Justia Public Benefits Opinion Summaries

This case was a qui tam action alleging violations of the False Claims Act (“FCA”) involving fraudulent reimbursements under the Medicare Act. Plaintiff Gerald Polukoff, M.D., was a doctor who worked with Defendant Sherman Sorensen, M.D. After observing some of Sorensen’s medical practices, Polukoff brought this FCA action, on behalf of the United States, against Sorensen and the two hospitals where Sorensen worked (collectively, “Defendants”). Polukoff alleged Sorensen performed thousands of unnecessary heart surgeries and received reimbursement through the Medicare Act by fraudulently certifying that the surgeries were medically necessary. Polukoff further alleged the hospitals where Sorensen worked were complicit in and profited from Sorensen’s fraud. The district court granted Defendants’ motions to dismiss, reasoning that a medical judgment could not be false under the FCA. The Tenth Circuit reversed and remanded, holding that a doctor’s certification to the government that a procedure is “reasonable and necessary” is “false” under the FCA if the procedure was not reasonable and necessary under the government’s definition of the phrase. View "Polukoff v. St. Mark's Hospital" on Justia Law

At issue in this mandamus proceeding was whether the proportionate-responsbility scheme in Chapter 33 of the Texas Civil Practice and Remedies Code applies to a civil-remedy action under the Texas Medical Fraud Prevention Act (TMFPA).The State sued Xerox Corporation and Xerox State HealthCare, LLC (collectively, Xerox), which administered the Texas Medicaid program, for a civil remedy under the TMFPA. Xerox sought to unite the TMFPA proceedings for purposes of shifting liability to the service providers sued by the State who had directly received disputed Medicaid payments. The trial court granted the State’s motion to strike Xerox’s third-party petition seeking contribution under Chapter 33, holding Chapter 33 inapplicable to the TMFPA action. The court also denied Xerox’s motion to designate responsible third parties under Chapter 33. The Supreme Court denied Xerox’s petition for writ of mandamus, holding that Chapter 33 does not apply to a TMFPA action because (1) the statutory remedy does not constitute “damages” subject to apportionment under Chapter 33; and (2) an irreconcilable conflict exists between the proportionate-responsibility statute and the TMFPA’s mitigation and fault-allocation scheme. View "In re Xerox Corp." on Justia Law

In this interlocutory appeal, the Supreme Court held that sovereign immunity barred the counterclaims filed by Defendants against the State and that it lacked interlocutory jurisdiction to address the trial court’s dismissal of the Defendants’ third-party claims.The State brought this enforcement action under the Texas Medicaid Fraud Prevention Act, alleging that Defendants - several dentists and their professional associations and employees - fraudulently obtained Medicaid payments for providing dental and orthodontic treatments to children. Defendants asserted counterclaims and third-party claims alleging that the State and its contractor mismanaged the payment-approval process and misled Defendants regarding the requirements imposed by the Texas Medical Program. The trial court granted the State’s plea to the jurisdiction against the counterclaims and motion to dismiss the third-party claims. Defendants filed this interlocutory appeal. The court of appeals affirmed the trial court’s order dismissing Defendants’ counterclaims and concluded that it lacked jurisdiction over the order dismissing the third-party claims. The Supreme Court affirmed, holding (1) sovereign immunity barred the counterclaims, and (2) this Court lacked interlocutory jurisdiction to address the order dismissing the third-party claims. View "Nazari v. State" on Justia Law

Plaintiffs were 23 federally qualified health centers (FQHC’s) and rural health clinics (RHC’s) that served medically underserved populations (the Clinics). The dispute before the Court of Appeal centered on coverage for adult dental, chiropractic, and podiatric services the FQHC’s and RHC’s provided to Medi-Cal patients for a period between 2009 and 2013. Prior to July 1, 2009, the Department processed and paid claims for these services. In 2009, in a cost-cutting measure due to budget problems, the Legislature enacted Welfare and Institutions Code section 14131.101 to exclude coverage for these services (and others) “to the extent permitted by federal law.” After the Department stopped paying claims for these services, various FQHC’s and RHC’s challenged the validity of section 14131.10, claiming it conflicted with federal Medicaid law. In California Assn. of Rural Health Clinics v. Douglas, 738 F.3d 1007 (9th Cir. 2013), the Ninth Circuit held section 14131.10 was invalid to the extent it eliminated coverage for these services when provided by FQHC’s and RHC’s because the federal Medicaid Act imposed on participating states the obligation to cover these services by these providers. In response to CARHC, the Department announced it would reimburse FQHC’s and RHC’s for these services for dates of service only on or after September 26, 2013, the date of the Ninth Circuit’s mandate. Seeking reimbursement for services provided prior to September 26, 2103, the Clinics petitioned for a writ of mandate to compel the Department to accept, process, and pay claims for these services for the period July 1, 2009, to September 26, 2013. The trial court granted the petition in part and entered judgment for the Clinics. The Department appeals. Characterizing the Clinics’ writ petition as a suit for damages, it contended: (1) sovereign immunity barred the Clinics’ claims for retroactive payment; (2) the CARHC decision was retroactive because the Medicaid Act is spending clause legislation and its terms were not sufficiently clear as to the requirement to cover adult dental, chiropractic, and podiatric services provided by FQHC’s and RHC’s; and (3) retroactive relief violated the separation of powers doctrine because it forces the Legislature to appropriate money. The Court of Appeal disagreed with the Department’s characterization of the Clinics’ lawsuit. "Rather than a suit for damages, the lawsuit seeks an order to compel performance of a mandatory duty and did not result in a money judgment. Under well-settled California law, such a mandamus proceeding is not barred by sovereign immunity. The Department’s contentions based on spending clause legislation and separation of powers are new arguments raised for the first time on appeal. We exercise our discretion to consider only the spending clause argument. We reject it because the Department has not shown its obligations under Medicaid law, as determined by CARHC, came as a surprise. The separation of powers argument raises factual issues about appropriations that should have been presented in the trial court and we decline to consider this new argument." Accordingly, the Court affirmed the judgment. View "American Indian Health etc. v. Kent" on Justia Law

Raymond, a veteran of the U.S. Air Force, was born in 1947 and was a long-term resident of Middlesboro, Kentucky. He worked in the coal-mining industry for over 20 years and developed severe respiratory issues. Raymond, a non-smoker, sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901, but died while his claim was pending. Raymond’s claim was consolidated with a claim for survivor’s benefits submitted by his widow, Joanna. The ALJ awarded benefits to Joanna, on both Raymond’s behalf, and as his surviving spouse. The Benefits Review Board affirmed. Zurich, the insurer of Straight Creek Coal, sought review. The Sixth Circuit denied Zurich’s petition, upholding the ALJ’s conclusions that Zurich failed to rebut the presumption of timeliness, that Raymond had worked for at least 15 years in qualifying employment, and that Raymond had a total respiratory disability. Raymond worked only in surface mines or coal-preparation plants during his career; the ALJ properly relied on 20 C.F.R. 718.305(b)(2) and determined whether Raymond’s mining employment was “substantially similar” to underground mining. View "Zurich American Insurance Group v. Duncan" on Justia Law

Stephens was born in 1957 and has a ninth-grade education. He worked as a taxi dispatcher and a security guard in the 15 years preceding his alleged disability. Stephens contends that he is disabled by diabetes, kidney disease, knee and back pain, heart disease, high blood pressure, asthma, arthritis, and obesity. He was denied Supplemental Security Income (SSI) benefits. On remand, a different ALJ determined that Stephens’ impairments, although severe, were not disabling and that he could perform relevant past work. The district court and Seventh Circuit upheld the denial, rejecting arguments that the ALJ erred by improperly evaluating Stephens’s obesity (no longer a stand-alone disability) when determining the aggregate impact of his impairments; that the ALJ’s finding that the record lacked medical opinion evidence as to Stephens’ hypersomnolence or excessive sleepiness; and that the ALJ failed to incorporate all of his impairments and consider their combined impact to evaluate his residual functional capacity. View "Stephens v. Berryhill" on Justia Law

Stephens was born in 1957 and has a ninth-grade education. He worked as a taxi dispatcher and a security guard in the 15 years preceding his alleged disability. Stephens contends that he is disabled by diabetes, kidney disease, knee and back pain, heart disease, high blood pressure, asthma, arthritis, and obesity. He was denied Supplemental Security Income (SSI) benefits. On remand, a different ALJ determined that Stephens’ impairments, although severe, were not disabling and that he could perform relevant past work. The district court and Seventh Circuit upheld the denial, rejecting arguments that the ALJ erred by improperly evaluating Stephens’s obesity (no longer a stand-alone disability) when determining the aggregate impact of his impairments; that the ALJ’s finding that the record lacked medical opinion evidence as to Stephens’ hypersomnolence or excessive sleepiness; and that the ALJ failed to incorporate all of his impairments and consider their combined impact to evaluate his residual functional capacity. View "Stephens v. Berryhill" on Justia Law

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

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

The Ninth Circuit affirmed the district court's grant of summary judgment for the Department in an action brought by private ambulance companies challenging the reimbursement rate for their transportation of patients covered by Medi-Cal. The panel held that plaintiffs failed to carry their burden of producing evidence upon which a reasonable jury could return a verdict in their favor and thus the district court did not err in entering judgment in the Department's favor on the Takings Clause claim. The panel reasoned that the ambulance companies lacked a constitutionally protected property interest in a particular reimbursement rate, but the mandatory-care provision of Cal. Health & Safety Code 1317(d) implicated a constitutionally protected property right. The panel held that section 1317(d) did not effect a regulatory taking under the Penn Central test. The panel also held that the ambulance companies did not establish a due process claim regarding DHCS's failure to ensure that Medi-Cal reimbursement rates kept pace with their costs because they lacked a constitutionally protected interest in any particular reimbursement rate. View "Sierra Medical Services Alliance v. Kent" on Justia Law