On March 31, 2015, the Supreme Court issued the first of several expected decisions that will impact the healthcare industry this year, ruling that Medicaid providers have no constitutional or statutory right to challenge a state’s Medicaid reimbursement rates. In Armstrong v. Exceptional Child Center, Inc., a group of Idaho Medicaid providers had challenged the states’ reimbursement rates as violating the federal laws that govern the program, commonly known as the Medicaid Act.
Under the Medicaid Act, both the federal government and the individual states fund and administer the Medicaid program. Each state establishes the rates and other parameters within its Medicaid program, subject to overall federal approval. Each state must submit a plan outlining its Medicaid program to the Department of Health and Human Services (HHS). The Plan, among other things, is supposed to meet the Medicaid Act’s requirements that payments are sufficient to enlist enough providers so that covered care and services are available to Medicaid beneficiaries.
A group of Idaho Medicaid providers challenged Idaho’s Medicaid rates as violating this provision of the Medicaid Act. The Idaho Department of Health and Welfare had proposed rate increases which had been approved by HHS as part of the state’s overall Medicaid plan. However, the increases were never funded by the Idaho state legislature and thus never implemented. The providers filed a lawsuit seeking to impose higher Medicaid reimbursement rates on the grounds that Idaho had failed to follow its approved plan and had set reimbursement rates so low that providers were unwilling to enroll in the Medicaid program, denying Medicaid beneficiaries access to effective care.
Two lower courts had ruled in favor of the providers. However, the Supreme Court ruled that only HHS is entitled to enforce the requirements of the Medicaid Act. It is important to note that the case was purely procedural. While the Supreme Court held that Medicaid providers did not have a constitutional or statutory right to challenge a state’s Medicaid reimbursement rates, it did not rule on whether or not Idaho’s Medicaid reimbursement actually complies with the Medicaid Act requirements.
The increasing downward pressure on Medicaid reimbursement shows no signs of stopping, even as the Affordable Care Act expands Medicaid enrollment in many states. This case is a reminder that providers seeking to increase Medicaid reimbursement will need to also focus on obtaining federal and state legislative, not just judicial, solutions.
The Department of Justice (“DOJ”) announced another multi-million dollar settlement of alleged False Claims Act violations on March 11, 2014. Specifically, Halifax Hospital Medical Center and Halifax Staffing, Inc. agreed to settle various issues with the DOJ for $85 million in order to resolve allegations that they violated the False Claims Act (“FCA”) by submitting claims to Medicare that violated the federal prohibition on physician self-referrals, 42 USC §1395nn (the “Stark Law”). United States ex rel. Baklid-Kunz v. Halifax Hospital Medical Center, et al., No. 09-cv-1002 (M.D. Fla.).
The Stark Law and the Bona Fide Employment Exception
The Stark Law prohibits a physician from referring a patient for certain designated health services (“DHS”) to an entity in which the physician, or an immediate family member, has a financial interest, such as an ownership or investment interest in the entity or a compensation arrangement with the entity. Certain exceptions for arrangements are permitted under Stark. However, because the Stark Law is a strict liability statute, the arrangement must fit completely within the criteria of the exception in order not to violate the statute. At issue in Halifax, as explained below, is the bona fide employment exception, Continue reading
Posted in Acute Care, Civil Litigation, Corporate Integrity Agreements, DHHS, Florida, Fraud and Abuse, Health Care, Health Care Providers, Hospital, Medicare, OIG, Physicians, Regulatory Compliance, Reimbursement, Self-Referral, Settlements
Tagged Neurosurgery, Oncology, Stark Law
On January 25, 2013, the U.S. District Court for the Eastern District of Pennsylvania dismissed with prejudice the False Claims Act (“FCA”) claims that were alleged by a qui tam relator against two drug manufacturers because the whistleblower’s allegations were substantially similar to those that had been previously publically disclosed and the relater was not an original source of information. The court then also declined to exercise supplemental jurisdiction over the remaining state law claims. U.S. ex rel. Schumann v. AstraZeneca Pharmaceuticals LP, No. 03-5423, 2013 WL 300745 (E.D. Penn. Jan. 25, 2013). The same court previously dismissed identical FCS claims against Bristol-Meyers Squbb Company in an earlier opinion. U.S. ex rel. Schumann v. AstraZeneca PLC, No. 03-5423, 2010 WL 4025904 (E.D. Penn. Oct. 13, 2010). Continue reading
On June 18, 2012, Judge Sandra Beck of the US District Court for the Southern District of Ohio sided with a group of Veterans Affairs (VA) pension recipients in Ledford, et al., vs. Michael B. Colbert, director, Ohio Department of Job and Family Services, Case No. 1:10-cv-706.
Judge Beck found that the Ohio Department of Job and Family Services (ODJFS) violated federal law by not providing recipients of the Medicaid assisted living waiver a $90 Personal Needs Allowance (PNA) in the patient liability calculation of their Medicaid budget when the individual is a recipient of VA Aid and Attendance benefits. Continue reading
Posted in Assisted Living, Civil Litigation, Consumers, Continuing Care, Health & Human Services, Health Care, Health Care Providers, Health Reform, Long Term Care, Medicaid, Nursing Facility, Nursing Home, Ohio, Senior Housing, Skilled Nursing Facility
This morning, June 28, 2012, the United States Supreme Court released its decision upholding the constitutionality of the individual mandate – the centerpiece of President Obama’s health care law.
The individual mandate requires that all Americans maintain “minimum essential” health insurance coverage. Beginning in 2014, individuals that do not comply with the mandate must make a “shared responsibility payment” to the Federal Government. The amount of the payment varies with household income, subject to a floor and a ceiling based on the average annual premium that the individual would have to pay for private health insurance.
Interestingly, the Supreme Court rejected the Obama administration’s argument that the individual mandate was permissible under the Commerce Clause, instead concluding that the individual mandate was permissible under Congress’ taxing authority.
Another key provision of the Affordable Care Act is the expansion of the Medicaid program. The Affordable Care Act expands the scope of the Medicaid program and increases the number of individuals that states must cover. For example, the Act requires state programs to provide Medicaid coverage to adults that earn up to 133 percent of the federal poverty level. Many states only provide Medicaid to individuals whose incomes are significantly lower.
While the Act increases federal funding to cover the states’ costs in expanding coverage, it also threatened to withdraw all federal Medicaid funds for failure to comply. This morning, the Supreme Court ruled that while it was permissible to expand the Medicaid program, the Act could not withdraw existing Medicaid funds for states that opt out of the expansion.
A copy of the full opinion can be found here–> USCT ACA Opinion
For more information on the U.S. Supreme Court’s decision, please feel free to contact any member of our health care practice group for a further discussion.
Please all check back here often for further posts on the decision.
Posted in Accountable Care Organizations, Civil Litigation, Consumers, DHHS, Health & Human Services, Health Care, Health Care Providers, Health Insurance, Health Reform, Medicaid, Medicare, Payers, Regulation
On June 5, 2012, a lawsuit was filed in federal court in Virginia challenging the constitutionality of Virginia’s certificate of need (“CON”) law. This is the second recent lawsuit of its type challenging the constitutionality of state CON laws, and suggests an increased willingness of health care providers to challenge state CON laws following the relative success of the plaintiffs in the case of Yakima Valley Memorial Hospital v. Washington State Department of Health.
The U.S. 6th Circuit Court recently upheld a DHHS Departmental Appeals Board decision that found a skilled nursing facility’s (“SNF”) deficiencies were at an “immediate jeopardy” level relating to a failure to notify a physician or family member of a significant change in a patient’s condition. See, Claiborne-Hughes Health Center v. Sebelius, 6th Cir. No 09-3239, 6/25/10. Continue reading
Posted in Administrative Appeals, Civil Litigation, DAB Decisions, Health Care, Health Care Providers, Long Term Care, Medicare, Nursing Facility, Nursing Home, Post Acute Care, Skilled Nursing Facility, Tennessee