Articles Posted in Health Law

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Mimms, an Indiana-licensed physician, prescribes controlled substances to patients. Several times, CVS Pharmacy employees informed Mimms’s patients that they would not fill their prescriptions. Mimms sued, alleging defamation. CVS argued that Mimms had no evidence that the speakers knew their statements were false. The court granted summary judgment as to five statements and denied judgment for four statements, reasoning there was a material question of fact regarding whether the speakers knew that their statements were false, given evidence that CVS’s corporate office had investigated Mimms and had not stopped stores from filling his prescriptions. The court rejected CVS’s argument that knowledge held by the corporate office could not be imputed to the speakers. The statements were: “CVS doesn’t fill Dr. Mimms’[s] prescriptions or prescriptions for any other pill mills.” “Mimms went to jail.” “Mimms has been … or will be arrested.” “Mimms is under DEA investigation. A jury found CVS liable for defamation per se and awarded Mimms $1,025,000. The Seventh Circuit reversed. Mimms proffered no evidence that the first three statements were made with actual malice. CVS is entitled to a new trial on the fourth statement; the court should have allowed CVS to present evidence that Mimms was the subject of a DEA investigation and regarding Mimms’s reputation. In a defamation per se case, damage to reputation is presumed but evidence regarding the extent of the harm to his professional reputation was critical for minimizing damages. View "Mimms v. CVS Pharmacy, Inc." on Justia Law

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Stephens was born in 1957 and has a ninth-grade education. He worked as a taxi dispatcher and a security guard in the 15 years preceding his alleged disability. Stephens contends that he is disabled by diabetes, kidney disease, knee and back pain, heart disease, high blood pressure, asthma, arthritis, and obesity. He was denied Supplemental Security Income (SSI) benefits. On remand, a different ALJ determined that Stephens’ impairments, although severe, were not disabling and that he could perform relevant past work. The district court and Seventh Circuit upheld the denial, rejecting arguments that the ALJ erred by improperly evaluating Stephens’s obesity (no longer a stand-alone disability) when determining the aggregate impact of his impairments; that the ALJ’s finding that the record lacked medical opinion evidence as to Stephens’ hypersomnolence or excessive sleepiness; and that the ALJ failed to incorporate all of his impairments and consider their combined impact to evaluate his residual functional capacity. View "Stephens v. Berryhill" on Justia Law

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For several weeks, Redman posed as a psychiatrist at a Chicago medical clinic using the name and license number of Dr. Garcia. He “treated” patients for mental illnesses, and “prescribed” controlled substances. Redman actually did not attend school past the tenth grade. Before commencing employment, Redman provided falsified documentation: an employment application, payroll application, I‐9 Employment Eligibility Verification form, W‐9 form, photograph of an Indiana driver’s license with Redman’s picture, photocopy of an Illinois medical license, photocopy of a medical school diploma, a residency certificate for training in psychiatry, and a photocopy of a social security card. He used online counterfeiting services; he submitted an online Drug Enforcement Administration application and obtained malpractice insurance using false information. He was discovered when the real Dr. Garcia learned that someone had used his medical license number to obtain a DEA registration. A jury found Redman guilty of wire fraud, aggravated identity theft, furnishing false and fraudulent material information in documents required under the federal drug laws, and distributing controlled substances. The Seventh Circuit affirmed his 157-month sentence, upholding the application of two-level enhancements for use of sophisticated means and for conduct that involved a conscious or reckless disregard of a risk of death or serious bodily injury. View "United States v. Redman" on Justia Law

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Armenta worked at Passages as a certified nursing assistant and later as a regional director of certified nursing assistants. Passages billed its services to Medicare. Medicare paid $180 per patient per day for routine services but up to $700 for general inpatient services (GIP). Passages began paying directors based on the number of patients on GIP. The number of patients on GIP significantly increased because directors instructed nurses and nursing assistants to place patients who did not need that level of care on GIP. Passages received an audit request from a Medicare contractor. In response, Armenta and other Passages employees entered false information consistent with GIP care and billing into patient files, then submitted the altered files. Passages employees, including Armenta, were trained on the requirements for placing a patient on GIP. Armenta told the nurses to disregard the training. Armenta and others were charged with health care fraud. Only Armenta proceeded to trial. With a two-level enhancement for obstruction of justice based on lying on the stand and altering records, her Guidelines imprisonment range was 63-78 months.The Seventh Circuit affirmed her conviction and sentence of 20 months’ imprisonment plus $1.67 million in restitution. Although no government witness identified Armenta in court, the defense did not argue that the Armenta in the courtroom was not the same Armenta involved in the fraud. View "United States v. Armenta" on Justia Law

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After complaints about his professionalism, Indiana University Hospital required Dr. Hamdan, a U.S. citizen of Palestinian descent, to participate in a peer-review process, which resulted in disciplinary letters. Hamdan successfully appealed. The hospital ultimately voided the letters. Nonetheless, Hamdan resigned and relinquished his hospital privileges. Hamdan sued the hospital for discriminating against him based on race. Hamdan was not a hospital employee and could not sue under Title VII, so he sued under 42 U.S.C. 1981, part of the Civil Rights Act of 1866, intended to protect the ability of newly-freed slaves to enter and enforce contracts. Hamdan alleged discrimination in his contractual relationship with the hospital. The Seventh Circuit affirmed a verdict for the hospital, rejecting an argument that the district court erred in allowing the hospital to ask Hamdan impeachment questions relating to his prior work at other hospitals. The court noted Hamdan’s testimony that his reputation was “untarnished” before he received the disciplinary letters. The Seventh Circuit also rejected an argument that the court erred in permitting the hospital to try to impeach him with questions about matters that were confidential under the peer-review statutes of Indiana, Louisiana, and Michigan. Even if the state laws applied, the judge did not abuse his discretion in allowing impeachment questions about incident reports. View "Hamdan v. Indiana University Health North Hospital, Inc." on Justia Law

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After complaints about his professionalism, Indiana University Hospital required Dr. Hamdan, a U.S. citizen of Palestinian descent, to participate in a peer-review process, which resulted in disciplinary letters. Hamdan successfully appealed. The hospital ultimately voided the letters. Nonetheless, Hamdan resigned and relinquished his hospital privileges. Hamdan sued the hospital for discriminating against him based on race. Hamdan was not a hospital employee and could not sue under Title VII, so he sued under 42 U.S.C. 1981, part of the Civil Rights Act of 1866, intended to protect the ability of newly-freed slaves to enter and enforce contracts. Hamdan alleged discrimination in his contractual relationship with the hospital. The Seventh Circuit affirmed a verdict for the hospital, rejecting an argument that the district court erred in allowing the hospital to ask Hamdan impeachment questions relating to his prior work at other hospitals. The court noted Hamdan’s testimony that his reputation was “untarnished” before he received the disciplinary letters. The Seventh Circuit also rejected an argument that the court erred in permitting the hospital to try to impeach him with questions about matters that were confidential under the peer-review statutes of Indiana, Louisiana, and Michigan. Even if the state laws applied, the judge did not abuse his discretion in allowing impeachment questions about incident reports. View "Hamdan v. Indiana University Health North Hospital, Inc." on Justia Law

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St. Vincent Health group acquired Randolph County Hospital and decided to replace the 80-year-old building. In 2002 the Hospital financed the project by borrowing $15.3 million from a fraternal corporation. Within a year, St. Vincent Health group was acquired by Ascension, the nation’s largest Roman Catholic health-care system. Ascension loaned the Hospital $15.6 million to refinance the loan. The Hospital sought reimbursement under 42 U.S.C. 1395f(b)(1), 1395x(v)(1)(A), and 42 C.F.R. 413.153, for “the necessary and proper costs of financing medical facilities.” Recognizing its problems with poor documentation, the Hospital withdrew its request that Medicare cover any expense before 2004 but requested compensation for 2004-2008, after Ascension had refinanced the loan in compliance with section 413.153(c)(2). The Provider Reimbursement Review Board ordered the 2004-2008 claims paid, finding that problems with the 2002 loan did not taint the refinancing. The Centers for Medicare and Medicaid Services reversed. The district court rejected reasoning concerning the initial loan but granted summary judgment, finding that the Hospital had not established that the Ascension loan refinanced that loan. The Seventh Circuit vacated, stating the “taint” theory is legally untenable and cannot be reasserted on remand, but the agency is free to request more or better documentation and to explore the significance of the difference in the principal amounts of the loans. View "St. Vincent Randolph Hospital, v. Price" on Justia Law

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Rosewood is a skilled nursing facility, 42 U.S.C. 1395i-3(a), participating in Medicare and Medicaid as a provider. The Secretary of Health and Human Services, which enforces the statutory and regulatory provisions governing nursing homes operating in the Medicare/Medicaid network, assessed a civil monetary penalty against Rosewood on the grounds that it had failed to protect a resident from abuse, failed to timely report or to investigate thoroughly allegations of abuse, and failed to implement its internal policies on abuse, neglect, and misappropriation of property. The Centers for Medicare and Medicaid Services (CMS) determined that these deficiencies placed residents in “immediate jeopardy.” An Administrative Law Judge and the Department Appeals Board affirmed the $6,050 per day penalty imposed by CMS. The Seventh Circuit affirmed. Substantial evidence supports the Agency’s findings. The court noted three specific examples of noncompliance and concluded that there was a systemic failure to implement Rosewood’s policies aimed at conforming to federal regulations View "Rosewood Care Center of Swansea v. Price" on Justia Law

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Hartgrove, a psychiatric hospital, is enrolled with the Illinois Department of Healthcare and Family Services to receive Medicaid reimbursement. Hartgrove agreed to comply with all federal and state laws and “to be fully liable for the truth, accuracy and completeness of all claims submitted.” Upon receipt of Medicaid reimbursements, Hartgrove is required to certify that the services identified in the billing information were actually provided. On 13 occasions in 2011, adolescent patients suffering from acute mental illness were placed in a group therapy room, rather than patient rooms, sleeping on roll-out beds until patient rooms were available. Hartgrove submitted Medicaid claims for inpatient care for those patients. Bellevue, a Hartgrove nursing counselor until 2014, voluntarily provided the information on which his allegations are based to federal and state authorities, then filed a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729, and the Illinois False Claims Act. Both declined to intervene. The district court dismissed and denied Bellevue’s motion to reconsider in light of the Supreme Court’s 2016 “Universal Health” holding that an implied false certification theory is a viable basis for FCA liability. The Seventh Circuit affirmed. Bellevue’s allegations fall within the FCA's public‐disclosure bar; the information was available in audit reports and letters. View "Bellevue v. Universal Health Services of Hartgrove, Inc." on Justia Law

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Plaintiffs purchased Illinois nursing homes and obtained new state licenses and federal Medicare provider numbers. Most of the residents in the 10 homes qualify for Medicaid assistance. The Illinois Department of Healthcare and Family Services (IDHFS) administers Medicaid funds under 42 U.S.C. 1396-1396w-5, reimbursing nursing homes for Medicaid-eligible expenses on a per diem basis. The rate must be calculated annually based on the facility's costs. When ownership of a home changes, state law requires IDHFS to calculate a new rate based on the new owner’s report of costs during at least the first six months of operation. The Medicaid Act requires states to use a public process, with notice and an opportunity to comment, in determining payment rates. The owners allege that IDHFS failed to: recalculate their reimbursement rates; provide an adequate notice-and-comment process; and comply with the state plan, costing them $12 million in unreimbursed costs. The Seventh Circuit affirmed denial of a motion to dismiss. Section 1396a(a)(13)(A) confers a right that is presumably enforceable under 42 U.S.C. 1983; it benefits the owners and is not so amorphous that its enforcement would strain judicial competence. While the Eleventh Amendment may bar some of the requested relief, if it appears that owners have been underpaid, that does not deprive the court of jurisdiction over the case as a whole. View "BT Bourbonnais Care, LLC v. Norwood" on Justia Law