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

Southwest appealed the district court's dismissal of its claim regarding the Medicare Part D statute, 42 U.S.C. 1395w-101 et seq., for lack of subject matter jurisdiction. Citing Shalala v. Illinois Council on Long Term Care, Southwest argued that its claim provided a narrow exception to 42 U.S.C. 405(h)'s requirement that required a plaintiff to exhaust administrative remedies before filing a claim in federal court. The court concluded that caselaw interpreting the application of section 405(h) to Medicare claims emphasized that the Illinois Council exception was extremely narrow and appropriately applied only in cases where judicial review would be entirely unavailable through the prescribed administrative procedures. Because Southwest has not carried its heavy burden of showing that the Illinois Council exception applied, the court affirmed the district court's order dismissing the suit. View "Southwest Pharmacy Solutions, Inc. v. Centers for Medicare & Medicaid, et al" on Justia Law

Defendants pleaded guilty to defrauding health-care insurers by billing for pain injections that they never administered. Defendants appealed the district court's order that they pay over $43 million in restitution to 32 victims defrauded by the scheme. The court concluded that the record did not support the entire restitution amount recommended and therefore the district court abused its discretion in adopting the unsupported figure. The court held, however, that the district court did not abuse its discretion in declining to apply a restitution credit. Accordingly, the court vacated the order of restitution and remanded for recalculation. As defendants' plea agreements stipulated to a forfeiture money judgment in the same amount as the restitution award, the court also vacated the amount of the forfeiture award and remanded for recalculation. The court further held that the government did not breach the plea agreements with defendants. View "United States v. Sharma" on Justia Law

A trade group and a physician-owned hospital sued the Secretary of the Department of Health and Human Services. They sought injunctive relief to remedy multiple alleged constitutional infirmities with Section 6001 of the Patient Protection and Affordable Care Act. Section 6001 limits Medicare reimbursement for services furnished to a patient referred by a physician owner. Although it denied the Secretary's motion to dismiss for lack of jurisdiction, the district court granted summary judgment to the Secretary, concluding that Congress had a rational basis for enacting Section 6001, the new law did not constitute a real or regulatory taking, and the law's requirements were not unconstitutionally vague. The plaintiffs appealed. The Fifth Circuit Court of Appeals vacated the district court's decision and dismissed the appeal, holding that the district court lacked subject matter jurisdiction over this case. View "Physician Hosps. of Am. v. Sebelius" on Justia Law

Petitioner pled guilty to the charge of conspiring to possess cocaine with intent to distribute. He was not informed that his conviction made him eligible for deportation. Later, an immigration judge conducted a hearing and ordered Petitioner's removal. On appeal to the Board of Immigration Appeals (BIA), Petitioner claimed derivative citizenship under 321 of the former Immigration and Nationality Act (INA). The BIA denied Petitioner's appeal. The Fifth Circuit Court of Appeals affirmed, holding (1) because Petitioner's parents never legally separated, and because Petitioner failed to carry his burden of proving that his mother was deceased, Petitioner failed to satisfy INA 321; and (2) INA 321 did not violate Petitioner's equal protection rights. View "Ayton v. Holder" on Justia Law

This appeal involved a challenge to the 2011 Medicare payment rate set by the Secretary of Health and Human Services for partial hospitalization services. Paladin claimed that the Secretary's use of both hospital-based and community mental health center cost data in establishing and adjusting the 2011 relative payment weights and ultimate payment rate was in excess of her statutory authority. Paladin filed suit in district court without first presenting an administrative claim, alleging jurisdiction was proper under 28 U.S.C. 1331. The court found that Congress expressly precluded judicial review of the Secretary's determinations and that her actions were not a facial violation of a clear statutory mandate. Accordingly, the court affirmed the district court's dismissal for lack of subject matter jurisdiction. View "Paladin Commty Mntl Hlth Ctr, et al. v. Sebelius, et al." on Justia Law

Plaintiff appealed the district court's summary judgment dismissing her suit to recover health insurance benefits under an employee plan governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001-1461. Aetna, a Texas health maintenance organization (HMO), provided and administered the plan's health insurance benefits under an agreement giving Aetna discretion to interpret the plan's terms. Aetna refused to reimburse plaintiff for care she received from a specialist outside of the Aetna HMO to whom she had been referred by a physician in the HMO. Aetna denied her claim because the referral was not pre-authorized by Aetna. The district court found as a matter of law that Aetna did not abuse its discretion in denying coverage. The court found, however, that the plan was ambiguous and the need for pre-authorization was not clearly stated in Aetna's summary description of the plan. And under the circumstances of the case, it could not be said as a matter of law that Aetna did not abuse its discretion in denying coverage. View "Koehler v. Aetna Health, Inc." on Justia Law

Defendant was convicted by a jury of defrauding Medicaid and Medicare of $1.4 million. On appeal, defendant argued that the evidence was insufficient; prejudicial evidence was admitted; the jury instructions were flawed; her sentencing level was erroneously increased for obstruction of justice; and the district court erred by denying her request for post-trial contact with a juror. The court affirmed the judgment because there was sufficient evidence to support the conviction and there was no reversible error.

Plaintiffs, physicians and abortion providers, sued the State under 42 U.S.C. 1983 for declaratory and injunctive relief against alleged constitutional violations resulting from Texas House Bill 15, an act "relating to informed consent to an abortion." Plaintiffs contended that H.B. 15 abridged their First Amendment rights by compelling the physician to take and display to the woman sonogram images of her fetus, make audible its heartbeat, and explain to her the results of both exams, as well as have her sign a consent form. The court held that the enumerated provisions of H.B. 15 requiring disclosures and written consent were sustainable under Planned Parenthood v. Casey, were within the State's power to regulate the practice of medicine, and did not violate the First Amendment. The court also held that the phrase "the physician who is to perform the abortion," the conflict between section 171.012(a)(4) and section 171.0122, and the provision in section 171.0123 regarding the failure to provide printed materials were not unconstitutionally vague. Therefore, plaintiffs failed to establish a substantial likelihood of success on any of the claims on which the injunction was granted and the court vacated the preliminary injunction.

Plaintiff sued the Louisiana State Board of Practical Nurse Examiners, claiming its status requirement violated the Constitution when the Board denied her a license solely on account of her immigration status. Plaintiff was an alien who had applied for permanent residence. The district court granted the Board summary judgment on all grounds. The court held that because applicants for permanent resident status did not constitute a suspect class under the Equal Protection Clause, and a rational basis supported the immigration-status requirement, the judgment was affirmed.

Plaintiff (relator) filed a qui tam complaint under the False Claims Act (FCA), 31 U.S.C. 3730, against defendants, alleging that they participated in a fraudulent scheme where the durable medical equipment (DME) supplier allowed the nursing home to keep a portion of the reimbursement from Medicare in return for a guarantee that the nursing home would buy all of its DME from that supplier. The district court subsequently dismissed relator's action on the ground that it violated the public disclosure provisions of the FCA. Relator appealed, arguing that this suit was not based on public disclosures and that he was an original source of the information on which his suit was based. The court held that because relator's action included no allegations specific to defendants, but merely repeated a general description of fraud easily available in several government documents, the court affirmed the judgment of the district court.