Justia U.S. 11th Circuit Court of Appeals Opinion SummariesArticles Posted in Health Law
Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Co.
The Eleventh Circuit affirmed the district court's dismissal of the Hospitals' suit to recover recoupments. At issue was whether, under the Medicare Act, 42 U.S.C. 1395w-21 to 1395w-29, the Hospitals must exhaust their administrative remedies before bringing suit for underpayment by the Medicare Advantage Organization (MAO) that manages enrollee benefits. The court held that the Hospitals, who were challenging CIP's recoupment decision, were parties to an "organization determination" who were subject to the administrative exhaustion requirements of the Medicare Act. The court noted that although it was sympathetic to the concern HHS has expressed in amicus briefs, the language of the Medicare Act and its implementing regulations was clear that billing disputes between MAOs and noncontract provider assignees qualify as "organization determinations" and were thus subject to the Act's exhaustion requirement. View "Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Co." on Justia Law
Silva v. Baptist Health South Florida
The Eleventh Circuit reversed the grant of summary judgment to defendants on plaintiff's suit alleging unlawful discrimination because plaintiffs could not effectively communicate with hospital staff in the absence of auxiliary aids or services. The Eleventh Circuit held that plaintiffs had Article III standing to seek prospective injunctive relief; rejected the district court's substantive standard for liability; and concluded that for an effective-communication claim brought under the Americans with Disabilities Act (ADA), 42 U.S.C. 12101 et seq., and Section 504 of the Rehabilitation Act of 1973 (RA), 29 U.S.C. 794, there is no requirement that a plaintiff show actual deficient treatment or to recount exactly what plaintiff did not understand. Rather, the relevant inquiry is whether the hospitals' failure to offer an appropriate auxiliary aid impaired the patient's ability to exchange medically relevant information with hospital staff. In this case, plaintiffs have offered sufficient evidence to survive summary judgment where the record demonstrated that plaintiffs' ability to exchange medically relevant information was impaired. On remand, the district court was directed to consider the deliberate-indifference issue in regards to monetary damages. View "Silva v. Baptist Health South Florida" on Justia Law
MSP Recovery LLC v. AllState Ins. Co.
The seven consolidated cases in this appeal all involve attempts by assignees of a health maintenance organization (HMO) to recover conditional payments via the Medicare Secondary Payer Act's (MSP Act), 42 U.S.C. 1395y(b)(2)(B)(ii), (b)(3)(A), private cause of action. At issue is whether a contractual obligation, without more (specifically, without a judgment or settlement agreement from a separate proceeding), can satisfy the “demonstrated responsibility” requirement of the private cause of action provided for by the MSP Act. The court held that a plaintiff suing a primary plan under the private cause of action in the MSP Act may satisfy the demonstrated responsibility prerequisite by alleging the existence of a contractual obligation to pay. A judgment or settlement from a separate proceeding is not necessary. Therefore, the court vacated the district courts' judgments and remanded for further proceedings. View "MSP Recovery LLC v. AllState Ins. Co." on Justia Law
Humana Medical Plan v. Western Heritage Ins. Co.
Humana filed suit against Western, alleging claims for double damages pursuant to the Medicare Secondary Payer Act (MSP), 42 U.S.C. 1395y(b)(3)(A), private cause of action and for a declaratory judgment regarding Western’s obligation to reimburse Humana for Medicare benefits that Humana paid on behalf of its Medicare Advantage plan enrollee. The district court granted summary judgment to Humana. At issue, as a matter of first impression, is whether the MSP private cause of action permits a Medicare Advantage Organization (MAO) to sue a primary payer that refuses to reimburse the MAO for a secondary payment. The court joined the Third Circuit and held that an MAO may sue a primary payer under the MSP private cause of action. Accordingly, the court affirmed the judgment. View "Humana Medical Plan v. Western Heritage Ins. Co." on Justia Law
Posted in: Health Law
Florida Agency for Health Care Admin. v. Bayou Shores
The Secretary determined that Bayou Shores was not in substantial compliance with the Medicare program participation requirements, and that conditions in its facility constituted an immediate jeopardy to residents’ health and safety. The bankruptcy court assumed authority over Medicare and Medicaid provider agreements as part of the debtor’s estate, enjoined the Secretary from terminating the provider agreements, determined for itself that Bayou Shores was qualified to participate in the provider agreements, required the Secretary to maintain the stream of monetary benefit under the agreements, reorganized the debtor’s estate, and finally issued its Confirmation Order. The district court upheld the Secretary’s jurisdictional challenge and reversed the Confirmation Order with respect to the assumption of the debtor’s Medicare and Medicaid provider agreements. The court concluded that the statutory revision in this case does not demonstrate Congress's clear intention to vest the bankruptcy courts with jurisdiction over Medicare claims. Therefore, the court agreed with the district court that the bankruptcy court erred as a matter of law when it exercised subject matter jurisdiction over the provider agreements in this case. The bankruptcy court was without 28 U.S.C. 1334 jurisdiction under the 42 U.S.C. 405(h) bar to issue orders enjoining the termination of the provider agreements and to further order the assumption of the provider agreements. Accordingly, the court affirmed the judgment. View "Florida Agency for Health Care Admin. v. Bayou Shores" on Justia Law
Allstate Ins. Co. v. Vizcay
Allstate filed suit against multiple defendants, alleging claims of fraud, negligent misrepresentation, and unjust enrichment. Defendants are medical clinics that appointed Dr. Sara Vizcay as their medical director. Allstate’s central allegation is that Dr. Vizcay failed to systematically review billings as required by Florida’s Health Care Clinic Act, Fla. Stat. 400.990 et seq., which caused the clinics to submit unlawful or fraudulent insurance claims to Allstate. A jury found the clinics liable and awarded damages to Allstate. The clinics challenge the jury’s verdict, and the district court’s denial of their dispositive motions, on numerous grounds. The court held that, under Florida law, there is judicial remedy for a licensed clinic’s violation of the Clinic Act; a licensed clinic can be held responsible for its medical director’s failure to comply with the duties enumerated in the Clinic Act; the evidence is sufficient to support the jury’s finding that Dr. Vizcay failed to substantially comply with those duties; Allstate's fraud claims are not barred by Florida's statute of limitations; and the district court did not err in denying defendants' motions to bifurcate the trial. Accordingly, the court affirmed the judgment. View "Allstate Ins. Co. v. Vizcay" on Justia Law
Vitreo Retinal Consultants v. U.S. Dep’t of Health & Human Servs.
VRC filed suit against HHS and the Secretary, seeking the recoupment of payments VRC returned to Medicare after it was issued notice of an overpayment. At issue is the reimbursement rate of the intravitreal injection of Lucentis. VRC did not follow the Lucentis label’s instructions limiting dosage to one per vial. Instead, VRC treated up to three patients from a single vial. Because VRC was extracting up to three doses from a single vial, it was reimbursed for three times the average cost of the vial and three times the amount it would have received had it administered the drug according to the label. The court affirmed the denial of recoupment, concluding that VRC's charge to Medicare did not reflect its expense and was not medically reasonable; the Secretary's decision was supported by substantial evidence; and VRC is liable for the overpayment. View "Vitreo Retinal Consultants v. U.S. Dep't of Health & Human Servs." on Justia Law
Eternal Word Television Network v. Secretary
In these consolidated appeals, plaintiff challenged the regulations implementing the contraceptive mandate of the Affordable Care Act, 42 U.S.C. 300gg-13(a), arguing that the regulations’ accommodation for nonprofit organizations with a religious objection to providing contraceptive coverage violates the Religious Freedom Restoration Act (RFRA), 42 U.S.C. 2000bb, et seq. The court concluded that the regulations do not substantially burden plaintiffs' religious exercise and, alternatively, because (1) the government has compelling interests to justify the accommodation, and (2) the accommodation is the least restrictive means of furthering those interests. The court rejected EWTN’s challenges under the Establishment and Free Exercise Clauses because the accommodation is a neutral, generally applicable law that does not discriminate based on religious denomination. The court also rejected EWTN’s challenge under the Free Speech Clause because any speech restrictions that may flow from the accommodation are justified by a compelling governmental interest and are thus constitutional. View "Eternal Word Television Network v. Secretary" on Justia Law
LabMD, Inc. v. Federal Trade Commission
LabMD appealed the district court's dismissal of its challenges to the FTC's ability to regulate and conduct enforcement proceedings in the area of healthcare data privacy, arguing that the FTC's enforcement action violates the Administrative Procedure Act (APA), 5 U.S.C. 704; is ultra vires; and is unconstitutional. The court held that the FTC's order denying LabMD's motion to dismiss was not a "final agency action," as required of claims made under the APA and, therefore, those claims were properly dismissed. The court also concluded that LabMD's other claims are intertwined with its APA claim for relief and may only be heard at the end of the administrative hearing. Therefore, the court affirmed the district court's order dismissing the case for lack of subject-matter jurisdiction. View "LabMD, Inc. v. Federal Trade Commission" on Justia Law
Osheroff v. Humana Inc.
Relator filed a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729-3733, alleging that healthcare clinics provided, and the Humana defendants either knew of or promoted, a variety of free services for patients and health plan members. Relator alleged that the clinics offered such services without regard for medical purpose or financial need and that the value of the services is more than nominal. The court affirmed the district court's dismissal of the amended complaint with prejudice where, under the prior or amended version of section 3730 of the FCA, relator cannot overcome the public disclosure bar. View "Osheroff v. Humana Inc." on Justia Law