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Twelve Medicaid-participating hospitals (“Hospitals”) challenged the Department of Medicaid’s (“DOM’s”) recalculation of their Medicaid outpatient rates for fiscal year 2001. The chancery court affirmed the opinion of the DOM, finding that “DOM interpreted its own regulation – the State Plan, which is its contract with the federal government and which it is required to follow to receive federal funds to require Medicaid to calculate the cost to charge ratio by using Medicare Methodology, which at that time was using a blended rate.” The Mississippi Supreme Court found the plain language of Attachment 4.19-B of the State Plan provided a cost-to-charge-ratio formula for calculating outpatient rates. Laboratory and radiology charges were to be excluded from this formula, because they were reimbursed on a fee-for-service basis. DOM’s inclusion of radiology and laboratory services in the charges and substitution of costs with Medicare blended payment amounts was a clear violation of the State Plan. Therefore, the Court reversed the judgments of DOM and the chancery court. Consistent with its opinion, the Court remanded and ordered the Executive Director of DOM to recalculate the Hospitals’ cost-to-charge ratio using the Hospital’s submitted costs in their cost reports, excluding laboratory and radiology services, and reimbursing the Hospitals the appropriate amounts determined by using the State Plan. View "Crossgates River Oaks Hospital v. Mississippi Division of Medicaid" on Justia Law

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The Supreme Court affirmed the district court’s grant of summary judgment in favor of Defendants, holding that Plaintiffs' claims were either moot or failed to state a claim as a matter of law. The hospital at which an injured child received medical care sought to secure payment for that care by asserting liens against the child’s interest in the tort claim against the driver of the car that struck the child. The child and his mother brought claims against the hospital owner and its payments vendor, arguing that the liens violated Medicaid law. When the liens were released, the district court granted summary judgment in favor of Defendants. The Supreme Court affirmed on the principles of mootness and Plaintiffs’ failure to state a claim as a matter of law. View "Shaffer v. IHC Health Services, Inc." on Justia Law

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The Supreme Court affirmed the district court’s grant of summary judgment in favor of Defendants, holding that Plaintiffs' claims were either moot or failed to state a claim as a matter of law. The hospital at which an injured child received medical care sought to secure payment for that care by asserting liens against the child’s interest in the tort claim against the driver of the car that struck the child. The child and his mother brought claims against the hospital owner and its payments vendor, arguing that the liens violated Medicaid law. When the liens were released, the district court granted summary judgment in favor of Defendants. The Supreme Court affirmed on the principles of mootness and Plaintiffs’ failure to state a claim as a matter of law. View "Shaffer v. IHC Health Services, Inc." on Justia Law

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Akin, a 47-year-old woman, claims that she became disabled in 2011 principally from fibromyalgia, back and neck pain, and headaches. An administrative law judge denied her application for Supplemental Security Income. The Seventh Circuit remanded, based on Akin’s arguments that the ALJ wrongly discounted her allegations of back pain; improperly credited the opinions of agency physicians who had not reviewed all of the medical records, including relevant MRI scans; and ignored her complaints of headaches. The ALJ impermissibly “played doctor” by impermissibly interpreting the MRI results himself. The ALJ should have developed a more fulsome record about Akin’s testimony of pain before discounting it and improperly discredited Akin because of her conservative course of treatment. View "Akin v. Berryhill" on Justia Law

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The First Circuit affirmed the district court’s ruling that the “set-off rule” announced by the United States Secretary of Health and Human Services (Secretary) in the form of answers to Frequently Asked Questions (FAQs) posted on medicaid.gov represented a substantive policy decision that could not be adopted without notice and comment. In 1981, Congress authorized the payment of sums in addition to Medicaid payments hospitals that treat indigent patients receive in order to cover the full costs of care. Congress later passed a law seeking to cap those payments at each hospital’s “costs incurred.” At issue was to what extent “costs incurred” equals the total costs of service rather than the costs net of payments from sources such as Medicare and private insurance. With two exceptions, Congress stated that “costs incurred” are “as determined by the Secretary.” In 2010, the Secretary made its FAQs announcement that the payments to be offset against total costs in calculating “costs incurred” also included reimbursements received from Medicare and private insurance. The First Circuit held that the Secretary’s rule was procedurally improper for having failed to observe the notice-and-comment procedures prescribed by the Administrative Procedure Act. View "New Hampshire Hospital Ass’n v. Hargan" on Justia Law

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The Supreme Court affirmed in part and reversed and remanded in part the decision of the Workers’ Compensation Court of Appeals (WCCA) upholding the decision of the compensation judge ordering that Atlas Staffing, Inc. and its insurer, Meadowbrook Claims Services, pay workers’ compensation benefits to Anthony Gist. The compensation judge found that Gist’s exposure to silica, a known cause of end stage renal disease (ESRD), during his employment with Atlas was a substantial contributing factor to his kidney disease. In the consolidated appeals brought by Appellants and Fresenius Medical Care, which treated Gist after Appellants denied coverage and accepted payments from Medicaid and Medicare for the costs of that treatment, the Supreme Court held (1) the compensation judge did not abuse her discretion by relying on a certain medical report to find that work-related silica exposure was a substantial contributing factor to Gist’s kidney failure; (2) under 42 C.F.R. 447.15, a provider cannot recover payment from third parties for any services billed to Medicaid after the provider has accepted payment from Medicaid for those services; and (3) the WCCA erred when it dismissed Fresenius’s cross-appeal as untimely. View "Gist v. Atlas Staffing, Inc." on Justia Law

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The First Circuit affirmed the district court’s decision affirming an administrative law judge’s (ALJ) finding that Appellant was not disabled within the meaning of the Social Security Act and thus not entitled to Supplemental Security Income benefits, holding that the ALJ’s determination was supported by substantial evidence. Specifically, the Court held (1) the ALJ did not err in according only slight weight to the testimony of an orthopedic physician who treated Appellant for a non-displaced fracture of her left femur; and (2) the ALJ was entitled to rely on testimony of an impartial vocational expert presented by the Commissioner of the Social Security Administration about available jobs that Appellant was entitled to perform. View "Purdy v. Berryhill" on Justia Law

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Saunders served on active duty in the Army, 1987-1994. Saunders did not previously experience knee problems but, during her service, sought treatment for knee pain and was diagnosed with patellofemoral pain syndrome (PFPS). Saunders’s exit examination reflected normal lower extremities but noted Saunders’s history of knee swelling. The VA denied Saunders’s 1994 claim for disability compensation because she failed to report for a medical examination. In 2008, Saunders filed a new claim, which was denied. In 2011, a VA examiner noted that Saunders reported bilateral knee pain while running, squatting, bending, and climbing but had no anatomic abnormality, weakness, or reduced range of motion. Saunders had functional limitations on walking, was unable to stand for more than a few minutes, and sometimes required a cane or brace. The examiner concluded that Saunders’s knee condition was at least as likely as not caused by, or a result of, Saunders’s military service but stated there was no pathology to render a diagnosis. The Board of Veterans’ Appeals and Veterans Court rejected her claim under 38 U.S.C. 1110. The Federal Circuit reversed; “disability” in section 1110 refers to the functional impairment of earning capacity, not the underlying cause, which need not be diagnosed. Pain alone can serve as a functional impairment and qualify as a disability, no matter the underlying cause. View "Saunders v. Wilkie" on Justia Law

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The Ninth Circuit reversed the district court's partial grant of summary judgment for the Department and held that the Department did not violate the dormant Commerce Clause in adopting Medi-Cal policies related to reimbursement to out-of-state hospitals. The panel held that when a state was acting as a market participant, rather than a market regulator, its decisions were exempted from the dormant Commerce Clause. In this case, the Department sets rates of reimbursement to hospitals for those who were essentially insured as beneficiaries under Medi-Cal in a manner much like that of a private insurer participating in the market. Therefore, the Department was acting as a market participant, rather than a regulator and was exempt from dormant Commerce Clause requirements. View "Asante v. California Department of Healthcare Services" on Justia Law

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The Supreme Court affirmed in part and reversed in part a district court order granting in part and denying in part judicial review of the Montana Department of Public Health and Human Services (DPHHS) fair hearing proposed decision that DPHHS overpaid IMS under the Medicaid program and was entitled to reimbursement in the amount of $670,152 from Independence Medical Supply, Inc. (IMS). IMS appealed, and DPHHS cross appealed the district court’s order. The Supreme Court held (1) the district court did not abuse its discretion by affirming the hearing officer’s determination that physician affidavits introduced by IMS did not cure technical violations of the supply orders submitted to DPHHS; and (2) the district court erred in holding that a letter sent by DPHHS on January 8, 2014 commenced an action for recovery of the overpayment because DPHHS did not commence an action within the meaning of Mont. Code Ann. 27-2-102(1)(b) and Mont. R. Civ. P. 3. View "Independence Medical Supply, Inc. v. Montana Department of Public Health & Human Services" on Justia Law