Justia Health Law Opinion Summaries

The case revolves around Gracie and Jeff Richardson, the legal guardians of their adult son, JMR, who suffers from severe developmental and intellectual disabilities. JMR requires full-time care and receives the highest level of Medicaid benefits offered through the Home and Community Based Services Waiver Program (HCBS Program) administered by the Wyoming Department of Health. The HCBS Program offers numerous services to participants like JMR to meet their individually assessed needs. In 2017, the Department entered into a settlement agreement with the Richardsons to establish an individual plan of care for JMR that permitted him to spend his individual budget amount on adult day services, residential habilitation services (community living services), and respite services.In 2021, the Department reviewed JMR’s individual plan of care pursuant to a quality improvement review. The Department discovered JMR’s providers had been billing for respite services at the same time JMR had been receiving community living services. Under the Department’s Comprehensive and Supports Waiver Service Index (the Index), providers are not authorized to bill for both the daily rate of community living services and the fifteen-minute units of respite services. The Department, relying on the Index, notified the Richardsons that it was required to remove respite services from JMR’s individual plan of care. The Richardsons requested an administrative hearing, which upheld the Department’s decision. The Richardsons appealed to the district court, which affirmed the decision. The Richardsons then appealed to the Supreme Court of Wyoming.The Supreme Court of Wyoming affirmed the lower court's decision. The court found that the Department acted in accordance with law when it removed respite services from JMR’s individual plan of care. The court held that the Index, which was incorporated by reference in the Department’s Medicaid regulations, constituted a rule with the force and effect of law. The court also found that the Department’s quality improvement review, which was used to identify the billing deemed erroneous under the Index, was not considered a “rule” under the Wyoming Administrative Procedure Act and therefore did not require the rulemaking process before implementation. Finally, the court concluded that the Department’s removal of respite services from JMR’s individual plan of care did not violate the parties’ 2017 Settlement Agreement. View "Richardson v. State of Wyoming, Ex Rel. Wyoming Department of Health" on Justia Law

The case involves a man, Dominic N., who was involuntarily committed for mental health treatment. Dominic N. has a history of being charged with sexual abuse of a minor and has been deemed incompetent to stand trial multiple times. He has been diagnosed with numerous mental health and behavioral conditions, including major depressive disorder, selective mutism, and borderline intellectual functioning. In 2021, he was again charged with sexual abuse of a minor and found mentally incompetent to stand trial. While at the Alaska Psychiatric Institute (API) for competency restoration, he was diagnosed with additional disorders, including antisocial personality disorder.The Superior Court of the State of Alaska, Third Judicial District, Anchorage, held a competency hearing and found Dominic mentally incompetent. The court ordered his commitment to API for further evaluation and restoration. The State petitioned for an order authorizing Dominic’s evaluation to determine whether he was mentally ill and likely to cause harm to others. The court granted the petition, and API staff filed a petition for 30-day civil commitment. After a hearing, the court found that Dominic was mentally ill and likely to cause harm to others, and ordered his commitment to API for 30 days.Dominic appealed to the Supreme Court of the State of Alaska, arguing that the State failed to prove that he was mentally ill as defined by statute and that his diagnoses were the type of intellectual and developmental disabilities excluded from the definition. The Supreme Court affirmed the superior court’s order, concluding that there was clear and convincing evidence that Dominic suffered from mental illness that is more than his excluded disabilities. The court found that Dominic’s impulse control disorder and pedophilic disorder were distinct from his intellectual and developmental disabilities, satisfying the statutory definition of mental illness. View "In re Hospitalization of Dominic N." on Justia Law

Dr. Ryan Kime, an emergency medicine physician, applied for privileges in the emergency department of two hospitals owned by Dignity Health, Inc. (Dignity) while he was under disciplinary proceedings by the Medical Board of California. The proceedings resulted in a public reprimand. Dignity stopped processing Kime’s application a few days after the reprimand took effect. Kime sued Dignity for injunctive relief and damages, alleging that Dignity violated his common law and statutory rights by denying his application without offering him a hearing. Dignity moved for summary judgment, arguing that it had a policy not to consider applicants with disciplinary histories for emergency department privileges, and that no hearing is required when privileges are denied due to such a policy. The trial court granted Dignity’s motion for summary judgment and denied Kime’s motion for summary adjudication.The Court of Appeal of the State of California First Appellate District affirmed the trial court's decision. The court found that Dignity's policy of not considering applicants with disciplinary histories for emergency department privileges was a quasi-legislative decision, which did not require a hearing under the common law right to fair procedure. The court also found that Dignity's decision to deny Kime's application did not require a hearing under the statutory right set forth in the Business and Professions Code, as the decision was not made by a peer review body and did not require the filing of a report under section 805 of the Code. The court concluded that Kime had no right to a hearing under either the common law or statutory law. View "Kime v. Dignity Health, Inc." on Justia Law

The case involves Alice Chu, who was indicted in September 2019 and convicted of one count of conspiracy to commit health care fraud and five counts of health care fraud. Chu's trial was initially set for February 22, 2021, but due to the COVID-19 pandemic, the Chief Judge of the District of New Jersey issued multiple standing orders that delayed trials and excluded these delays from Speedy Trial Act (STA) calculations. Chu's trial eventually commenced on March 1, 2022.Chu moved to dismiss multiple times on STA grounds, arguing that the delays denied her right to a speedy trial under the Sixth Amendment and that the government abused the grand jury process causing inexcusable delay. The District Court denied these motions. After her conviction, Chu filed two motions for a new trial, claiming she was unfairly prejudiced by trial testimony about prior bad acts and that newly discovered evidence could change the probability of a conviction at trial. The District Court denied both motions.The United States Court of Appeals for the Third Circuit affirmed the District Court's decisions. The Court of Appeals agreed with the District Court that the exclusions resulting from the COVID-19 pandemic did not violate defendants’ rights under the STA. The Court also found no clear error in the District Court’s adoption of the factual findings contained within the COVID Standing Orders. The Court of Appeals further agreed with the District Court that Chu failed to show that the government’s “sole or dominant purpose” was to impermissibly delay her trial. The Court of Appeals concluded that the District Court did not abuse its discretion in denying Chu's motions for a new trial and that the evidence at trial was sufficient to prove Chu’s knowledge and intent to commit health care fraud. View "United States v. Chu" on Justia Law

The case involves a group of plaintiffs, led by Chris Calnan, who challenged a rule implemented by Maine Emergency Medical Services (Maine EMS) requiring emergency medical service (EMS) workers to be fully vaccinated against COVID-19 and influenza. The plaintiffs sought a declaratory judgment that Maine EMS lacked statutory authority to implement such a rule.The Superior Court (Kennebec County) dismissed the plaintiffs' complaint. The court concluded that the plaintiffs had named the correct defendants, that it had jurisdiction to consider the challenge to the rulemaking, and that the EMS Board acted within its authority in implementing the immunization rule. The court also dismissed the plaintiffs' motion for summary judgment as moot.On appeal, the Maine Supreme Judicial Court affirmed the lower court's decision. The court found that the EMS Board did not exceed its statutory authority in issuing the immunization rule. The court also concluded that the rule aligns with the purpose of the Maine Emergency Medical Services Act of 1982, which is to ensure optimum patient care and the safe handling and transportation of patients. Lastly, the court determined that the EMS Board followed the applicable rulemaking process for the promulgation of the immunization rule. View "Calnan v. Hurley" on Justia Law

The case revolves around a dispute over the amount of reimbursements for medical expenses that an insurer, Allstate Insurance Company, was required to pay under a personal injury protection (PIP) policy. The dispute arose when Revival Chiropractic, LLC, a medical provider, submitted charges for services rendered to two of Allstate's policyholders. Allstate paid 80% of the submitted charges, which was less than the amount that would have been reimbursable under the statutory schedule of maximum charges. Revival Chiropractic argued that Allstate was required to pay either 80% of the maximum charge under the schedule or the full amount of the submitted charge.The United States District Court for the Middle District of Florida agreed with Revival Chiropractic, ruling that Allstate violated Florida law by paying only 80% of the submitted charges when the charges were less than the amounts allowed under the statutory schedule of maximum charges. Allstate appealed the decision to the United States Court of Appeals for the Eleventh Circuit, which certified a question to the Supreme Court of Florida due to the lack of controlling precedent.The Supreme Court of Florida, after reviewing the relevant statutory provisions and the terms of Allstate's PIP policy, concluded that Allstate was entitled to pay 80% of the billed charges. The court found that the PIP policy expressly authorized such a payment and that nothing in the statutory scheme stood in the way of that policy provision. The court held that the PIP statute contemplates that an insurer providing notice that it may use the schedule of maximum charges will not thereby be precluded from paying 80% of reasonable charges as otherwise determined under the provisions of the statute. The court also rejected the argument that the statutory provision requiring an insurer to pay the full amount of the charge submitted when that amount is below the reimbursement payable under the schedule was mandatory. The court concluded that the provision was permissive and did not displace the statutory provision limiting reimbursements to 80% of reasonable charges. The court answered the certified question in the affirmative and returned the case to the Eleventh Circuit Court of Appeals. View "Allstate Insurance Company v. Revival Chiropractic, LLC" on Justia Law

In September 2020, George Fluitt was indicted on three counts of fraud and offering kickbacks related to genetic testing services that his company, Specialty Drug Testing LLC, provided to Medicare beneficiaries. As part of a nationwide investigation into genetic testing fraud, the Government executed search warrants at laboratories referred to as the Hurricane Shoals Entities (“HSE”), allegedly operated by Khalid Satary. The Government copied several terabytes of data from HSE, some of which were later determined to be material to Fluitt’s defense.In the lower courts, the Government established a “Filter Team” to review materials seized in its investigation and identify any that might be privileged. The Filter Team’s review was governed in part by a Protocol Order, which established a multi-step process for notifying a third party that it might have a claim of privilege and then adjudicating that claim. HSE and Satary provided privilege logs to the Filter Team, asserting thousands of claims of privilege. Both Fluitt and the Filter Team found these privilege logs to be facially deficient as they made only threadbare assertions of privilege, without any accompanying explanation.In the United States Court of Appeals Fifth Circuit, the court affirmed the lower court's decision. The court found that the appellants failed to establish their claims of privilege. The court also found that the appellants' argument that they are not bound by the Protocol Order was a red herring, as the magistrate judge evaluated the appellants’ privilege logs under the standards established by federal caselaw. The court also rejected the appellants' argument that Fluitt “has not shown a need for the documents” and has not “demonstrated any kind of relevancy.” The court found that the record suggests that Fluitt “has a need” for the potentially privileged documents, as the Government determined that the potentially privileged materials were material to preparing Fluitt’s defense. View "United States v. Fluitt" on Justia Law

The case revolves around a patient, Tommy Harris, who contracted bacterial sepsis due to repeated infections from his dialysis treatment at a clinic in Belleville, Illinois. Harris filed a malpractice lawsuit against the operators of the clinic and later included a claim against Durham Enterprises, Inc., the janitorial company responsible for cleaning the facility. The case primarily concerns Durham’s insurance coverage. Durham submitted the lawsuit to Ohio Security Insurance Company, its insurer, which denied coverage based on the insurance policy’s exclusion for injuries caused by fungi or bacteria. Harris and Durham then negotiated an agreement in which Durham promised not to mount a defense and Harris promised to seek recovery only from the insurer. The state trial judge granted a motion to sever Harris's claim against Durham and set it for a bench trial. The judge held a short, uncontested bench trial and entered judgment against Durham for more than $2 million.Ohio Security was not a party to the state court proceedings and the insurance policy was not in the record. However, the consent judgment includes findings on insurance issues, notably, that the insurer breached its duty to defend and is estopped from asserting any policy defenses. After the judgment became final, Harris filed an amended complaint purporting to add Ohio Security as a defendant. Ohio Security removed the action to federal court and sought a declaration of its coverage obligations. The district court held that the bacteria exclusion precludes coverage.In the United States Court of Appeals for the Seventh Circuit, Harris and Durham jointly appealed, challenging the no-coverage ruling but also raising a belated challenge to subject-matter jurisdiction under the Rooker–Feldman doctrine. The court found the jurisdictional argument meritless, as the Rooker–Feldman doctrine does not block federal jurisdiction over claims by nonparties to state-court judgments. The court also affirmed the district court's ruling that the policy’s bacteria exclusion precludes coverage for this loss. View "Mitchell v. Durham Enterprises, Inc." on Justia Law

The case involves Christine Matlock Dougherty, who sued U.S. Behavioral Health Plan, California (USB) for claims related to her son's healthcare. Dougherty's son, Ryan, was enrolled in a UnitedHealthcare HMO health plan, which Dougherty had access to through her employer. Ryan admitted himself into a residential treatment facility for severe drug addiction, but USB denied coverage for his stay after three days, arguing that he could be treated at home. Ryan fatally overdosed shortly after his discharge from the facility. Dougherty then sued USB, claiming that its wrongful denial of coverage for Ryan's treatment caused his death. USB petitioned to compel arbitration of her claims, but the trial court denied the petition, stating that USB's arbitration agreement was not enforceable because it did not comply with the disclosure requirements imposed by Health & Safety Code section 1363.1.The trial court denied USB's petition to compel arbitration on the grounds that the arbitration agreement did not comply with the disclosure requirements of Health & Safety Code section 1363.1. The court found that there were two separate contracts, one between Dougherty and UnitedHealthcare, and another between Dougherty and USB. The court ruled that the arbitration agreement in the supplement, which governed Dougherty's claims against USB, did not comply with section 1363.1's disclosure requirements.The Court of Appeal of the State of California Fourth Appellate District Division Two reversed the trial court's decision. The appellate court concluded that USB forfeited its argument that the issue of whether the arbitration agreement was valid under the disclosure requirements of section 1363.1 was delegated to the arbitrator. However, the court agreed with USB that the trial court erroneously denied USB’s petition because USB complied with section 1363.1. The court found that the only "health care service plan" at issue that "includes terms that require binding arbitration" is Dougherty’s plan with UnitedHealthcare, which includes both the EOC and the supplement as components of the plan. Therefore, the court concluded that there was no section 1363.1 violation and reversed the trial court's order denying the petition to compel arbitration. View "Dougherty v. U.S. Behavioral Health Plan" on Justia Law

The case involves a dispute over the adjusted Medicaid reimbursement rates for for-profit residential health care facilities in New York. The New York State Department of Health and its Commissioner, in response to a legislative mandate, eliminated a component known as the "residual equity reimbursement factor" from the computation formula used to set these rates. This change was part of a broader effort to reduce Medicaid costs in the state. The petitioners, 116 for-profit nursing homes, challenged this adjustment, arguing that it was retroactively applied and violated their rights under the Public Health Law and the Equal Protection Clause.The Supreme Court partially granted the petitioners' motion for a preliminary injunction against enforcement of the clause pending a final determination of the proceeding. It also partially granted the respondents' motion for summary judgment, dismissing the petitioners' claims that the adjusted rates were not "reasonable and adequate to meet costs" under the Public Health Law and violated their equal protection rights. However, the court found that the adjusted rates were improperly applied retroactively. The Appellate Division affirmed the Supreme Court's decision.The New York Court of Appeals, in its review, held that the Department of Health did not violate the legislature's intent when it announced the recalculated rates for services provided on or after April 2, 2020. The court found that the legislature clearly expressed its intent for the elimination clause to be applied without delay, and that the initial implementing ratemaking was not subject to the usual 60-day advance notice requirement. The court also rejected the petitioners' claims that the adjusted rates were not "reasonable and adequate to meet costs" and violated their equal protection rights. The court modified the order of the Appellate Division in accordance with its opinion and, as so modified, affirmed it. View "In re Aaron Manor Rehabilitation & Nursing Ctr., LLC v Zucker" on Justia Law