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

Four liver-transplant candidates and more than a dozen transplant hospitals challenged HHS's adoption of a new policy for allocating donated livers. The Eleventh Circuit held that plaintiffs have not shown a substantial likelihood of success on the merits of their first claim—their allegation that the Secretary failed to follow legally required procedures under 42 C.F.R. 121.4(b) during the new liver-allocation policy's development. The court held that section 121.4(b) does not require the Secretary to take two procedural steps that all agree he did not: (1) referral of the new liver allocation policy to an entity called the Advisory Committee on Organ Transplantation and (2) publication of the new policy in the Federal Register for public comment. The court remanded for the district court to consider plaintiffs' remaining Administrative Procedure Act and Fifth Amendment claims that it failed to address in the first instance. View "Callahan v. U.S. Department of Health and Human Services" on Justia Law

The Department of Justice filed suit against the State of Florida, seeking declaratory and injunctive relief under Title II of the Americans with Disabilities Act (ADA) and 28 C.F.R. 35.130(d). The Department alleged that Florida was failing to meet its obligations under Title II by unnecessarily institutionalizing hundreds of children with disabilities in nursing facilities. The Department also alleged that Florida's Medicaid policies and practices placed other children who have "medically complex" conditions, or who are "medically fragile," at risk of unnecessary institutionalization.The Eleventh Circuit held that the Attorney General has a cause of action to enforce Title II of the ADA. The court held that when Congress chose to designate the "remedies, procedures, and rights" in section 505 of the Rehabilitation Act, which in turn adopted Title VI, as the enforcement provision for Title II of the ADA, Congress created a system of federal enforcement. The court also held that the express statutory language in Title II adopts federal statutes that use a remedial structure based on investigation of complaints, compliance reviews, negotiation to achieve voluntary compliance, and ultimately enforcement through "any other means authorized by law" in the event of noncompliance. Therefore, courts have routinely concluded that Congress's decision to utilize the same enforcement mechanism for Title II as the Rehabilitation Act, and therefore Title VI, demonstrates that the Attorney General has the authority to act "by any other means authorized by law" to enforce Title II, including initiating a civil action. Accordingly, the court reversed the district court's judgment and remanded. View "United States v. State of Florida" on Justia Law

After three former AseraCare employees alleged that AseraCare had a practice of knowingly submitting unsubstantiated Medicare claims in violation of the False Claims Act, the Government intervened and filed the operative complaint.The Eleventh Circuit held that a clinical judgment of terminal illness warranting hospice benefits under Medicare cannot be deemed false, for purposes of the False Claims Act, when there is only a reasonable disagreement between medical experts as to the accuracy of that conclusion, with no other evidence to prove the falsity of the assessment. However, the court held that the Government should have been allowed to rely on the entire record, not just the trial record, in making its case that disputed issues of fact, beyond just the difference of opinion between experts, existed sufficient to warrant denial of the district court’s post-verdict sua sponte reconsideration of summary judgment on the falsity question. Accordingly, the court affirmed in part and remanded in part. View "United States v. Aseracare, Inc." on Justia Law

MSPA, a firm that obtains Medicare Secondary Payer Act (MSP Act) claims and brings them on behalf of Medicare Advantage Organizations (MAOs), filed suit against Tenet over a delayed reimbursement of $286. The Eleventh Circuit affirmed the district court's grant of Tenet's motion to dismiss. The court held that MSPA had standing to invoke a federal court's jurisdiction because it suffered an injury in fact when it had to wait seven months for appropriate reimbursement and it validly assigned the right to vindicate that injury to La Ley Recovery Systems, who in turn validly assigned it to MSPA.On the merits, the court held that the MSP Act's private cause of action was only available in the case of a primary plan which fails to provide for primary payment (or appropriate reimbursement). In this case, MSPA did not sue a primary plan, but instead, it sued two medical services providers. Because private MSP Act plaintiffs could only sue primary plans, and MSPA had not done so, its claim was not plausible on its face. Therefore, the district court correctly dismissed MSPA's complaint for failure to state a claim. View "MSPA Claims 1, LLC v. Tenet Florida, Inc." on Justia Law

The Eleventh Circuit affirmed the judgment of the district court ruling that the Alabama Unborn Child Protection from Dismemberment Abortion Act “constitutes an undue burden on abortion access and is unconstitutional” and granting as-applied injunctive relief to Plaintiffs, holding that, under Supreme Court precedent, the Act is unconstitutional.At issue was a method of abortion referred to as dilation and evacuation, or dismemberment abortion, which involves tearing apart and extracting piece-by-piece from the uterus, at the fifteen to eighteen week stage of development, what was until then a living unborn child. The State sought to make the procedure more humane by enacting the Act, which required the one performing the abortion to kill the unborn child before ripping apart its body during the extraction. See Ala. Code 26-23G-2(3). Plaintiffs brought this complaint claiming that the Act was unconstitutional on its face. The district court ruled that the Act was unconstitutional because it would place substantial obstacles before women seeking pre-viability abortions. The Eleventh Circuit affirmed after applying the undue burden test, holding (1) the methods of fetal demise that the State proposed were not safe, effective, or available; and (2) neither the Act’s health exception nor its intent requirement saves the Act. View "West Alabama Women's Center v. Miller" on Justia Law

The Eleventh Circuit affirmed the district court’s decision to deny Appellant unconditional release from civil commitment, holding that the district court did not commit clear error in finding that Appellant’s risk of danger to others was due to a “mental disease or defect” under 18 U.S.C. 4243(d).Appellant was found not guilty by reason of insanity by threatening the President of the United States, among other offenses. After a hearing, the district court found that Appellant’s underlying crimes involved a substantial risk of bodily injury to another and that there was a substantial risk that Appellant would harm others in the future. The district court then ordered Appellant civilly committed pursuant to 18 U.S.C. 4243(e). On appeal, Appellant argued that the district court erred in committing him because there was no evidence that he suffered from a present mental disease or defect. The Eleventh Circuit disagreed, holding that the district court did not clearly err in finding (1) Appellant suffered from a mental disease or defect, and (2) Appellant’s dangerousness was due to his mental disease or defect. View "United States v. McIntosh" on Justia Law

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

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

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

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