Justia Public Benefits Opinion Summaries

Prime Hospitals provide inpatient services under the Medicare program, submitting payment claims to private contractors, who make initial reimbursement determinations. Prime alleged that many short-stay claims were subject to post-payment review and denied. Prime appealed through the Medicare appeal process. Prime alleged short-stay claims audits were part of a larger initiative that substantially increased claim denials and that the Center for Medicare & Medicaid Services (CMS) was overwhelmed by the number of appeals. CMS began offering partial payment (68 percent) in exchange for dismissal of appeals. Prime alleged that it executed CMS's administrative settlement agreement so that CMS was contractually required to pay their 5,079 Medicare appeals ($23,205,245). CMS ultimately refused to allow the Prime to participate because it was aware of ongoing False Claims Act cases or investigations involving the facilities. Prime alleged that the settlement agreement did not authorize that exclusion. The district court denied a motion to dismiss Prime’s suit but transferred it to the Court of Federal Claims. The Federal Circuit affirmed in part. The breach of contract claim is fundamentally a suit to enforce a contract and does not arise under the Medicare Act, so the Claims Court has exclusive jurisdiction under the Tucker Act, 28 U.S.C. 1491. That court does not have jurisdiction, however, over Prime’s alternative claims seeking declaratory, injunctive, and mandamus relief from an alleged secret and illegal policy to prevent and delay Prime from exhausting administrative remedies. View "Alvarado Hospital, LLC v. Cochran" on Justia Law

John Boman appealed the grant of summary judgment in favor of the City of Gadsden. Boman worked as a Gadsden police officer from 1965 until he retired in 1991. Following his retirement, Boman elected to pay for retiree health coverage through a group plan offered by Gadsden to retired employees. This retired-employee-benefit plan was also administered by Blue Cross and provided substantially similar benefits to those Boman received as an active employee. In 2000, however, Gadsden elected to join an employee-health-insurance-benefit plan ("the plan") administered by the State Employees' Insurance Board ("the SEIB"). When Boman turned 65 in 2011, he was receiving medical care for congestive heart failure and severe osteoarthritis of the spine. After his 65th birthday, Blue Cross began denying his claims for medical treatment based on the failure to provide Blue Cross with a "record of the Medicare payment." However, Boman had no Medicare credits. Boman was hired before March 31, 1986, and, although Gadsden did begin participation in the Medicare program in 2006, Boman's employee group had not opted to obtain Medicare coverage before Boman retired. Consequently, Boman never paid Medicare taxes and did not claim to have Medicare coverage. The SEIB ultimately determined that the plan was the secondary payer to Medicare. Boman sued Gadsden, asserting that it had broken an agreement, made upon his employment, to provide him with lifetime health benefits upon his retirement. Boman also sued the members of the SEIB charged with administering the plan, challenging the SEIB's interpretation of the plan. Finding no reversible error in the grant of summary judgment to Gadsden, the Supreme Court affirmed. View "Boman v. City of Gadsden" on Justia Law

Plaintiff filed a class action against United Healthcare, alleging claims of unfair competition, unjust enrichment, and financial elder abuse. Plaintiff had enrolled in a private health plan offering benefits to persons 65 and over as well as disabled persons under the federally funded Medicare Advantage program, 42 U.S.C. 1395w-21 et seq. After he went to an urgent care center outside of the plan's network, he was forced to pay a $50 copayment instead of the $30 copayment for in-network centers. Plaintiff alleged that the plan’s marketing materials misled him (and other enrollees) as to the availability of in-network urgent care centers (and their smaller copayments) and that the absence of any in-network urgent care centers in California rendered the plan’s network inadequate. The court concluded that plaintiff’s misrepresentation and adequacy-of-network based claims was expressly preempted by the preemption clause applicable to Medicare Advantage plans, 42 U.S.C. 1395w-26(b)(3). The court also concluded that plaintiff’s claims, to the extent they challenge a denial of benefits, are subject to dismissal because plaintiff did not first exhaust his administrative remedies under the Medicare Act, 42 U.S.C. 405(g), (h) and 1395ii. Accordingly, the court affirmed the trial court's dismissal of the complaint. View "Roberts v. United Healthcare" on Justia Law

Luke Joerg (“Luke”) was a developmentally disabled adult who had lived with his parents his entire life and had never worked. Luke was struck by a car in 2007. John Joerg (“Joerg”), Luke’s father, filed an action against State Farm Mutual Automobile Insurance Company, Joerg’s uninsured motorist carrier. Joerg filed a motion in limine to exclude evidence of any collateral source benefits to which Luke was entitled, including discounted benefits under Medicare and Medicaid. The trial court precluded State Farm from introducing evidence of Luke’s future Medicare or Medicaid benefits. The jury awarded a total of $1,491,875 in damages, including $469,076 for future medical expenses. The Second District Court of Appeal reversed the award for future damages, concluding that Luke’s Medicare benefits should not have been excluded by the collateral source rule. The Supreme Court quashed the decision below, holding that the trial court properly excluded evidence of Luke’s eligibility for future benefits from Medicare, Medicaid, and other social legislation as collateral sources. View "Joerg v. State Farm Mut. Auto. Ins. Co." on Justia Law

In December, 2009, Heelan, a Vernon Hills police officer for approximately 20 years, responded to an emergency call, slipped on ice, and fell. He was ultimately diagnosed with significant osteoarthritis in both hips, aggravated by the fall, and had two hip replacement surgeries. He did not return to work. The Village Police Pension Board awarded a line-of-duty disability pension, 40 ILCS 5/3-114.1. The Village sought a declaration that it was not obligated to pay Heelan’s health insurance premium under the Public Safety Employee Benefits Act (the Act), 820 ILCS 320/10. The circuit court entered judgment in favor of Heelan. The appellate court and Illinois Supreme Court affirmed, Proof of a line-of-duty disability pension establishes a catastrophic injury under section 10(a) of the Act as a matter of law; a public safety officer’s employer-sponsored health insurance coverage expires upon the termination of the officer’s employment by the award of the line-of-duty disability pension. The Act lengthens such health insurance coverage beyond the termination of the officer’s employment. View "Village of Vernon Hills v. Heelan" on Justia Law

Pursuant to federal law, California’s Medi-Cal program requires beneficiaries to use other health coverage (OHC) they may have before accessing Medi-Cal benefits. The state Department of Health Care Services (DHCS) maintains a database with codes that indicate whether a Medi-Cal beneficiary has OHC and, to some extent, the scope of that coverage. The codes are available to providers when a beneficiary seeks services. Medi-Cal beneficiaries filed suit. Because DHCS allegedly permits Medi-Cal providers to refuse nonemergency services to beneficiaries with OHC, and because the codes are not always correct and the information is limited, beneficiaries may be improperly denied service and referred to other providers even when there is no OHC available for the requested service; beneficiaries may experience delays in receiving nonemergency care and may be subject to a higher copayment than permitted under Medi-Cal. Plaintiffs argued that the assignment of an OHC code should trigger notice and a hearing. The trial and appeals courts rejected their arguments. Neither Welfare and Institutions Code 10950 nor regulation 50951 nor the California Constitution requires DHCS to provide a hearing or notice when it assigns an OHC code. Plaintiffs did not establish any violation of a ministerial duty subject to enforcement by a writ of mandate. View "Marquez v. Dept. of Health Care Servs." on Justia Law

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

Appellant Jeffrey Allen, on behalf of his daughter, appealed the Administrative Law Court's (ALC) order affirming the Appeals Committee of the South Carolina Budget and Control Board Employee Insurance Program's (EIP Appeals Committee) decision to deny Appellant's insurance claim for his daughter's diabetes educational training session. Blue Cross's Appeals Review Committee upheld the denial of benefits on the basis that diabetes educational training was excluded under the State Health Plan, and that section 38-71-46 of the South Carolina Code, did not apply to the State Health Plan. Upon review, the Supreme Court reversed the ALC's decision that section 38-71­46 of the South Carolina Code did not apply to this matter. The EIP was mandated to promptly determine and pay the benefits that were due for Appellant's daughter under the State Health Plan. View "Allen v. SC Public Employee Benefit Authority" on Justia Law

Warner, insured by State Farm, was involved in an automobile accident. Following the accident, Michigan Spine provided Warner with about $26,000 of neurological treatment. State Farm denied coverage, stating that Warner’s condition was the result of a preexisting condition. Michigan Spine submitted the claim to Medicare, which approved a conditional payment of $5,000 under the Medicare Secondary Payer Act, 42 U.S.C. 1395y. Michigan Spine sued State Farm under Michigan’s No-Fault Act and the Medicare Secondary Payer Act, which permits private causes of action against primary plans that fail to pay medical expenses for which they are responsible. The district court dismissed, holding that a private party can recover under the Secondary Payer Act only if a “primary plan” has failed to provide appropriate reimbursement only because the planholder is entitled to Medicare benefits, and State Farm did not deny coverage on that basis. The Sixth Circuit reversed and remanded. Although the text of the Secondary Payer Act is unclear as to whether a private cause of action is available against a non-group health plan that denies coverage on a basis other than Medicare eligibility, accompanying regulations and congressional intent indicate that the requirement applies only to group health plans and not to non-group health plans. Michigan Spine may pursue its claim under the Secondary Payer Act. View "MI Spine & Brain Surgeons, PLLC v. State Farm Mut. Auto Ins Co" on Justia Law

This case involved a petition for injunctive and declaratory relief brought by plaintiffs Harbor Homes, Inc. and Gary Dube, Thomas Taylor, Cynthia Washington, and Arthur Furber against defendants the New Hampshire Department of Health and Human Services (DHHS), the Commissioner of DHHS, the Associate Commissioner of DHHS, and the Administrator of the Bureau of Behavioral Health seeking, in part, to enjoin DHHS from denying the individual plaintiffs the right to obtain Medicaid-funded services from their chosen provider, Harbor Homes. The individual plaintiffs received Medicaid-funded rehabilitative services from Harbor Homes. Since 1991, Harbor Homes participated in New Hampshire's Medicaid program pursuant to a Medicaid Provider Enrollment Agreement. On June 23, 2008, Harbor Homes entered into an interagency agreement (IAA) with a community mental health program, Community Council of Nashua, NH, now known as Greater Nashua Mental Health Center (GNMHC), which authorized Harbor Homes to provide certain Medicaid-funded rehabilitative services to GNMHC patients. In February 2011, Harbor Homes learned that GNMHC did not intend to renew its IAA and that the Medicaid reimbursable services provided by Harbor Homes would be transitioned to GNMHC. This was done pursuant to Administrative Rule He-M 426.04(a)(2), which meant that Harbor Homes would no longer have an IAA with a community mental health provider, and it would no longer be permitted to provide Medicaid funded mental health services to approximately one hundred and forty of its clients, including the individual plaintiffs in this case. Plaintiffs filed a petition for injunctive and declaratory relief, seeking a court order enjoining DHHS from "terminating or limiting Harbor Homes' status as a qualified Medicaid provider" and to direct the State to allow the individual plaintiffs to obtain community mental health services from Harbor Homes, the provider of their choice. Following two hearings, the court denied the plaintiffs' request for a preliminary injunction. Thereafter, all parties moved for partial summary judgment on the plaintiffs' claim that DHHS's reliance upon the IAA requirement as a reason to terminate Harbor Homes' status as a qualified Medicaid provider was improper because the requirement was invalid both on its face and as applied in this case. Plaintiffs appealed rulings of the Superior Court that denied their summary judgment motions and granting the defendants' cross-motions for summary judgment on two counts in the plaintiffs' petition. Upon review of the matter, the Supreme Court reversed the Superior Court's ruling that New Hampshire Administrative Rules, He-M 426.04(a)(2) did not violate the federal Medicaid Act. The case was remanded for further proceedings. View "Dube v. New Hampshire Dept. of Health & Human Svcs." on Justia Law