Justia Civil Procedure Opinion Summaries

In 2016, the Secretary of Health and Human Services (“HHS”) issued a final rule that implemented The Protecting Access to Medicare Act of 2014 (“PAMA” or “Act”), definition of “applicable laboratory” (“2016 Rule”). The American Clinical Laboratory Association (“ACLA”) filed a lawsuit challenging the 2016 Rule as arbitrary and capricious under the Administrative Procedure Act (“APA”) on the basis that it depresses Medicare reimbursement rates by excluding most hospital laboratories from PAMA’s reporting requirements. ACLA contended that because hospital laboratories tend to charge higher prices than standalone laboratories, their exclusion from reporting obligations results in an artificially low weighted median.   On remand, the parties cross-moved for summary judgment. The district court declined to reach the merits of ACLA’s APA challenge to the 2016 Rule, based on its determination that the Secretary had issued a new rule (“2018 Rule”) that superseded the 2016 Rule and mooted ACLA’s lawsuit.   The DC Circuit concluded that the case is not moot. Accordingly, the court reversed the district court’s dismissal for lack of subject matter jurisdiction and reached the merits of ACLA’s APA claim. The court explained that the 2016 Rule is arbitrary and capricious because the agency “failed to consider an important aspect of the problem.” The court wrote that PAMA provides that an applicable laboratory “means a laboratory that” receives “a majority” of its Medicare revenues from the Physician Fee Schedule or Clinical Laboratory Fee Schedule. Thus, hospital laboratories that provide outreach services may, in some instances, constitute “applicable laboratories” under PAMA. View "American Clinical Laboratory Association v. Xavier Becerra" on Justia Law

Genesis Healthcare was a healthcare provider participating in the federal “340B Program,” which was designed to provide drugs to qualified persons at discounted prices. Under the Program, the Secretary of the Department of Health and Human Services (“HHS”) enters into agreements with drug manufacturers to sell drugs at discounted prices to entities such as Genesis Healthcare, which could, in turn, sell the drugs to their patients at discounted prices. After Genesis Healthcare purchased the covered drugs from the manufacturers, it dispensed them to patients through its wholly owned pharmacies or contract pharmacies. After the Health Resources and Services Administration (“HRSA”) conducted an audit of Genesis Healthcare in June 2017 for Program compliance, HRSA removed Genesis Healthcare from the 340B Program. The audit report found, among other things, that Genesis Healthcare dispensed 340B drugs to individuals who were ineligible because they were not “patients” of Genesis Healthcare. HRSA rejected Genesis Healthcare’s challenges; Genesis Healthcare, in turn, filed suit seeking a declaration it did not violate the requirements of the Program, and injunctive relief requiring HRSA to reinstate it into the Program and to retract any notifications that HRSA had provided to manufacturers stating that Genesis Healthcare was ineligible under the Program. In response to the lawsuit, HRSA ultimately: (1) notified Genesis Healthcare by letter that it “ha[d] voided” all audit findings and that Genesis Healthcare “ha[d] no further obligations or responsibilities in regard to the audit” and (2) filed a motion to dismiss Genesis Healthcare’s action as moot based on the letter. The district court granted HRSA’s motion, finding that the action was moot. The Fourth Circuit reversed the district court's finding the case was moot: Genesis Healthcare continued to be governed by a definition of “patient” that, Genesis maintained, was illegal and harmful to it. Therefore, there remained a live controversy between the parties. View "Genesis HealthCare, Inc. v. Becerra" on Justia Law

Patricia Allen appealed the Idaho Industrial Commission’s (the “Commission”) decision denying unemployment benefits. Allen was employed by Partners in Healthcare, Inc., doing business as North Canyon Medical Center (“NCMC”), between February 5, 1999, and May 8, 2020. On May 8, 2020, the CEO of NCMC and the HR director met with Allen to discuss her job performance. Allen was presented with a performance improvement plan (“PIP”), which outlined examples of Allen’s poor job performance and identified expectations for improving her performance. It was explained to Allen that if she wanted to forego the PIP, she could sign a severance agreement. Allen was then presented with a proposed severance agreement. Allen asked if she could discuss her options with her husband, but was pressed to make her decision then and there. The CEO told Allen that he thought it was in her best interest to take the severance package. Allen decided to forgo the PIP and took the severance agreement. After separating from NCMC, Allen filed an unemployment claim with the Idaho Department of Labor (“IDOL”). NCMC’s response to the Idaho Department of Labor was prepared by the Idaho Hospital Association (“IHA”), NCMC’s third-party administrator. IHA’s human resources director identified Allen’s reason for separation as “Fired/Discharged” and indicated Allen did not receive any compensation after her separation. IDOL determined Allen was eligible for unemployment benefits. NCMC’s HR director appealed the IDOL decision; IDOL sent NCMC and Allen a hearing notice on whether Allen quit voluntarily and, if so, whether she quit for good cause or was discharged for misconduct in connection with her employment. Following the hearing, the appeals examiner issued a written decision that denied Allen unemployment benefits. The examiner also found that Allen did not follow the grievance procedures to report her issues with her supervisor prior to quitting. In reversing the Commission’s decision, the Idaho Supreme Court concluded the Commission erred in failing to analyze whether the PIP was a viable option that would have allowed Allen to continue working. The matter was remanded for further proceedings. View "Allen v. Partners in Healthcare, Inc." on Justia Law

Plaintiff’s doctors prescribed him Optune, a medical technology that had recently received FDA approval for treating recurrent GBM. The device delivers tumor treating field therapy (TTFT) to inhibit cancer-cell replication. A company called Novocure is the sole supplier of the Optune device, which is rented by patients on a monthly basis.   Because Plaintiff is a Medicare Part B beneficiary, he and Novocure asked Medicare to cover his TTFT. Novocure was held liable for the claims. Plaintiff and Novocure submitted 13 claims to Medicare, corresponding to 13 months of TTFT. The district court held that Plaintiff lacked standing because he hadn’t suffered an injury in fact.   The Eleventh Circuit was tasked with deciding whether Plaintiff has standing to challenge a denial of Medicare coverage where the costs of his treatment were imposed not on him, but rather on a third-party supplier. The court affirmed the district court’s determination that Plaintiff hadn’t suffered an injury in fact.   Here, Plaintiff’s alleged harm will only come to pass due to the challenged action if, at some indefinite point in the future: (1) his condition worsens, (2) he has paid his premiums and stayed on Medicare Part B, (3) he elects to resume TTFT, (4) his doctor prescribes the therapy (5) Plaintiff receives the treatment, (6) he files a claim, (7) which is denied at every level of the Medicare appeals process, (8) the adjudicators determine that Plaintiff’s hypothetical future case presents a “comparable situation,” and (9) they further find that the instant coverage denial and no other source put Plaintiff on notice that he could be held liable. View "Edwin R. Banks v. Secretary, Department of Health and Human Services" on Justia Law

In July 2019, the Appeals Council denied Claimant’s appeal without elaboration. Claimant challenged, among other rulings, the ALJ’s analysis of her testimony. Claimant did not assert any constitutional challenges to the district court. The district court entered a judgment reversing the ALJ’s denial of benefits and remanded the matter to the agency for further proceedings. The Commissioner filed a motion pursuant to Federal Rule of Civil Procedure 59(e) to amend or alter the judgment, arguing that the court had clearly erred by overlooking the ALJ’s explanation for rejecting Claimant’s testimony. The district court agreed with the Commissioner and entered an order granting the Rule 59(e) motion   The Ninth Circuit affirmed the amended judgment in favor of the Commissioner.  The court upheld the Commissioner’s decision denying her application for benefits because claimant did not show that the removal provision caused her any actual harm. Further, Federal Rule of Civil Procedure 59(e) allows a district court to alter or amend a judgment if the court determines that its original judgment was clearly erroneous. Because the district court properly concluded that it had clearly erred in its original ruling in favor of Claimant, the court’s granting of the Commissioner’s Rule 59(e) motion fell within the court’s considerable discretion View "JODY KAUFMANN V. KILOLO KIJAKAZI" on Justia Law

The Department of Human Services for Arapahoe County (“the Department”) sued Monica Velarde and Michael Moore to enforce a final order it had issued against them to recover Medicaid overpayments. But the Department did so only after undertaking extensive efforts on its own to recoup the fraudulently obtained benefits. The district court dismissed the Department’s suit, finding that section 24-4-106(4), C.R.S. (2021), which was part of the State Administrative Procedure Act (“APA”), required an agency seeking judicial enforcement of one of its final orders to do so within thirty-five days of the order’s effective date. The Colorado Supreme Court determined district court and the court of appeals incorrectly relied on an inapplicable statutory deadline in ruling that the complaint was untimely filed. Each court was called upon to determine whether a thirty-five-day deadline governing proceedings initiated by an adversely affected or aggrieved person seeking judicial review of an agency’s action also applied to proceedings initiated by an agency seeking judicial enforcement of one of its final orders. Both courts answered yes. The Supreme Court, however, answered no. Judgment was reversed and the case remanded for further proceedings. View "Arapahoe County v. Velarde & Moore" on Justia Law

In 2012, United Healthcare of Mississippi (United) entered into provider agreements with Mississippi’s fourteen Community Mental Health Centers (CMHCs) to provide Medicaid services under the Division of Medicaid’s (DOM’s) managed care program. From 2012 until 2019, United paid the CMHCs an agreed upon amount for Medicaid services - 100 percent of the medicaid fee schedule rates. In July 2019, United unilaterally imposed a 5 percent rate cut, retroactive to January 1, 2019, and later demanded that the CMHCs refund 5 percent of all payments made from July 1, 2018, through December 31, 2018, all of which totaled more than $1 million. The CMCHs demanded that United immediately cease and desist from the 5 percent rate cut and recoupments. When United refused, the CMHCs filed a Complaint for Damages and Injunctive Relief, specifically requesting, inter alia, a preliminary injunction. United responded with a motion to compel arbitration and to stay the proceedings. After a two-day evidentiary hearing, the circuit court denied United’s motion to compel arbitration, granted the CMHCs’ request for injunctive relief, and issued a preliminary injunction. The limited issues presented to the Mississippi Supreme Court were whether the trial court properly enjoined United from imposing a 5 percent rate cut and whether the trial court erred by denying arbitration. After review, the Supreme Court affirmed the trial court’s decision to grant a preliminary injunction and to deny the motion to compel arbitration. View "United Healthcare of Mississippi Inc. et al. v. Mississippi's Community Mental Health Commissions, et al." on Justia Law

Plaintiffs-appellees Ronda Owens, Darryl Hubbard, Selena Freymiller, Shanika Crowley, Valerie Killman, Michael Lee Pitts, Ebony Warrior, John Ball, Michelle Bullock, Logan Bellew, Sondia Bell, Tumeeka Baker, and Jay Reid (collectively "Citizens") filed the underlying lawsuit seeking declaratory and injunctive relief. Citizens claimed that Oklahoma Governor J. Kevin Stitt and Defendant-appellant Shelley Zumwalt, in her official capacity as Executive Director of the Oklahoma Employment Security Commission, acted without authority and violated 40 O.S.2011 section 4-313 of the Oklahoma Employment Security Act by terminating agreements with the U.S. Department of Labor to administer COVID-related unemployment programs. The trial court entered a preliminary injunction ordering Zumwalt to immediately reinstate and administer the programs. Zumwalt appealed, and the Oklahoma Supreme Court stayed the trial court's order pending appeal. The Supreme Court found 40 O.S. 4-313 did not create a private right of action and, therefore, the trial court abused its discretion by granting a preliminary injunction. View "Owens, et al. v. Zumwalt" on Justia Law

The State redesigned the dental insurance plan offered to public retirees in 2014, narrowing coverage but also decreasing premiums paid by retirees. The Retired Public Employees of Alaska challenged the redesign. After a bench trial the superior court concluded that the new plan unconstitutionally diminished retirees’ accrued benefits. The State appealed, arguing that the superior court erred by determining the dental plan was a constitutionally protected “accrued benefit” and by refusing to consider premium rates for retirees as relevant to the diminishment analysis. The Alaska Supreme Court agreed with the State on the second point only: "The Alaska Constitution does protect public retirees’ option to purchase dental insurance as an accrued benefit, but both coverage for retirees and price to retirees influence the value of this option." The Court therefore vacated and remanded for the superior court to reevaluate the plan changes and incorporate premium pricing into its analysis. View "Tshibaka v. Retired Public Employees of Alaska, Inc." on Justia Law

This case arose from the cancellation of long-term-care Medicaid benefits for two claimants when an Oklahoma agency concluded that the claimants’ resources exceeded the regulatory cap for eligibility. One claimant, Idabelle Schnoebelen died, mooting her claim. The eligibility of the other claimant, Nelta Rose, turned on whether her resources included a 2018 promissory note. In 2017 and 2018, Rose loaned money to her daughter-in-law in exchange for three promissory notes. The daughter-in-law provided the first two promissory notes in 2017 (before Rose applied for Medicaid benefits). The Oklahoma Department of Human Services initially approved Rose for Medicaid, declining to regard the 2017 promissory notes as resources. In 2018, the daughter-in-law provided the third promissory note. But the Department of Human Services concluded that the 2018 promissory note: (1) was a resource because the payment to the daughter-in-law did not constitute a bona fide loan; and (2) was a deferral that turned the 2017 promissory notes into resources. The extra resources put Rose over the eligibility limit for Medicaid, so the Department of Human Services cancelled Rose’s benefits. A district court concluded that the agency’s conclusion did not conflict with federal law. In the Tenth Circuit's view, however, a reasonable factfinder could disagree. Summary judgment was reversed and the matter remanded for further proceedings. View "Baker, et al. v. Brown, et al." on Justia Law