Justia U.S. 7th Circuit Court of Appeals Opinion Summaries

Woodson received prenatal treatment from Dr. Ramsey at NorthShore Health Centers. Ramsey informed Woodson that she would likely need to deliver her baby by C-section. Ramsey delivered P.W. vaginally at Anonymous Hospital. Woodson noticed immediately that something was wrong with P.W.’s left arm. P.W.’s arm did not improve.NorthShore is a Federally-qualified health center (FQHC) that receives federal money (42 U.S.C. 1396d(l)(2)(B)); its employees are deemed Public Health Service employees, covered against malpractice claims under the Federal Tort Claims Act (FTCA), 42 U.S.C. 233(g). NorthShore appears in the federal government's online public database of federal funding recipients whose employees may be deemed Public Health Service employees. Woodson’s attorney, Sandoval, failed to recognize NorthShore’s status as an FQHC. Sandoval reviewed the Indiana Department of Insurance (IDOI) and Indiana Patient’s Compensation Fund online databases and learned that Ramsey and Anonymous Hospital were “qualified” providers under the Indiana Medical Malpractice Act. The IDOI forwarded Woodson’s complaint to Ramsey and his insurance carrier. Those claims remain pending.On December 16, 2015, NorthShore informed Sandoval that NorthShore was a federally funded health center. Woodson filed administrative tort claims, which were denied. Nearly three years after P.W.’s birth, Woodson filed suit against the government and Anonymous Hospital. The Seventh Circuit affirmed that the claims accrued on December 7, 2013, the day P.W. was born, and were untimely under the FTCA’s two-year statute of limitations. Woodson had enough information shortly after P.W.'s birth to prompt her to inquire whether the manner of delivery caused P.W.’s injury. The FTCA savings provision does not apply because the IDOI never dismissed the claims. Neither Ramsey nor NorthShore had a duty to inform Woodson of their federal status. View "P.W. v. United States" on Justia Law

Smith suffered an injury from a car accident, retained an attorney for a personal injury lawsuit, and authorized her attorney to obtain her healthcare information. The attorney requested Smith’s medical records from MHS, on three occasions. RecordQuest, not MHS, answered those requests and charged Smith’s attorney (who paid on her behalf) a $20.96 handling fee and an $8.26 certification fee each time.Smith brought a class action, alleging these charged fees contravened the permissible fee schedule set out in Wis. Stat. 146.83(3f)(b) for healthcare records requests and resulted in the unjust enrichment of RecordQuest. The district court dismissed both claims, reasoning that the statute imposes a duty upon only healthcare providers.” RecordQuest is not a healthcare provider but is the agent of MHS; “no principle of agency law holds that a principal’s liability is imputed to the agent when the agent performs the act that results in the principal’s liability.” Smith’s unjust enrichment claim failed because any unjust benefit that Smith allegedly conferred to RecordQuest belonged to MHS.The Wisconsin Court of Appeals subsequently expressly disagreed with the district court’s analysis of Smith’s statutory claim. The Seventh Circuit reversed the dismissal of the statutory claim but affirmed as to Smith’s unjust enrichment claim. Under section 146.83(3f)(b), Smith has a remedy at law for any “injustice” that allegedly resulted from excessive payments; the equitable remedy of unjust enrichment is derivative of and predicated upon the statutory claim. View "Smith v. RecordQuest LLC" on Justia Law

Cutchin’s wife and daughter were killed in an automobile accident that occurred when another driver, Watson, age 72, struck their vehicle. Cutchin alleges that Watson’s driving ability was impaired by medications she had been prescribed, including an opioid. Cutchin filed a malpractice suit against Watson’s healthcare providers, charging them with negligence for an alleged failure to warn Watson that she should not be driving given the known motor and cognitive effects of those medications. After the providers and their malpractice insurer agreed to a settlement of $250,000, the maximum amount for which they can be held individually liable under the Indiana Medical Malpractice Act (MMA), Cutchin sought further relief from the Patient’s Compensation Fund, which acts as an excess insurer. The Fund argued that the MMA does not apply to Cutchin’s claim and that he is barred from seeking excess damages from the Fund. The district court agreed.The Seventh Circuit certified to the Indiana Supreme Court the questions: Whether Ithe MMA prohibits the Fund from contesting the Act’s applicability to a claim after the claimant concludes a court‐approved settlement with a qualified healthcare provider, and whether the MMA applies to claims brought against individuals (survivors) who did not receive medical care from the provider, but who are injured as a result of the provider’s negligence in providing medical treatment to someone else. View "Cutchin v. Robertson" on Justia Law

Alleging debilitating pain in her back, legs, and hands, Zoch sought disability insurance benefits, 42 U.S.C. 413, 423. An ALJ denied the application, finding that, based on the opinions of three of her four treating physicians, a consulting physician, and the objective medical evidence, she could perform sedentary work.The district court and Seventh Circuit affirmed, rejecting Zoch’s arguments that the ALJ improperly discounted her assertions and an opinion by a physician who relied on those assertions. Substantial evidence supports the ALJ’s decision. Zoch’s testimony of incapacitating pain conflicted with the objective medical evidence, including normal test results: lumbar MRI, wrist x-rays, range of motion, straight-leg raising, strength in extremities, and pressure on her nerves. Zoch’s testimony that she usually walked with a cane conflicted with the doctors’ reports that at all but one appointment she walked normally. Zoch’s testimony that she could not raise her arms or bend over to dress conflicted with a doctor’s observation that Zoch could comfortably bend over to touch her fingertips to her knees. Zoch’s hearing testimony that she could not perform the usual activities of daily living was inconsistent with her assertions in her application. View "Zoch v. Saul" on Justia Law

Most people eligible for Medicaid benefits are “categorically needy” because their income falls below a threshold of eligibility. People with higher income but steep medical expenses are “medically needy” once they spend enough of their own assets to qualify, 42 U.S.C. 1396a(a)(10). Plaintiffs contend that medical expenses they incurred before being classified as “medically needy” should be treated as money spent on medical care, whether or not those bills have been paid, which would increase Illinois's payments for their ongoing care.The Seventh Circuit affirmed the dismissal of their suit. Medicaid is a cooperative program through which the federal government reimburses certain expenses of states that abide by the program’s rules. Medicaid does not establish anyone’s entitlement to receive particular payments. The federal-state agreement is not enforceable by potential beneficiaries. Plaintiffs bypassed their administrative remedies and do not have a judicial remedy under 1396a(r)(1)(A). Section 1396a(a)(8) provides that a state’s plan must provide that all individuals wishing to apply for medical assistance under Medicaid shall have the opportunity to do so and that assistance shall be furnished with reasonable promptness to all eligible individuals; some courts have held that this requirement can be enforced in private suits. If such a claim were available, it would fail. Plaintiffs are receiving benefits. The court also rejected claims under the Americans with Disabilities Act, 42 U.S.C. 12131–34, and the Rehabilitation Act, 29 U.S.C. 794. Plaintiffs receive more governmental aid than nondisabled persons. View "Nasello v. Eagleson" on Justia Law

The False Claims Act, 31 U.S.C. 3729–3733, authorizes relators to file qui tam suits on behalf of the U.S. government. If such an action is successful, the relator receives part of the recovery. The Act prohibits presenting to a federal healthcare program a claim for payment that violates the Anti-Kickback Statute, 42 U.S.C. 1320a-7b(b), Venari formed 11 daughter companies, each for the purpose of prosecuting a separate qui tam action, alleging essentially identical violations of the False Claims Act by pharmaceutical companies. CIMZNHCA, a Venari company, filed suit alleging illegal kickbacks to physicians for prescribing Cimzia to treat Crohn’s disease in patients who received federal healthcare benefits. The government did not exercise its right “to intervene and proceed” as the plaintiff but moved to dismiss the action, representing that it had investigated the Venari claims and found them to lack merit. The court denied that motion, finding the government’s general evaluation of the Venari claims insufficient as to CIMZNHCA and that the decision to dismiss was “arbitrary and capricious.”The Seventh Circuit reversed with instructions to dismiss, construing the government’s motion as a motion to both intervene and dismiss. By treating the government as seeking to intervene, a court can apply Federal Rule of Civil Procedure 41, which provides: “The Government may dismiss the action” without the relator’s consent if the relator receives notice and opportunity to be heard. View "United States v. UCB, Inc." on Justia Law

Vaughn, a quadriplegic, has received home‐based care for over 30 years. She requires help with personal care, household maintenance, mobility exercises, transportation, medications, suctioning secretions from her tracheostomy, and use of the ventilator. When nursing shifts cannot be staffed, Vaughn has relied on friends. Indiana funded her care through two federally-reimbursed Medicaid programs: A&D waiver and core Medicaid. Vaughn could select her own caregivers to receive A&D waiver funds but could not personally direct nursing care funded through core Medicaid. In 2016, Vaughn was hospitalized with pneumonia. She was cleared to be discharged but the state could not find nurses to provide round‐the‐clock care at home at Medicaid rates Vaughn was transferred to a nursing home and filed suit under the Americans with Disabilities Act, 42 U.S.C. 12132; the Rehabilitation Act, 29 U.S.C. 794; and the Medicaid Act, 42 U.S.C. 1396a(a)(8). The court granted Vaughn summary judgment with an injunction requiring the state to “do whatever is necessary to achieve” round‐the‐clock home‐based care, fully paid for by the state.The Seventh Circuit vacated. Vaughn is not entitled to the services she has requested under Indiana’s version of the Medicaid program, as the program was structured before the state adopted a new pilot program. The state is not obligated to reimburse Vaughn’s providers at rates above the approved Medicaid caps, nor must it use funds outside the Medicaid program to comply with a rule about accommodation within the program. View "Vaughn v. Walthall" on Justia Law

Mitze unsuccessfully appealed the denial of her application for social security benefits. Several years later, Mitze moved to seal her medical information and all other information pertaining to her case, citing “harassing phone calls from solicitors” who knew her personal medical information because the courts had “publicized” it by issuing opinions. She claims that she and her children have experienced social stigma and that thieves broke into her home to steal pain medication, which publicly available documents revealed that she had been prescribed.The Seventh Circuit affirmed the denial of Mitze’s motion. A strong presumption exists in favor of publishing dispositional orders, even in cases involving substantial privacy interests such as state secrets, trade secrets, and attorney-client privilege. The court acknowledged that the existing remedies of proceeding anonymously, requesting redactions, or sealing records may be inadequate in the social security context. News outlets have the right to publish information obtained from public court records and cannot be ordered to remove articles reporting on the decisions in her case. The court rejected an argument under the Health Insurance Portability and Accountability Act, 42 U.S.C. 1320d-6, which regulates the disclosure of information by only healthcare providers and their affiliates. View "Mitze v. Saul" on Justia Law

HCI, on behalf of the Illinois Department of Aging, coordinates services for low-income seniors in an effort to keep them at home. HCI sometimes referred clients who needed in-home healthcare services to home healthcare companies owned by MPI. Qui tam claims against MPI, its home healthcare companies, and HCI, alleged that they orchestrated an illegal patient referral scheme that violated the Anti-Kickback Statute, 42 U.S.C. 1320a-7b(g), and, by extension, the state and federal False Claims Acts, 31 U.S.C. 3730(b)(1). The district court entered judgment for the defendants.The Seventh Circuit reversed. The evidence showed that MPI made monthly payments to HCI in return for access to the non-profit’s client records and used that information to solicit clients. The Anti-Kickback Statute definition of a referral is broad, encapsulating both direct and indirect means of connecting a patient with a provider. It goes beyond explicit recommendations; the inquiry is a practical one that focuses on substance, not form. The plaintiff’s theory was that MPI’s payments to HCI under the Management Services Agreement constituted kickbacks intended to obtain referrals in the form of receiving access to the HCI files that the defendants then exploited to solicit clients. A factfinder applying an erroneously narrow understanding of "referral "might find those facts, devoid of an explicit direction of a patient to a provider, to fall outside its scope. View "Stop Illinois Health Care Fraud, LLC v. Sayeed" on Justia Law

Until 2010, Reinaas, now in his mid‐fifties, worked as a machine operator. He injured his spine and tore his rotator cuff on the job, and underwent two neck fusion surgeries. Reinaas planned to return to work but continued to suffer from severe headaches (treated with hydrocodone), shoulder pain, and a decreased range of motion. A neurologist diagnosed him with cervicogenic headaches, and his family doctor diagnosed “long term nuchal headaches” and “[p]ermanent pain syndrome post cervical fusion.” Dr. Bodeau, a Mayo Clinic occupational physician, opined that Reinaas could not return to his factory job and suggested surgical intervention. In 2013, Reinaas had shoulder surgery and attended physical therapy; he took naproxen and Vicodin for pain.Reinaas applied for social security disability benefits. Benefits were denied after state‐retained physicians reviewed his records and concluded that Reinaas’s accounts of his symptoms were not fully credible. Dr. Bodeau opined that Reinaas had “deteriorated significantly” and was “highly unlikely to successfully regain employment at any physical demand level.” The ALJ concluded that Reinaas was not disabled. In determining Reinaas’s residual functional capacity, the ALJ afforded great weight to the opinions of the two non‐examining physicians and gave little weight to Dr. Bodeau’s opinion, explaining that Bodeau lacked knowledge of Social Security disability rules and that his report was based on subjective complaints of questionable credibility.The Seventh Circuit vacated. Substantial evidence does not support the ALJ’s decision to discount the treating physician’s opinion and the ALJ did not adequately evaluate Reinaas’s subjective complaints. View "Reinaas v. Saul" on Justia Law