Justia U.S. 11th Circuit Court of Appeals Opinion Summaries

Articles Posted in Health Law
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In the United States Court of Appeals for the Eleventh Circuit, the Court reviewed a case involving the estates of two patients who passed away after undergoing liposuction procedures at CJL Healthcare, LLC in Georgia. After the patients' deaths, their estates filed lawsuits against the clinic and its doctor. The clinic's insurer, Prime Insurance Co., defended the clinic under a reservation of rights but ultimately withdrew its defense after the costs of defending the lawsuits exhausted the insurance coverage.The estates of the patients and the clinic then filed a lawsuit against the insurers, Prime Insurance Co., Prime Holdings Insurance Services, and Evolution Insurance Brokers, claiming they had breached their duties, contract, and acted negligently. They also claimed the insurers had unlawfully sold surplus lines insurance. The district court dismissed the case, and the plaintiffs appealed.The Court of Appeals affirmed the district court's decision. The Court held that the policy unambiguously provided a $50,000 limit for a single professional liability claim and a $100,000 aggregate limit for all claims. The Court further held that the insurers' duty to defend the clinic ended when the policy limits were exhausted by payment of damages and claim expenses. The Court also affirmed the district court's finding that the Georgia Surplus Lines Insurance Act did not provide a private cause of action for the unauthorized sale of surplus lines insurance. View "Jumlist v. Prime Insurance Co." on Justia Law

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In this appeal, Marcus Raper contested the Social Security Administration’s (SSA) 2020 denial of his claim for disability insurance benefits. Raper raised three arguments: (1) that the administrative law judge's (ALJ) initial lack of constitutional appointment under the Appointments Clause tainted his later constitutionally appointed review of his case, (2) that the ALJ failed to clearly articulate good cause for not fully crediting his treating physician’s medical opinion, and (3) that the ALJ wrongly discredited his subjective complaints of pain by not properly considering evidence other than objective medical evidence.The United States Court of Appeals for the Eleventh Circuit affirmed the lower court’s decision. First, the court found no Appointments Clause violation as the ALJ's initial decision, made when he was unconstitutionally appointed, had been vacated on the merits and the case was remanded to the same ALJ who was then constitutionally appointed. Second, the court held that the ALJ articulated good cause for discounting Raper's treating physician’s opinion, finding the opinion inconsistent with the record. Lastly, the court found that the ALJ had properly considered Raper’s subjective complaints in light of the record as a whole and adequately explained his decision not to fully credit Raper’s alleged limitations on his ability to work. View "Raper v. Commissioner of Social Security" on Justia Law

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Defendants Gladden and Linton were convicted of conspiracy to commit health care fraud and mail fraud, and the substantive offenses of health care fraud, mail fraud, and aggravated identity theft, for their roles in a multi-year scheme to defraud insurance companies. The government alleged Defendants received inflated reimbursement payments by billing for medically unnecessary and fraudulent prescriptions.The Eleventh Circuit found that the evidence presented at trial was sufficient to support the jury’s verdict as to all of Linton’s convictions and as to Gladden’s convictions for conspiracy, health care fraud, and mail fraud. In addition, the Eleventh Circuit found that the district court did not clearly err in calculating Gladden’s restitution and forfeiture amounts. The Court also vacated Galdden's conviction for aggravated identity theft and remanded for further proceedings consistent with this opinion. View "USA v. John Gladden, et al" on Justia Law

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In the winter of 2020, the Secretary of Health and Human Services (HHS) determined that the threat posed by the novel SARS-CoV-2 virus constituted a public health emergency. The CDC published the rule at issue—the Requirement for Persons to Wear Masks While on Conveyances and at Transportation Hubs, 86 Fed. Reg. 8025-01 (Feb. 3, 2021) (“Mandate”). Plaintiffs initiated this litigation, arguing that the Mandate was unlawful under the Administrative Procedure Act, 5 USC Section 706(2) (APA), and unconstitutional under non-delegation and separation-of-powers tenets.   The Eleventh Circuit vacated the district court’s judgment and instructed the district court to dismiss the case as moot. The court explained that it found Plaintiffs’ contention that there is a reasonable expectation that the CDC will issue another nationwide mask mandate for all conveyances and transportation hubs to be speculative. Conjectures of future harms like these do not establish a reasonable expectation that a mask mandate from the CDC will reissue. Further, the court reasoned that there is no “reasonable expectation or a demonstrated probability that the same controversy will recur involving the same complaining party.” View "Health Freedom Defense Fund, et al v. President of the United States, et al" on Justia Law

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Eight South Florida hospitals dutifully provided out-of-network emergency treatment to numerous Cigna customers. When Cigna reimbursed the hospitals just 15% of what they had charged, the hospitals sued, accusing Cigna of paying less than the “community” rate. As proof, the hospitals showed that they normally receive five times as much for the care they provided here. In response, Cigna asserted that the hospitals’ data proved nothing because, it insisted, the relevant “community” necessarily includes more than just the eight plaintiff hospitals. The district court agreed and granted Cigna summary judgment.   The Eleventh Circuit reversed. The court explained that even if the relevant “community” here extends beyond the eight plaintiff hospitals, their receipts alone are enough to create a genuine factual dispute about what the “community” rates are. The court reasoned that to survive summary judgment, a plaintiff needn’t present evidence that compels a single, airtight inference—just evidence that allows a reasonable one. The court explained that the way to rebut an inference allegedly skewed by limited data is to add data. And Cigna can do just that—at trial. If it can show there that most other providers in the “community” charge less than the plaintiff hospitals do, then it may well debunk the hospitals’ estimate. But unless and until that happens, it remains the case that a reasonable jury could conclude that the eight plaintiff hospitals’ rates reflect the prevailing community rate—and thus that Cigna shortchanged them. View "North Shore Medical Center, Inc., et al v. Cigna Health and Life Insurance Company" on Justia Law

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Based in Auburn, Alabama, Plaintiff and her pharmacy were one of the thousands of businesses that answered the call to provide Covid-19 tests to the public. However, the Alabama Board of Pharmacy (the Board) concluded that Plaintiff’s administration of these tests fell short of the medical safety standards required under Alabama law. When the Board instituted an administrative enforcement proceeding against Plaintiff, she sought to avail herself of the legal immunity provided by the Secretary’s PREP Act Declaration. Plaintiff filed a federal suit, seeking to enjoin the Board from even considering the charges against her. The district court exercised its discretion to abstain under Younger v. Harris, 401 U.S. 37 (1971) and declined to intervene in the Board’s proceedings.   The Eleventh Circuit affirmed the district court’s decision to abstain under Younger. The court concluded that Plaintiff has not established that she lacks an adequate opportunity to present her federal claims to the Alabama Board of Pharmacy or an adequate opportunity to obtain judicial review of her claims in Alabama’s courts, and so Younger abstention is warranted. The court wrote that it did not decide today whether Plaintiff is immune from the Board’s charges or if they are, in fact, preempted by the PREP Act. All the court concluded is that this is not one of the “extraordinary circumstances” that would justify federal intervention in a state proceeding that is adequate to hear Plaintiff’s claims. View "Lisa Hill Leonard, et al. v. The Alabama State Board of Pharmacy, et al." on Justia Law

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Several states challenged the portion of the vaccine mandate as it pertains to employees who work on or in connection with a covered contract, or share a workplace with another employee who does. The district court determined that Plaintiffs were entitled to a preliminary injunction.On appeal, the Eleventh Circuit agreed with the district court that Plainitffs were likely to prevail on the merits. However, the court also found that the injunction’s nationwide scope was too broad. Thus, the Eleventh Circuit affirmed the district court’s order to the extent that it enjoins federal agencies from enforcing the mandate against the plaintiffs and to the extent that it bars the federal government from considering a bidder’s compliance with the mandate when deciding whether to grant a contract to a plaintiff or to a nonparty bidder. However, the Eleventh Circuit vacated the remaining portion of the preliminary injunction. View "State of Georgia, et al v. President of the United States, et al" on Justia Law

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Defendants 1 and 2 are siblings and were indicted on substantive counts of health care fraud, conspiracy to commit health care fraud, money laundering, and conspiracy to commit money laundering related to their activities running a "pill mill." The District Court precluded evidence that Defendant 1 provided good care to his patients. The court also precluded evidence proffered by Defendant 2 (the younger sibling) that it is part of the Nigerian culture to defer to older siblings' decisions. Following their convictions, Defendant's challenged the court's evidentiary rulings as well as the sufficiency of the evidence.The Eleventh Circuit affirmed Defendants' convictions, rejecting all claims of error. The court also determined that the evidence was sufficient to support their convictions. View "USA v. Patrick Emeka Ifediba, et al" on Justia Law

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Various actors in the Medicare Advantage program assigned claims for failure to pay or reimburse medical expenses owed under the Medicare Secondary Payer Act to Plaintiffs—MSP Recovery Claims, Series LLC; MSPA Claims 1, LLC; and MAO-MSO Recovery II LLC, Series PMPI, (collectively, “MSP Recovery”). MSP Recovery then asserted those claims against Metropolitan General Insurance Company, Metropolitan Casualty Insurance Company, Metropolitan Group Property & Casualty Insurance Company, Metlife Auto & Home Group, and Metropolitan P&C Insurance Company (collectively, “Defendants”).   The district court dismissed MSP Recovery’s claims because the complaint failed to show that Defendants had a “demonstrated responsibility” to reimburse MSP Recovery’s assignors for the medical expenses at issue. The Eleventh Circuit held that at this procedural stage MSP Recovery’s complaint plausibly alleged that Defendants had a demonstrated responsibility to pay the claims, and the court, therefore reversed and remanded this case to the district court for further proceedings consistent with this opinion.   The court explained that the district court found that it would not consider Exhibit A, which was attached to and referenced by incorporation in the factual allegations of MSP Recovery’s complaint. Because “documents attached to a complaint or incorporated in the complaint by reference can generally be considered by a federal court in ruling on a motion to dismiss under Rule 12(b)(6),” the court concluded that the district court erred in failing to consider whether the complaint and Exhibit A, taken together, plausibly alleged that Defendants’ responsibility to pay had been demonstrated prior to suit. View "MSP Recovery Claims, Series LLC, et al v. Metropolitan General Insurance Company, et al" on Justia Law

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Defendant was convicted of conspiracy and substantive health care fraud for fraudulently billing Medicare and Medicaid for millions of dollars for visits to nursing home patients that he never made. He challenged the convictions, sentence, restitution amount, and forfeiture amount on appeal. In an April 12, 2022 opinion, the Eleventh Circuit affirmed Defendant's convictions and sentence.Following the court's initial opinion, Defendant filed a petition for rehearing en banc. The Eleventh Circuit considered Defendant's petition as a petition for a panel rehearing. The court granted Defendant's petition, vacated its previous opinion and issued a revised opinion that did not change the court's judgment or Defendant's sentence. Defendant was given 21 days to file a supplemental brief. View "USA v. Douglas Moss" on Justia Law