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

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

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

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

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

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

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

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

Methodist and Saint Francis are the two largest hospitals in Peoria, Illinois. Saint Francis is considerably larger and more profitable. Methodist filed suit, charging Saint Francis with violating the Sherman Act by entering into exclusive contracts with insurance companies, covering more than half of all commercially-insured patients in the area. Methodist argued that it could not obtain a sufficiently high volume of patients to enable it to invest in improvements. The Seventh Circuit affirmed summary judgment in favor of Saint Francis, noting that health insurers regard Saint Francis as a “must have” hospital, because it provides certain services that the other hospitals in the area do not provide, such as solid-organ transplants, neonatal intensive care, and a Level 1 trauma center. The contracts are a form of requirements contract; an insurance company may get better rates from a hospital by agreeing to an exclusive contract, which will drive more business to the hospital. The contracts are of fixed duration; when they terminate, the insurance companies are free to contract with other hospitals. Competition-for-the-contract is protected by the antitrust laws and is common. The court noted that none of the other four area hospitals had joined the case and the Department of Justice declined to file a case. View "Methodist Health Services Corp v. OSF Healthcare System" on Justia Law

Indiana’s 2015 Vapor Pens and E-Liquid Act regulates the manufacture and distribution of vapor pens and the liquids used in e-cigarettes, Ind. Code 7.1-7- 1-1. The Act has extraterritorial reach and imposed detailed requirements of Indiana law on out-of-state manufacturing operations. It purported to regulate the design and operation of out-of-state production facilities, including requirements for sinks, cleaning products, and even the details of contracts with outside security firms and the qualifications of those firms’ personnel. The Seventh Circuit reversed dismissal of a challenge to the Act. Imposing these Indiana laws on out-of-state manufacturers violates the dormant Commerce Clause. Indiana has ample authority to regulate in-state commerce in vapor pens, e-liquids, and e-cigarettes to protect the health and safety of its residents, by prohibiting sales to minors and requiring child-proof packaging, ingredient labeling, and purity. The requirements for in-state production facilities pose no inherent constitutional problems. Indiana may not, however, try to achieve its health and safety goals by directly regulating out-of-state factories and commercial transactions. View "Legato Vapors, LLC v. Cook" on Justia Law

Flambeau adopted an employee wellness program, requiring its employees, as a condition of receiving employer-subsidized health insurance, to fill out a medical questionnaire and to undergo biometric testing. One employee did not meet those requirements in time for the 2012 benefit year;, he and his family were briefly without health insurance. He filed a complaint with the Equal Employment Opportunity Commission, which filed suit, arguing that Flambeau’s requirement violated the Americans with Disabilities Act (ADA) ban on involuntary medical examinations, 42 U.S.C. 12112(d)(4). The district court dismissed; the Seventh Circuit affirmed. The court declined to address whether wellness programs are exempt from the limits on medical examinations because the ADA does not “restrict … [an] organization … administering the terms of a bona fide benefit plan that are based on underwriting risks, classifying risks, or administering such risks that are based on or not inconsistent with State law” or the EEOC argument that this insurance safe harbor does not apply to wellness programs. The court held that the relief the EEOC sought is either unavailable or moot. The employee resigned before suit was filed. He did not incur damages as a result of Flambeau’s policy and is not entitled to punitive damages. Flambeau abandoned its wellness program requirements for reasons unrelated to the litigation. View "Equal Employment Opportunity Commission v. Flambeau, Inc." on Justia Law