Justia U.S. 10th Circuit Court of Appeals Opinion Summaries

Among its reforms, the Patient Protection and Affordable Care Act (“ACA”) required private health insurers to provide coverage for individuals regardless of their gender or health status, including preexisting conditions. Congress anticipated these reforms might hamper the ability of insurers to predict health care costs and to price health insurance premiums as more individuals sought health insurance. To spread the risk of enrolling people who might need more health care than others, Congress established a risk adjustment program for the individual and small group health insurance markets. Congress tasked the Department of Health and Human Services (“HHS”) with designing and implementing this risk adjustment program with the states. HHS developed a formula to calculate how much each insurer would be charged or paid in each state. The formula relied on the “statewide average premium” to calculate charges and payments. Plaintiff-Appellee New Mexico Health Connections (“NMHC”), an insurer that was required to pay charges under the program, sued the HHS Defendants-Appellants under the Administrative Procedure Act (“APA”), alleging that HHS’s use of the statewide average premium to calculate charges and payments in New Mexico from 2014 through 2018 was arbitrary and capricious. The district court granted summary judgment to NMHC, holding that HHS violated the APA by failing to explain why the agency chose to use the statewide average premium in its program. It remanded to the agency and vacated the 2014, 2015, 2016, 2017, and 2018 rules that implemented the program. After the district court denied HHS’s motion to alter or amend judgment under Federal Rule of Civil Procedure 59(e), HHS appealed. The Tenth Circuit Court of Appeals: (1) determined NMHC’s claims regarding the 2017 and 2018 rules were moot, so the matter was remanded to the district court to vacate its judgment on those claims and dismiss them as moot; (2) reversed the district court’s grant of summary judgment to NMHC as to the 2014, 2015, and 2016 rules because it determined HHS acted reasonably in explaining why it used the statewide average premium in the formula. Because the Court reversed the district court on its summary judgment ruling in favor of NMHC, it did not address the denial of HHS’s Rule 59(e) motion. View "New Mexico Health Connections v. HHS" on Justia Law

Cameo Williams, Sr. was a veteran of the United States Army, who spent his entire service stateside - never overseas or in combat. But for years, based on false statements about combat service, he obtained VA benefits for combat-related PTSD. The issue presented for the Tenth Circuit Court of Appeals in this case was whether it mattered about Williams’ lies about overseas service to obtain his PTSD benefits. The Court rejected Williams’s argument that his lie was not material under 18 U.S.C. 1001(a)(2), as well as his two challenges to evidentiary rulings. View "United States v. Williams" on Justia Law

Blue Valley Hospital, Inc., (“BVH”) appealed a district court’s dismissal of its action for lack of subject matter jurisdiction. The Department of Health and Human Services (“HHS”) and the Centers for Medicare and Medicaid Services (“CMS”) terminated BVH’s Medicare certification. The next day, BVH sought an administrative appeal before the HHS Departmental Appeals Board and brought this action. In this action, BVH sought an injunction to stay the termination of its Medicare certification and provider contracts pending its administrative appeal. The district court dismissed, holding the Medicare Act required BVH exhaust its administrative appeals before subject matter jurisdiction vested in the district court. BVH acknowledged that it did not exhaust administrative appeals with the Secretary of HHS prior to bringing this action, but argued: (1) the district court had federal question jurisdiction arising from BVH’s constitutional due process claim; (2) BVH’s due process claim presents a colorable and collateral constitutional claim for which jurisdictional exhaustion requirements are waived under Mathews v. Eldridge, 424 U.S. 319 (1976); and (3) the exhaustion requirements foreclosed the possibility of any judicial review and thus cannot deny jurisdiction under Bowen v. Michigan Academy of Family Physicians, 476 U.S. 667 (1986). The Tenth Circuit disagreed and affirmed dismissal. View "Blue Valley Hospital v. Azar" on Justia Law

A federal grand jury indicted Steven DeLia on one count of healthcare fraud. But the government filed the indictment outside the ordinarily applicable statute of limitations. Notwithstanding this filing, the government argued the indictment was timely because: (1) the Wartime Suspension of Limitations Act suspended the limitations period from running in this case; and (2) DeLia waived his asserted statute-of-limitations defense. The Tenth Circuit rejected both reasons and concluded the prosecution was time-barred. DeLia’s conviction was vacated and the indictment was dismissed. View "United States v. DeLia" on Justia Law

This appeal presented a question of whether established law supported Plaintiff Joseph Leiser's claim that two jail officials in Coffey County, Kansas, violated his constitutional rights by disclosing medical information about him that they had properly obtained. Plaintiff was set to be extradited from Illinois to Kansas, and the Kansas jail requested Illinois arrange for multiple medical examinations of Plaintiff to determine whether he had suffered injuries after being tasered by U.S. Marshals. The Kansas official learned Plaintiff had bone lesions and possibly cancer. This information was conveyed to the Coffey County Sheriff, who conveyed it to Coffey County Hospital, then to Plaintiff's family and friends, without first obtaining Plaintiff's permission. The Tenth Circuit determined the prison officials were entitled to qualified immunity, and dismissed his case. View "Leiser v. Moore" on Justia Law

This case was a qui tam action alleging violations of the False Claims Act (“FCA”) involving fraudulent reimbursements under the Medicare Act. Plaintiff Gerald Polukoff, M.D., was a doctor who worked with Defendant Sherman Sorensen, M.D. After observing some of Sorensen’s medical practices, Polukoff brought this FCA action, on behalf of the United States, against Sorensen and the two hospitals where Sorensen worked (collectively, “Defendants”). Polukoff alleged Sorensen performed thousands of unnecessary heart surgeries and received reimbursement through the Medicare Act by fraudulently certifying that the surgeries were medically necessary. Polukoff further alleged the hospitals where Sorensen worked were complicit in and profited from Sorensen’s fraud. The district court granted Defendants’ motions to dismiss, reasoning that a medical judgment could not be false under the FCA. The Tenth Circuit reversed and remanded, holding that a doctor’s certification to the government that a procedure is “reasonable and necessary” is “false” under the FCA if the procedure was not reasonable and necessary under the government’s definition of the phrase. View "Polukoff v. St. Mark's Hospital" on Justia Law

A former small-town doctor, defendant Joel Miller, was charged with multiple counts of health-care fraud, money laundering, and distributing a controlled substance outside the usual course of professional treatment, as well as one count of making a false statement on an application submitted to the Drug Enforcement Administration. A jury acquitted him on all of the financial charges as well as several of the drug distribution charges, but found him guilty on seven counts of distributing a controlled substance, and one count of making a false statement to the DEA. The district court granted Defendant’s post-judgment motion for acquittal on one of the controlled-substances counts based on an error in the indictment. The court then sentenced him to forty-one months of imprisonment on the six remaining distribution counts, plus a consecutive sentence of nineteen months on the false-statement count, for a total sentence of sixty months of imprisonment. Defendant appealed his convictions and sentence. The Tenth Circuit found no error in the imposition of defendant’s sentence on the six distribution counts; however the Court reversed and remanded on the false statement count. The Court was persuaded that trial court proceedings “broadened the possible bases for conviction beyond those found in the operative charging document. …we are persuaded that the trial proceedings in this case effected a constructive amendment.” View "United States v. Miller" on Justia Law

Plaintiff Jimmy Vasquez, an inmate in the Colorado Department of Corrections (“CDOC”), filed suit under 42 U.S.C. 1983, contending CDOC medical providers were deliberately indifferent to his serious medical needs in violation of the Eighth Amendment. Vasquez specifically alleged Defendants delayed treating him for the hepatitis C virus (“HCV”), resulting in his suffering life-threatening permanent liver damage. In appeal No. 17-1026, the Tenth Circuit affirmed the district court’s decision to grant Defendants summary judgment, concluding Vasquez’s claims against Defendants Davis, Webster, Melloh, and Chamjock were time-barred, and Vasquez failed to present sufficient evidence that Defendant Fauvel acted with deliberate indifference. In appeal No. 17-1044, the Court vacated an injunction requiring the CDOC to test Vasquez’s liver function every three months. View "Vasquez v. Davis" on Justia Law

In 2016, Kansas sent notices of decisions to terminate its Medicaid contracts with two Planned Parenthood affiliates, Planned Parenthood of Kansas and Mid-Missouri (“PPGP”), and Planned Parenthood of the St. Louis Region (“PPSLR”). The notices cited concerns about the level of PPGP’s cooperation in solid-waste inspections, both Providers’ billing practices, and an anti-abortion group’s allegations that Planned Parenthood of America (“PPFA”) executives had been video-recorded negotiating the sale of fetal tissue and body parts. Together, the Providers and three individual Jane Does (“the Patients”) immediately sued Susan Mosier, Secretary of the Kansas Department of Health and Environment (“KDHE”), under 42 U.S.C. 1983, alleging violations of 42 U.S.C. 1396a(a)(23) and the Equal Protection Clause of the Fourteenth Amendment. The Plaintiffs sought a preliminary injunction enjoining Kansas from terminating the Providers from the state’s Medicaid program. "States may not terminate providers from their Medicaid program for any reason they see fit, especially when that reason is unrelated to the provider’s competence and the quality of the healthcare it provides." The Tenth Circuit joined four of five circuits that addressed this same provision and affirmed the district court’s injunction prohibiting Kansas from terminating its Medicaid contract with PPGP. But the Court vacated the district court’s injunction as it pertained to PPSLR, remanding for further proceedings on that issue, because Plaintiffs failed to establish standing to challenge that termination. But on this record, the Court could not determine whether PPSLR itself could establish standing, an issue the district court declined to decide but now must decide on remand. View "Planned Parenthood v. Andersen" on Justia Law

Plaintiff-Appellant Suture Express, Inc. appeals from the district court’s entry of summary judgment in favor of Cardinal Health 200, LLC (“Cardinal”) and Owens & Minor Distribution, Inc. (“O&M”) under Section 1 of the Sherman Antitrust Act, Section 3 of the Clayton Act, and the Kansas Restraint of Trade Act (“KRTA”). Suture Express, Cardinal, and O&M compete in the national broadline medical-and-surgical (“med-surg”) supply and distribution market. After Suture Express entered the "suture-endo" market and steadily grew its market share, Cardinal and O&M responded by instituting bundling packages in their contracts. Suture Express sued Cardinal and O&M, alleging that their bundling arrangements constituted an illegal tying practice in violation of federal and state antitrust laws. The court held that Suture Express’s federal claims failed as a matter of law because it could not establish that either Cardinal or O&M individually possessed sufficient market power in the other-med-surg market that would permit it to restrain trade in the suture-endo market. Even were this not the case, however, the court also held that: (1) Suture Express could not establish antitrust injury because it had not shown that competition itself had been harmed; and (2) Cardinal and O&M cited sufficient procompetitive justifications for the bundling arrangement to overcome any harm caused by any anticompetitive effects resulting from the bundle. Viewing the evidence in the light most favorable to Suture Express, the Tenth Circuit did not think the company could survive summary judgment under Section 1 of the Sherman Act, Section 3 of the Clayton Act, or the Kansas Restraint of Trade Act. "There simply is not enough probative evidence by which a reasonable jury could find that Cardinal’s and O&M’s bundling arrangement unreasonably restrained trade in violation of federal or state antitrust law." View "Suture Express v. Owens & Minor" on Justia Law