Justia Government Contracts Opinion Summaries

MedQuest is a diagnostic testing company that operates more than 90 testing facilities in 13 states. In 2006 a former MedQuest employee, brought a qui tam suit against MedQuest alleging violations of the False Claims Act. The United States intervened and obtained summary judgment ($11,110,662.71) that MedQuest used supervising physicians who had not been approved by the Medicare program and the local Medicare carrier to supervise the range of tests offered at the Nashville-area sites, and after acquiring one facility, MedQuest failed to properly re-register the facility to reflect the change in ownership and enroll the facility in the Medicare program, instead using the former owner’s payee ID number. The Sixth Circuit reversed, stating that the Medicare regulatory scheme (42 U.S.C. 1395x) does not support FCA liability for failure to comply with the supervising-physician regulations. MedQuest’s failure to satisfy enrollment regulations and its use of a billing number belonging to a physician’s practice it controlled do not trigger the hefty fines and penalties created by the FCA. View "United States v. MedQuest Assocs, Inc." on Justia Law

In 2004 the U.S. Department of Health and Human Services promulgated 42 C.F.R. § 412.106(b), concerning the amount that certain hospitals are entitled to receive as enhancements to their regular reimbursement payments from the Medicare program. In connection with the Medicare program, Congress created a statutory formula to identify hospitals that serve a disproportionate number of low-income patients and to calculate the increased payments due such hospitals. Metropolitan Hospital challenged the way that the Secretary of HHS interprets this statutory formula to exclude certain patients who are simultaneously eligible for benefits under both Medicare and Medicaid, claiming that exclusion of dual-eligible patients cost it more than $2.1 million in 2005. The district court ruled that the challenged HHS regulation was invalid as violating the statute that it purported to implement. The Sixth Circuit reversed, upholding HHS’s interpretation of 42 U.S.C. 1395. View "Metro. Hosp. v. U.S. Dept of Health & Human Servs." on Justia Law

After a 2008 Indiana flood, the President authorized the Federal Emergency Management Agency to provide disaster relief under the Stafford Act, 42 U.S.C. 5121–5207. Columbus Regional Hospital was awarded approximately $70 million, but suit under the Tucker Act, 28 U.S.C. 1346, 1349, claiming that it was entitled to about $20 million more. The district judge granted FEMA summary judgment. In response to the Seventh Circuit’s questioning of subject-matter jurisdiction, the Hospital argued that the Court of Federal Claims was the right forum and requested transfer. FEMA argued that the district court had jurisdiction. The Seventh Circuit agreed with FEMA, holding that the suit was not for “money damages.” The Hospital wants money, but not as compensation for FEMA’s failure to perform some other obligation, but as “the very thing to which [it] was entitled” under the disaster-relief program. The court noted that only the district court can serve as a forum for all of the Hospital’s legal theories, then rejected all of those theories. View "Columbus Reg'l Hosp. v. Fed. Emergency Mgmt. Agency" on Justia Law

Reimbursement providers for inpatient services rendered to Medicare beneficiaries is adjusted upward for hospitals that serve disproportionate numbers of patients who are eligible for Supplemental Security Income. The Centers for Medicare & Medicaid Services annually submit the SSI fraction for eligible hospitals to a “fiscal intermediary,” a Health and Human Services contractor, which computes the reimbursement amount and sends the hospitals notice. A provider may appeal to the Provider Reimbursement Review Board within 180 days, 42 U. S. C. 1395oo(a)(3). The PRRB may extend the period, for good cause, up to three years, 42 CFR 405.1841(b). A hospital timely appealed its SSI fraction calculations for 1993 through 1996. The PRRB found that errors in CMS’s methodology resulted in a systematic under-calculation. When the decision was made public, hospitals challenged their adjustments for 1987 through 1994. The PRRB held that it lacked jurisdiction, reasoning that it had no equitable powers save those granted by legislation or regulation. The district court dismissed the claims. The D. C. Circuit reversed. The Supreme Court reversed. While the 180-day limitation is not “jurisdictional” and does not preclude regulatory extension, the regulation is a permissible interpretation of 1395oo(a)(3). Applying deferential review, the Court noted the Secretary’s practical experience in superintending the huge program and the PRRB. Rejecting an argument for equitable tolling, the Court noted that for nearly 40 years the Secretary has prohibited extensions, except as provided by regulation, and Congress not amended the 180-day provision or the rule-making authority. The statutory scheme, which applies to sophisticated institutional providers, is not designed to be “unusually protective” of claimants. Giving intermediaries more time to discover over-payments than providers have to discover underpayments may be justified by the “administrative realities” of the system: a few dozen intermediaries issue tens of thousands of NPRs, while each provider can concentrate on its own NPR. View "Sebelius v. Auburn Reg'l Med. Ctr." on Justia Law

Ruppel sued CBS in Illinois alleging CBS’s predecessor, Westinghouse, caused the mesothelioma from which he suffers. Westinghouse had included asbestos in the turbines it supplied to the U.S. Navy, and Ruppel was allegedly exposed to it during his Naval service and later when he worked on an aircraft carrier as a civilian. CBS removed the case under the federal officer removal statute, which permits removal of certain suits where a defendant that acted under a federal officer has a colorable federal defense, 28 U.S.C. 1442(a)(1). Ruppel moved to remand and, without allowing response, the district court granted the motion. The district court concluded Ruppel only sued CBS for failing to warn about the dangers of asbestos for which there is no federal defense. The Seventh Circuit reversed. CBS’s relationship with Ruppel arises solely out of CBS’s duties to the Navy. It also has a colorable argument for the government contractor defense, which immunizes government contractors when they supply products with specifications approved by the government. View "Ruppel v. CBS Corp." on Justia Law

Tasis and his brother ran a sham medical clinic, recruited homeless Medicare recipients who had tested positive for HIV, hepatitis or asthma, paid the “patients” small sums in exchange for their insurance identification, then billed Medicare for infusion therapies that were never provided. During four months in 2006, the Center billed Medicare $2,855,785 and received $827,000 in return. The scheme lasted 15 months, during which Tasis and his collaborators submitted $9,122,159.35 in Medicare claims. An auditor notified the FBI. After an investigation, prosecutors indicted Tasis on fraud and conspiracy claims. Over Tasis’s objection, co-conspirator Martinez testified that she and Tasis had orchestrated a a similar scam in Florida. The court instructed the jury to consider Martinez’s testimony about the Florida conspiracy only as it related to Tasis’s “intent, plan and knowledge.” The jury found Tasis guilty, and the trial judge sentenced him to 78 months in prison and required him to pay $6,079,445.93 in restitution. The Sixth Circuit affirmed, rejecting various challenges to evidentiary rulings. View "United States v. Tasis" on Justia Law

TriCenturion audited Nichole Medical as a Program Safeguard Contractor under the Medicare Integrity Program, 42 U.S.C. 395ddd(a), and concluded that Nichole “might” be improperly billing for medical equipment; that Nichole had received overpayments; and that it had not maintained sufficient medical records to establish reasonableness or medical necessity. TriCenturion directed Nichole’s carrier, HealthNow, to withhold payments. TriCenturion calculated the actual overpayment of several specific claims, used those as a representative sampling, and extrapolated an overpayment amount for all relevant claims. The Attorney General found no evidence of fraud and refused to prosecute; HealthNow stopped withholding payments. TriCenturion instructed HealthNow’s successor to re-institute the offset. Nichole went out of business, but pursued an appeal. An ALJ determined that Nichole was entitled to reimbursement on some, but not all, appealed claims and found that the process for arriving at the extrapolated overpayment was flawed. The Medicare Appeals Council found that all 39 claims had been reopened and reviewed improperly. The district court dismissed Nichole’s suit against TriCenturion, which alleged torts and breach of the statutory duty of care under 42 U.S.C. 1320c-6(b). The Third Circuit affirmed. Defendants are immune from suit as officers or employees of the Secretary of the Department of Health and Human Services. View "Nichole Medical Equip & Supply, Inc. v. Tricenturion, Inc." on Justia Law

Semrau, a Ph.D. in clinical psychology, owned companies that provided psychiatric care to nursing home patients in Tennessee and Mississippi, using contracting psychiatrists who submitted records describing their work. The companies then billed the services to Medicare or Medicaid through private insurance carriers. Services are categorized into five-digit Current Procedural Terminology Codes, published by the American Medical Association. The Centers for Medicare and Medicaid Services sets reimbursement levels for each code as well as “relative value units” corresponding to the amount of work typically required for each service. After audits indicated that the companies had been billing at a higher rate than could be justified by the services actually performed, “upcoding,” Semrau was convicted of healthcare fraud, 18 U.S.C. 1347, and was sentenced to 18 months of imprisonment and ordered to pay $245,435 in restitution. The Sixth Circuit affirmed, rejecting Semrau’s claim that results from a functional magnetic resonance imaging lie detection test should have been admitted to prove the veracity of his denials of wrongdoing. There was ample evidence that Semrau was aware of accepted definitions of the CPT codes; he expressly agreed not to “submit claims with deliberate ignorance or reckless disregard of their truth or falsity.” View "United States v. Semrau" on Justia Law

Jewish Home of Eastern Pennsylvania (JHEP) provides nursing care to Medicare beneficiaries and is required to comply with the mandatory health and safety requirements for participation. JHEP must submit to random surveys conducted by state departments of health. In 2005, the Pennsylvania Department of Health conducted a survey that concluded that JHEP had eight regulatory deficiencies, including violations of 42 C.F.R. 483.25(h)(2), which requires a facility to ensure that each resident receives adequate supervision and assistance with devices to prevent accidents. Based on those deficiencies and those found in a 2006 survey, the Center for Medicare and Medicaid Services imposed fines totaling $17,150 and $12,800. JHEP claimed that the allegations of noncompliance were based on the inadmissible disclosure of privileged‖ quality assurance records and that the monetary penalties violated its right to equal protection because they were the product of selective enforcement based on race and religion. An ALJ upheld the fines against JHEP. The Third Circuit denied a petition for review. View "Jewish Home of E. PA v. Centers for Medicare and Medicaid Servs." on Justia Law

Suppliers appealed the district court's dismissal of their action against the Secretary of the Department of Health and Human Services and the Administrator of the Centers for Medicare and Medicaid Services (CMS). Suppliers challenged a regulation addressing the "applicable financial standards" that a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) supplier must meet to be eligible for a Medicare contract under the competitive process established in 42 U.S.C. 1395w-3 (DMEPOS Statute). The court affirmed the district court's dismissal on the ground that section 1395w-3(11) precluded judicial review of the Secretary's financial standards regulation and that the district court therefore lacked subject matter jurisdiction. View "Texas Alliance For Home Care, et al. v. Sebelius, et al." on Justia Law