Justia U.S. 5th Circuit Court of Appeals Opinion Summaries

Scott Breimeister and four codefendants were tried for allegedly defrauding public and private healthcare programs of over $140 million through a scheme involving false claims for prescription drugs. During the trial, the Government made late disclosures of evidence favorable to the defense, affecting a significant portion of the testimony. The district court, concerned about the fairness of the trial, declared a mistrial sua sponte after determining that curative measures would not suffice to ensure a fair verdict.The United States District Court for the Southern District of Texas denied Breimeister's subsequent motion to bar retrial, finding that the Double Jeopardy Clause did not preclude a second trial because the mistrial was a "manifest necessity." Breimeister appealed this decision.The United States Court of Appeals for the Fifth Circuit reviewed the case and affirmed the district court's decision. The appellate court held that Breimeister had impliedly consented to the mistrial by failing to object contemporaneously, and thus, the Double Jeopardy Clause did not bar retrial. Additionally, the court found that the district court did not abuse its discretion in declaring a mistrial due to manifest necessity, given the extensive impact of the Government's late disclosures on the trial's fairness. The appellate court concluded that the district court had carefully considered alternatives and acted within its discretion in declaring a mistrial. View "United States v. Breimeister" on Justia Law

Relators Tiffany Montcrief and others filed a False Claims Act suit against Peripheral Vascular Associates, P.A. (PVA), alleging that PVA billed Medicare for vascular ultrasound services that were not completed. The claims were categorized into "Testing Only" and "Double Billing" claims. The district court granted partial summary judgment to Relators, concluding that PVA submitted knowingly false claims. A jury found these claims material and awarded approximately $28.7 million in damages against PVA.The district court granted partial summary judgment to Relators on the issues of falsity and knowledge of falsity. The jury found that the claims were material and caused the Government to pay out money. The district court entered judgment against PVA, including statutory penalties and treble damages. PVA appealed, challenging the district court's grant of partial summary judgment and certain rulings during and after the trial.The United States Court of Appeals for the Fifth Circuit reviewed the case. The court affirmed the district court's grant of partial summary judgment on the Testing Only claims but remanded for a new trial on damages. The court reversed the partial summary judgment ruling on the Double Billing claims, vacated the final judgment, and remanded for a new trial consistent with its opinion. The court concluded that the district court erred in interpreting the CPT–4 Manual and in concluding that the Manual required PVA to create separate, written reports for vascular ultrasounds before billing Medicare. The court also found that the district court abused its discretion in relying on Relators' post-trial expert declaration to calculate damages. View "Montcrief v. Peripheral Vascular" on Justia Law

In this case, inmates at the Louisiana State Penitentiary (LSP) filed a class action lawsuit in 2015 against the warden, the Louisiana Department of Public Safety and Corrections, and other officials. The plaintiffs alleged that the defendants were deliberately indifferent to their serious medical needs, violating the Eighth Amendment, the Rehabilitation Act of 1973, and the Americans with Disabilities Act (ADA). The district court bifurcated the case into liability and remedy phases. After an eleven-day bench trial, the court found in favor of the plaintiffs on all claims. Subsequently, a ten-day trial on remedies concluded that the plaintiffs were entitled to permanent injunctive relief, but the court did not specify the relief in its judgment.The United States District Court for the Middle District of Louisiana entered a "Judgment" in favor of the plaintiffs and a "Remedial Order" outlining the appointment of special masters to develop remedial plans. The defendants appealed, arguing that the district court's judgment and remedial order were final and appealable under 28 U.S.C. § 1291 or, alternatively, under 28 U.S.C. § 1292(a)(1).The United States Court of Appeals for the Fifth Circuit reviewed the case and concluded that the district court had not entered a final decision appealable under 28 U.S.C. § 1291, nor had it entered an injunction appealable under 28 U.S.C. § 1292(a)(1). The appellate court determined that the district court's actions were not final because they contemplated further proceedings, including the appointment of special masters and the development of remedial plans. Consequently, the Fifth Circuit dismissed the appeal for lack of jurisdiction and vacated the stay of the remedial order. View "Parker v. Hooper" on Justia Law

A group of anesthesiology specialty medical practices sued the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) to challenge the Merit-based Incentive Payment System (MIPS). MIPS evaluates eligible clinicians across several performance categories and adjusts their Medicare reimbursement rates accordingly. The plaintiffs received unfavorable MIPS scores and argued that the Total Per Capita Cost (TPCC) measure, one of MIPS’s performance metrics, was arbitrary and capricious as applied to them.The United States District Court for the Northern District of Texas concluded that the plaintiffs' suit was statutorily barred and granted summary judgment for the defendants. The district court determined that 42 U.S.C. §§ 1395w-4(q)(13)(B)(iii) and (p)(10)(C) preclude judicial review of the plaintiffs' claims. Additionally, the court found that even if the claims were justiciable, CMS did not exceed its statutory authority in establishing the TPCC measure and its attribution methodology, and that the TPCC measure, as applied to the plaintiffs, was not arbitrary or capricious.The United States Court of Appeals for the Fifth Circuit reviewed the case and affirmed the district court’s dismissal. The appellate court agreed that 42 U.S.C. § 1395w-4(q)(13)(B)(iii) bars judicial review of the plaintiffs' challenge because CMS’s establishment of an attribution methodology for the TPCC measure falls within the “identification of measures and activities.” The court also concluded that 42 U.S.C. § 1395w-4(p)(10)(C) bars judicial review of the plaintiffs' claims, as it precludes review of the evaluation of costs, including the establishment of appropriate measures of costs. The court found no merit in the plaintiffs' assertion that CMS exceeded its statutory authority. Thus, the appellate court affirmed the district court’s decision to dismiss the plaintiffs' claims for lack of jurisdiction. View "U.S. Anesthesia Partners of Texas v. Health and Human Services" on Justia Law

Dr. Susan Neese and Dr. James Hurly, both doctors in Amarillo, Texas, filed a pre-enforcement challenge against the Department of Health and Human Services (HHS) regarding the Notification of Interpretation and Enforcement of Section 1557 of the Affordable Care Act and Title IX of the Education Amendments of 1972. The Notification, issued in May 2021, interprets the prohibition on sex discrimination to include discrimination based on sexual orientation and gender identity. The plaintiffs, who are unwilling to provide certain gender-affirming care, feared that their medical practices might be viewed as discriminatory under the Notification, potentially leading to enforcement actions and loss of federal funding.The United States District Court for the Northern District of Texas granted summary judgment in favor of the plaintiffs. The district court found that the plaintiffs had standing to challenge the Notification and ruled in their favor.The United States Court of Appeals for the Fifth Circuit reviewed the case and determined that the plaintiffs lacked Article III standing. The court found that the plaintiffs had not demonstrated how their conduct constituted gender-identity discrimination under any plausible interpretation of the Notification. The plaintiffs did not view their own practices as discriminatory, nor did they provide evidence that HHS would view them as such. Additionally, there was no indication that an enforcement proceeding was imminent. As a result, the Fifth Circuit vacated the district court's judgment and remanded the case with instructions to dismiss the plaintiffs' claims for lack of jurisdiction. View "Neese v. Becerra" on Justia Law

Sekhar Rao was involved in a scheme to defraud TRICARE, a federal health benefit plan, by ordering medically unnecessary toxicology and DNA cancer screening tests. These tests were billed to TRICARE through a shell company, ADAR Group, LLC, which set up fraudulent testing sites. Rao, a physician, was hired to sign off on these tests without reviewing patient medical information or meeting the patients. He was paid per test ordered. The scheme involved using a signature stamp of Rao’s signature to sign requisition forms, which Rao allegedly knew about and consented to.In the United States District Court for the Northern District of Texas, Rao was acquitted of conspiracy to commit health care fraud but was convicted of two counts of substantive health care fraud related to specific fraudulent claims submitted to TRICARE. The district court sentenced him to 48 months of imprisonment, followed by three years of supervised release, and calculated the loss amount under the United States Sentencing Guidelines based on the intended loss.The United States Court of Appeals for the Fifth Circuit reviewed the case. Rao raised three issues on appeal: the sufficiency of the evidence for his convictions, the exclusion of testimony regarding statements made to him by the scheme’s leader about legal vetting, and the calculation of the loss amount under the Sentencing Guidelines. The Fifth Circuit found no reversible error in the district court’s decisions. The court held that there was sufficient evidence for a reasonable jury to conclude that Rao caused the submission of the fraudulent claims and that he knew about and authorized the use of his signature stamp. The court also held that the district court did not plainly err in excluding the testimony about legal vetting and did not err in calculating the intended loss amount. The Fifth Circuit affirmed Rao’s convictions and sentence. View "United States v. Rao" on Justia Law

A group of healthcare and air-ambulance providers challenged certain agency rules regarding the No Surprises Act, which aims to protect patients from unexpected medical bills. The key issues involved the calculation of the "qualifying payment amount" (QPA), deadlines for insurers to respond to provider bills, and disclosure requirements for insurers.The United States District Court for the Eastern District of Texas reviewed the case and held several provisions of the rules unlawful, vacating them. The court found that the rules conflicted with the Act's terms and were arbitrary and capricious. The defendant agencies appealed the decision regarding certain provisions, while the plaintiffs cross-appealed the court's upholding of the disclosure requirements.The United States Court of Appeals for the Fifth Circuit reviewed the case. The court reversed the district court's vacatur of the QPA calculation provisions, holding that the rules did not conflict with the Act and were not arbitrary and capricious. The court affirmed the district court's vacatur of the deadline provision, agreeing that it conflicted with the Act's unambiguous terms. The court also affirmed the district court's decision upholding the disclosure requirements, finding them reasonable and adequately explained.In summary, the Fifth Circuit reversed the district court's decision on the QPA calculation provisions, affirmed the vacatur of the deadline provision, and upheld the disclosure requirements. The court concluded that the proper remedy for the unlawful deadline provision was vacatur, not remand, and rejected the idea of party-specific vacatur. View "Texas Medical Association v. Health and Human Services" on Justia Law

The case involves the National Infusion Center Association (NICA) and other plaintiffs challenging the constitutionality of the Drug Price Negotiation Program established by the Inflation Reduction Act. This program requires the Department of Health and Human Services (HHS) to negotiate drug prices with manufacturers, setting a "maximum fair price" between 40% and 75% of the market price. Manufacturers who do not comply face significant fines or must withdraw from Medicare coverage entirely.The United States District Court for the Western District of Texas dismissed NICA's lawsuit for lack of subject-matter jurisdiction. The district court reasoned that NICA's claims had to be "channeled" through HHS as required by 42 U.S.C. § 405, which mandates that claims arising under the Medicare Act be decided by the relevant agency before being brought to federal court. The district court also dismissed the remaining plaintiffs due to improper venue without NICA.The United States Court of Appeals for the Fifth Circuit reviewed the case and found that NICA had standing based on both economic and procedural injuries. The court determined that NICA's claims did not arise under the Medicare Act but rather under the Inflation Reduction Act, and thus did not require channeling through HHS. The court held that the district court had subject-matter jurisdiction over NICA's claims and reversed the lower court's dismissal, remanding the case for further proceedings. View "Natl Infusion Center v. Becerra" on Justia Law

The case involves healthcare providers and air ambulance services challenging regulations established by the Departments of Health and Human Services, Labor, and the Treasury. These regulations were designed to guide independent arbitrators in resolving insurance reimbursement disputes under the No Surprises Act, which aims to protect patients from unexpected medical bills by limiting their out-of-pocket costs for emergency and certain non-emergency services provided by out-of-network providers.The United States District Court for the Eastern District of Texas reviewed the case and vacated the regulations, finding that they improperly favored the qualifying payment amount (QPA) over other statutory factors that arbitrators are required to consider. The court held that the regulations conflicted with the No Surprises Act and violated the Administrative Procedure Act (APA) by imposing additional requirements not found in the statute. The court also found that the plaintiffs had standing to sue based on procedural and financial injuries.The United States Court of Appeals for the Fifth Circuit reviewed the case and affirmed the district court's decision. The Fifth Circuit held that the regulations exceeded the Departments' authority by imposing a sequence in which arbitrators must consider the QPA first, disregarding information deemed not credible or unrelated, and requiring arbitrators to explain why they deviated from the QPA. The court found that these provisions placed undue emphasis on the QPA, contrary to the statute's requirement that all factors be considered equally. The court also upheld the district court's universal vacatur of the challenged provisions, rejecting the Departments' arguments for more limited relief. View "Texas Medical Association v. Health and Human Services" on Justia Law

Caris MPI, Inc. (Caris) provided cancer diagnostic services to UnitedHealthcare, Inc. (United) for over ten years without a written contract. United audited Caris’s past claims and determined that Caris had used incorrect billing codes, resulting in overpayments. United began recouping these overpayments by offsetting them against new payment claims from Caris. Caris challenged United’s recoupment through United’s internal process, but after United rejected Caris’s appeals, Caris filed suit in Texas state court alleging various state law claims.United removed the case to the United States District Court for the Northern District of Texas, asserting federal officer jurisdiction under 28 U.S.C. § 1442(a)(1). The district court denied Caris’s motion to remand and dismissed Caris’s claims without prejudice, finding that Caris failed to exhaust administrative remedies under the Medicare Act.The United States Court of Appeals for the Fifth Circuit reviewed the case and agreed that federal officer jurisdiction existed. However, the court found that the district court erred in dismissing Caris’s claims for failure to exhaust administrative remedies. The Fifth Circuit held that the administrative review process under Medicare Part C does not extend to claims where an enrollee has no interest, and there were no administrative remedies for Caris to exhaust. The court distinguished this case from others by noting that no enrollee had requested an organization determination or appeal, and all enrollees had already received the services for which United sought recoupment. Consequently, the court affirmed the denial of the remand motion, reversed the dismissal of Caris’s claims, and remanded the case for further proceedings. View "Caris MPI v. UnitedHealthcare, Incorporated" on Justia Law