Health and Human Services could recover from beneficiaries’ estates an amount equivalent to certain Medicaid benefits paid to, or on behalf of, those beneficiaries during their lifetimes. Pursuant to the Michigan Medicaid estate-recovery program (MMERP), DHHS asserted creditor claims in the amount of those benefits against the estates of four deceased beneficiaries. In each case, the estate prevailed in the probate court and DHHS appealed. The Court of Appeals consolidated the appeals and reversed in part, concluding that DHHS could pursue its claims for amounts paid after MMERP’s July 1, 2011 implementation date, but not for amounts paid between that date and the program’s effective date, July 1, 2010. One estate appealed to the Michigan Supreme Court, arguing due process barred DHHS from recovering any amount paid before 2013, when the agency had directly notified the estate’s decedent of MMERP. DHHS applied for leave to appeal in all four cases, arguing that the Court of Appeals had erred in concluding that the agency was not entitled to recover the amounts paid between July 1, 2010, and July 1, 2011. The Supreme Court concluded DHHS was not barred from pursuing estate recovery for amounts paid after July 1, 2010. View "In re Gorney Estate" on Justia Law

In 2009, Lanigan injured his back at his job and hurt his neck in a car accident; in 2011 he was diagnosed with diabetes. Since then his medical impairments have been complicated by mental illness. Lanigan applied for Supplemental Security Income and Disability Insurance Benefits in 2012 when he was 38 years old. At a hearing, the ALJ asked a vocational expert to assess whether competitive employment would be available to a person: capable of performing low-stress jobs constituting light work if those jobs involve only routine tasks; do not require more than occasional interaction with coworkers or the public; do not involve piece work or a rapid assembly line; is limited to occasional stooping, crouching, kneeling, or crawling; and can be off task up to 10% of the workday in addition to regularly scheduled breaks. The ALJ did not explain the source of the 10% figure. The ALJ found his impairments to be severe but not disabling and denied benefits. The Appeals Council denied review. The district court upheld the ALJ’s decision. The Seventh Circuit remanded for further proceedings because the ALJ misinformed a vocational expert about Lanigan’s residual functional capacity, thus undermining the expert’s testimony that Lanigan could engage in competitive employment. View "Lanigan v. Berryhill" on Justia Law