Justia Public Benefits Opinion Summaries

Plaintiff is a health insurance company that offers a choice of federal government-regulated alternatives to Medicare known as Medicare Advantage plans. These plans allow Medicare-eligible individuals to purchase health insurance from private insurance companies. Those companies are reimbursed by the government for health care services provided to the plans’ members. Before the Supreme Judicial Court was Plaintiff’s demand for indemnification to cover losses resulting from health care claims for unprovided services paid through Plaintiff’s computer system. At issue was the coverage available to Plaintiff pursuant to Rider #3 of a financial institution bond issued by Defendant. The bond insured Plaintiff against various losses, and the Rider amended the bond to provide indemnification specifically for computer systems fraud. When Plaintiff suffered more than $18 million in losses for payment for fraudulent claims for services never actually performed under its Medicare Advantage plans, Plaintiff sought payment from Defendant for its post-deductible losses. Defendant denied coverage, and Plaintiff sued. Supreme Court granted summary judgment for Defendant. The Court of Appeals affirmed, holding that the Rider applies to losses resulting directly from fraudulent access, not to losses from the content submitted by authorized users. View "Universal Am. Corp. v Nat’l Union Fire Ins. Co. of Pittsburgh, PA" on Justia Law

Hansler was hired by Lehigh Valley in 2011. In 2013, Hansler began experiencing shortness of breath, nausea, and vomiting, of unknown origins. Hansler’s physician completed a medical certification form “requesting intermittent leave at a frequency of 2 times weekly starting on March 1, 2013 and lasting for a probable duration of one month.” Hansler submitted the certification as part of a formal request for leave under the Family Medical Leave Act, 29 U.S.C. 2601. Hansler was unable to work on March 13, 14, 23, 24, and 25. Without seeking further information from either Hansler or her physician, Lehigh terminated Hansler on March 28, citing absenteeism, including the five days she took off in March. Lehigh informed her, for the first time, that her leave request had been denied because her “condition presently does not qualify as a serious health condition under the criteria set forth by the [Act].” After her dismissal, Hansler received a diagnosis of diabetes and high blood pressure. The district court dismissed her suit under the Act, on the basis that the medical certification supporting Hansler’s request for leave was “invalid.” The Third Circuit reversed, finding that Lehigh violated the Act in failing to afford Hansler a chance to cure any deficiencies in her medical certification. View "Hansler v. Lehigh Valley Hosp. Network" on Justia Law

Plaintiff Diane Stayton suffered serious burns while a resident at Harbor Healthcare and Rehabilitation Center ("Harbor Healthcare"), a skilled nursing center in Lewes. She sued alleging medical negligence against those responsible for her care. In addition to general damages, Stayton sought special damages for the cost of her medical care after she was burned. Absent Medicare coverage, the burn hospital and other providers who treated her for her injuries would have billed Stayton $3,683,797.11. Because Stayton qualified for Medicare, the Centers for Medicare and Medicaid Services ("CMS") paid Stayton's healthcare providers $262,550.17 in full satisfaction of the expense of Stayton's hospital stay and other care. Medicare regulations required the write-off of $3,421,246.94, and Stayton's healthcare providers could not "balance bill" her for the amount written off. Defendants moved for judgment on the pleadings seeking judgment as a matter of law that Stayton's medical expense damages were limited to the amount actually paid by CMS, rather than the amount Stayton might have been billed for her care. Stayton opposed the motion, relying on the collateral source rule. The Superior Court granted defendants' motion, and limited Stayton's medical expense claim to the amount paid by CMS. The court decided that the collateral source rule did not apply to amounts required by federal law to be written off by healthcare providers. On appeal to the Supreme Court, Stayton argued that the Superior Court should have applied the collateral source rule to the Medicare write-offs. The Supreme Court concluded the collateral source rule did not apply to amounts required to be written off by Medicare. "Where a healthcare provider has treated a plaintiff covered by Medicare, the amount paid for medical services is the amount recoverable by the plaintiff as medical expense damages." View "Stayton v. Delaware Health Corporation, et al." on Justia Law

In 2013, Emma Reiger entered the Good Samaritan Society's basic care facility. She executed a general durable power of attorney appointing two women "to be my attorneys-in-fact and co-agents in my name and for my benefit." Rieger signed a "Designation of Authorized Representative" authorizing the Society to "(i) initiate an application for Medicaid benefits on my behalf, (ii) participate in all reviews of my eligibility for Medicaid benefits and (iii) take such action as may be necessary to establish my eligibility for Medicaid." On the same date, Rieger signed a separate document titled, "Assignment of Medicaid Benefits," which assigned to the Society her right to obtain Medicaid benefits for services provided to her by the Society, and an "Authorization for Release of Health Information." These documents were provided to the Department of Human Services. The Department oappealed a judgment reversing the Department's dismissal of Rieger's appeal challenging its denial of her Medicaid application and remanding for a fair hearing on the application. Because the law allowed The Evangelical Good Samaritan Society, doing business as the Good Samaritan Society - Mott ("Society"), to act as Rieger's authorized representative for purposes of appealing the Department's denial of her Medicaid application, the Court affirmed the judgment. View "Evangelical Good Samaritan Society v. N.D. Dep't of Human Services" on Justia Law

The Medicare program provides federally funded healthcare to the elderly and the disabled. See Title XVIII of the Social Security Act, 42 U.S.C. 1395. Under a “complex statutory and regulatory regime” called Medicare Part A, the Government reimburses participating hospitals for care that they provide to inpatient Medicare beneficiaries. Most hospitals are reimbursed for inpatient hospital services pursuant to a standardized rate, but the Social Security Act also provides a method for calculating reimbursement rates for certain rural hospitals that qualify as “sole community hospital[s]” (SCHs) or that qualify as “medicare-dependent small rural hospital[s]” (MDHs). SCHs and MDHs receive reimbursement based on either the standard rate or a hospital-specific rate derived from its actual costs of treatment in one of the base years specified in the statute, whichever is higher. MDHs and SCHs challenged revisions to the rules covering their Medicare reimbursements for inpatient hospital services, arguing that the Medicare statute forbids the Secretary from modifying the hospitals’ reimbursements with budget neutrality adjustments from years prior to the base year. The district court rejected the claims. The D.C. Circuit affirmed, finding that the revisions were neither arbitrary nor manifestly contrary to the statute. View "Adirondack Med. Ctr. v. Burwell" on Justia Law

Providers of “habilitation services” under Idaho’s Medicaid plan are reimbursed by the state Department of Health and Welfare. Section 30(A) of the Medicaid Act requires Idaho’s plan to “assure that payments are consistent with efficiency, economy, and quality of care” while “safeguard[ing] against unnecessary utilization of . . . care and services,” 42 U.S.C. 1396a(a)(30)(A). Providers of habilitation services claimed that Idaho reimbursed them at rates lower than section 30(A) permits. The district court entered summary judgment for the providers. The Ninth Circuit affirmed, concluding that the Supremacy Clause gave the providers an implied right of action, under which they could seek an injunction requiring compliance. The Supreme Court reversed, concluding that there is no private right of action. The Supremacy Clause instructs courts to give federal law priority when state and federal law clash, but it is not the source of any federal rights and does not create a cause of action. The suit cannot proceed in equity. The power of federal courts of equity to enjoin unlawful executive action is subject to express and implied statutory limitations. The express provision of a single remedy for a state’s failure to comply with Medicaid’s requirements, the withholding of Medicaid funds by the Secretary of Health and Human Services, 42 U.S.C. 1396c, and the complexity associated with enforcing section 30(A) combine to establish Congress’s “intent to foreclose” equitable relief. View "Armstrong v. Exceptional Child Ctr., Inc." on Justia Law

Pomianowski was 19 years old when she was in an automobile accident which left her a ventilator-dependent quadriplegic. She required total care in all aspects of daily living. A lawsuit filed against the County of Santa Cruz and Ford Motor Company, resulted in a settlement for $3,175,000.00. The court directed that the funds be deposited in a special needs trust (Probate Code sections 3600-3605). At age 23, Pomianowski died, with $1,294,453.23 left in the trust, which was ordered to reimburse the Department of Health Care Services for medical expenses paid on her behalf before her death. The trustee argued that the assets were exempt from reimbursement rights because the beneficiary was under 55 years of age when the services were provided. The court of appeal affirmed, holding that the Department was entitled to reimbursement under both the Medicaid statute, 42 U.S.C. 1396a, and the statutes and regulations implementing Medicaid through California’s Medi-Cal program. The statutes and regulations do not exempt beneficiaries under age 55, nor is there a public policy reason to shield the trust assets from recovery so that $417, 812.43 spent by the public can pass to the beneficiary’s parents along with the rest of the trust assets. View "Herting v. Cal. Dep;t of Health Care Servs." on Justia Law

Relators’ daughter was being treated by counselors at Arbour Counseling Services in Lawrence, Massachusetts when she was prescribed a medication for her purported bipolar disorder. The daughter experienced an adverse reaction to the drug and eventually suffered a fatal seizure. Relators filed this action against Defendant Universal Health Services, Inc., Arbour’s owner and operator, under both the federal and Massachusetts False Claims Acts, alleging that Arbour, in submitting reimbursement claims to the state Medicaid agency for services rendered by the staff members who treated their daughter, fraudulently misrepresented that those staff members were properly licensed and supervised, as required by law. Specifically, Relators alleged that Arbour’s alleged noncompliance with supervision and licensure requirements rendered its reimbursement claims actionably false. The district four dismissed the complaint for failure to state a claim. The First Circuit reversed the dismissal of the complaint with one limited exception, holding (1) a healthcare provider’s noncompliance with conditions of payment is sufficient to establish the falsity of a claim for reimbursement; and (2) Relators appropriately stated a claim with particularity under the False Claims Act. View "United States, ex rel. Escobar v. Universal Health Servs., Inc." on Justia Law

The Secretary of the United States Department of Health and Human Services imposed a civil money penalty on Plott Nursing Home in California for Plott’s violations of the Medicare Act’s standards of care for nursing home patients. The Department’s Appeals Board largely affirmed. Plott petitioned for review. The Ninth Circuit affirmed in part and reversed in part, holding (1) sufficient evidence supported the Secretary’s determination that Plott violated the quality of care for bed sores; (2) the Secretary’s finding that Plott violated the quality of care for urinary tract infections was not supported by substantial evidence on the record; and (3) Plott was entitled to administrative review of all cited deficiencies. Remanded with directions to review or dismiss the violations that were not reviewed by the agency. View "Plott Nursing Home v. Burwell" on Justia Law

Johnson began working for U.S. Steel in 2004. On May 12 2011, he left work, complaining of a headache, and went to a clinic where a physician’s assistant indicated that he had high blood pressure. The next day he provided a note that was deemed insufficient by his employer. His regular physician later indicated that Johnson's blood pressure was normal. Emails, memoranda, and letters indicate that Johnson was suspended on May 16 and then terminated for altering, falsifying, or forging the work excuse. U.S. Steel never provided him with notice of his FMLA rights and obligations. Nor was such notice included in the employee handbook. Johnson filed suit under the Family and Medical Leave Act (FMLA), 29 U.S.C. 2601-2654, alleging that U.S. Steel retaliated against him for taking protected FMLA leave, failed to reinstate him after a period of protected leave, and otherwise unlawfully interfered with his FMLA rights. The district court entered summary judgment for the employer. The Eighth Circuit affirmed. Johnson did not demonstrate how any alleged technical violations could have prejudiced him if his condition was not a serious health condition and did not qualify him for FMLA leave in the first place. View "Johnson v. Wheeling Mach. Prods." on Justia Law