Articles Posted in Health Law

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In an appeal by allowance, the issue presented to the Pennsylvania Supreme Court was whether the Superior Court applied the correct statute of limitations for a survival action in a medical professional liability case. In 2005, Elise Dubose was admitted to Albert Einstein Medical Center (Einstein) after she fell in her home and sustained severe head injuries, including anoxia and a brain injury. She was transferred to Willowcrest Nursing Home where Mrs. Dubose suffered malnourishment, dehydration, conscious pain from bedsores, a bone infection, and a sepsis systemic infection. An ulcers located at the sacral region of the spine which Mrs. Dubose developed during her initial hospitalization, gradually increased in size. The sacral ulcer became infected with bacteria from contact with feces. This infection caused sepsis in Mrs. Dubose in September 2007, and she was admitted to Einstein with sepsis. On October 18, 2007, Mrs. Dubose died from sepsis and multiple pressure sores. On August 13, 2009, Robert Dubose, as administrator for Mrs. Dubose's estate, filed a complaint against Willowcrest and Albert Einstein Healthcare Network (collectively Appellants) sounding in negligence and alleged wrongful death. The Supreme Court concluded the statute of limitations for medical professional liability cases in the form of wrongful death or survival actions was two years from the time of the decedent’s death. View "Dubose v. Willowcrest Nur. Home" on Justia Law

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A representative of Extendicare Health Facilities, Inc., d/b/a Havencrest Nursing Center (Extendicare), executed an arbitration agreement with Anna Marie Taylor (“Decedent”) requiring the arbitration of claims arising from Decedent’s stay at the Extendicare facility. Following Decedent’s death, Daniel and William Taylor (“the Taylors”) brought wrongful death claims on behalf of themselves as wrongful death beneficiaries and survival claims on behalf of Decedent’s estate against Extendicare and two other defendants. Extendicare moved to bifurcate the wrongful death and survival actions, and to compel arbitration of Decedent’s survival claim pursuant to the arbitration agreement and the Federal Arbitration Act (FAA). The trial court relied upon Pennsylvania Rule of Civil Procedure 213(e) to deny Extendicare’s motion to bifurcate, and the Superior Court affirmed. The Pennsylvania Supreme Court granted review to determine whether the FAA preempted the lower courts’ application of Rule 213(e) under the facts presented. Upon review, the Court concluded that the FAA preempted the application of Rule 213(e), and required arbitration of the survival claim against Extendicare. The Court therefore reversed the Superior Court, and remanded to the trial court for further proceedings. View "Taylor v. Extendicare Health Facilities, Inc." on Justia Law

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This appeal centered on the availability of attorneys’ fee awards against insurance companies that have invoked the peer-review provisions of the Motor Vehicle Financial Responsibility Law (MVFRL). In 2004, Angela LaSelva sustained injuries in a motor vehicle accident. She was treated by a licensed chiropractor, David Novatnak, D.C., who practiced with appellee Doctor’s Choice Physical Medicine and Rehabilitation Center, P.C. (“Provider”). Provider submitted invoices for the services directly to LaSelva’s first-party benefits insurance carrier, Appellant Travelers Personal Insurance Company (“Insurer”), as required per the Motor Vehicle Financial Responsibility Law. Insurer later requested peer review through IMX Medical Management Services (“IMX”), a peer review organization (“PRO”). IMX, in turn, enlisted Mark Cavallo, D.C., to conduct the peer review. Dr. Cavallo issued a report deeming certain of the treatments provided by Dr. Novatnak to have been unnecessary. Based on this report, Insurer denied reimbursement for the treatment aspects deemed as excessive. Provider opposed this withholding and commenced a civil action against Insurer. Among other things, the complaint alleged that all treatments undertaken through Provider were reasonable and necessary and that the review conducted by IMX did not comport with the mandates of Section 1797 of the MVFRL. Furthermore, Provider asserted that IMX failed to comply with requirements of the Pennsylvania Code directing PROs to apply national or regional norms in their determinations or, where such norms do not exist, to establish written criteria to be used in conducting reviews. As relevant here, the complaint included a specific demand for attorneys’ fees. After a bench trial, the common pleas court entered a verdict in the Provider’s favor, encompassing an award of attorneys’ fees of approximately $39,000. On appeal, the Superior Court reversed the decision to strike the fee award. The Supreme Court reversed the Superior Court: "the Superior Court’s cryptic pronouncement of 'absurdity' [regarding fee-shifting] that lacks foundation. . . . This Court remains cognizant of the shortcomings of the peer-review regime. We have no reasonable means, however, of assessing the degree to which these may be offset by the benefits of cost containment and potentially lower insurance premiums available to the public at large. Rather, the Legislature is invested with the implements to conduct investigations, hearings, and open deliberations to address such salient policy matters. In such landscape, we decline to deviate from conventional statutory interpretation to advance directed policy aims." View "Doctor's Choice v. Traveler's Personal Ins." on Justia Law

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The issue this case presented for the Pennsylvania Supreme Court’s review centered on review of a Commonwealth Court order Court interpreting a provision of a consent decree, negotiated by the Office of Attorney General of Pennsylvania ("OAG") and approved by the Commonwealth Court, between Appellant UPMC, a nonprofit health care corporation, and Appellee Highmark, a nonprofit medical insurance corporation, which established the obligations of both parties with respect to certain health care plans serving vulnerable populations. Specifically, the Court considered whether the Commonwealth Court erroneously interpreted this "vulnerable populations" provision as creating a contractual obligation for UPMC to treat all participants in Highmark’s "Medicare Advantage Plans" (for which Highmark and UPMC currently have provider contracts which UPMC has indicated it will terminate) as "in-network" for purposes of determining the rates it is permitted to charge these individuals for physician, hospital, and other medical services during the duration of the consent decree. After careful review, the Supreme Court affirmed the Commonwealth Court’s finding that the "vulnerable populations" clause of the consent decree required UPMC to "be in a contract" with Highmark for the duration of the consent decree, and, thus, that UPMC physicians, hospitals, and other services shall be treated as "in-network" for participants in Highmark Medicare Advantage plans which were subject to provider contracts between Highmark and UPMC set to be terminated by UPMC on December 31, 2015. The Court also affirmed the portion of the Commonwealth Court’s order requiring judicial approval for any further changes in business relationships between these parties which were governed by the consent decree, but quashed as not yet ripe for review the portion of the order which directed the OAG to file a request for supplemental relief to effectuate compliance with the consent decree. View "Pennsylvania v. UPMC" on Justia Law

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Consolidated direct appeals to the Pennsylvania Supreme Court centered on appellees' efforts to resurrect a defunct state-run health insurance program. Appellees were recipients of state-subsidized, low-cost health insurance via the "adultBasic" program, which was previously administered by the Department of Insurance and made available to certain qualifying adults in Pennsylvania. The program received the bulk of its funding from the proceeds of a 1998 multi-state master settlement agreement between forty-seven states and several major U.S. tobacco product manufacturers. The allocation and distribution of funds received annually by the Commonwealth under this settlement was initially administered outside of the Fiscal Code, via the Tobacco Settlement Act (TSA). As relevant here, for purposes of fiscal years 2010-2011 and 2011-2012, the General Assembly used modifications to the Fiscal Code to override the TSA’s requirements for tobacco settlement monies. One effect of the amendments was to divert tobacco settlement funds more generally to other fiscal priorities of the Commonwealth. In March 2011, Appellees Cheryl Sears and seventy-four other former recipients of adultBasic filed an original-jurisdiction petition for review at the Commonwealth Court, styled as a class action. As amended, the petition contended, inter alia, that the redirection of tobacco settlement monies under Acts 46 and 26 violated the TSA’s requirements for appropriation and allocation of tobacco settlement funds. The petition also asserted that these enactments offended various provisions of the Pennsylvania Constitution governing legislative processes, including the general requirement that no bill shall be passed containing more than a single subject. Appellees sought declaratory, mandamus, and injunctive relief retroactively reestablishing the adultBasic program and reimbursing the program over two hundred million dollars. Appellee Eric Weisblatt commenced a separate action, also styled as a class action, proffering materially similar allegations and claims for relief, in the relevant respects, only naming executive-branch officials and agencies as defendants. Appellees in both proceedings moved for a preliminary injunction to preclude the Treasury from disbursing the tobacco settlement monies which were due to be received that month as appropriated per Act 46. Relief was denied by the court, however, upon its finding that the harm asserted by Appellees was neither immediate nor irreparable. Several weeks after the Commonwealth Court’s issuance of its opinion in Sears, the court issued a divided decision in "Weisblatt." During the pendency of the appeals, additional omnibus amendments to the Fiscal Code were enacted into law, which, inter alia, effectuated a repeal of the allocation formula provided in the TSA; the result formally displaced adultBasic funding within the terms of the TSA itself. In light of these amendments, Appellees renewed their request for relief from the supersedeas, which was again denied. Upon review of both sides' arguments appealing the Commonwealth Court's decision, the Supreme Court held that Appellees lacked standing to pursue the relief requested in their petitions for review. View "Sears v. Wolf" on Justia Law

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The primary issue presented by this case for the Supreme Court's review centered on whether Section 306(b)(3) of the Workers’ Compensation Act (Act) required an employer to provide an injured employee with written “notice of ability to return to work” before offering alternative employment where the injured employee has not yet filed a claim petition and, thus, never proved entitlement to workers’ compensation benefits. The Court held that Section 306(b)(3) notice was required where the employer was seeking to modify existing workers’ compensation benefits based on medical evidence establishing that the injured employee was able to return to work in some capacity. Because the injured employee in this case had not yet received workers’ compensation benefits when the offer of alternative employment was rendered, the employer had no duty to provide notice of ability to work pursuant to Section 306(b)(3). View "Sch. Dist of Phila. v. WCAB" on Justia Law

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In 2008, Attorney David Landay submitted to appellant Rite Aid of Pennsylvania, Inc., an "authorization" on behalf of an individual, requesting copies of the that person's pharmacy records. In response to the requests, Rite Aid sent invoices for $50 to both Landay and PC&G (collectively, "Appellees") for "professional services rendered." Appellees paid the invoices, and Rite Aid provided the requested copies of the pharmacy records. In 2010, Appellees filed a class action against Rite Aid. In Count I of the complaint, Appellees claimed that Rite Aid breached an implied agreement between the parties and Rite Aid that Rite Aid would provide copies of its records to its customers in a manner consistent with Pennsylvania law, limiting the amount that may be charged to the estimated actual and reasonable expenses incurred in connection with the reproduction of the requested records. Specifically, Appellees maintained that Rite Aid's act of charging a flat fee for the reproduction of records violated Section 6152(a)(2)(i) of the Medical Records Act (MRA). In Count II of their complaint, Appellees requested a declaratory judgment that the MRA prohibited Rite Aid from charging more than the reasonable expenses it incurred to reproduce the requested records, and, further, precluded Rite Aid from charging a flat fee. In this discretionary appeal, the issue this case presented for the Supreme Court's review was whether the MRA applied to the reproduction of records by pharmacies, and, if so, whether, and under what circumstances, pharmacies may charge customers a flat fee for the reproduction of records. The Court held that the Act did not apply to pharmacies, and, as a result, it did not address the flat fee issue. View "Landay v. Rite Aid" on Justia Law

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Appellant, a six-year-old boy diagnosed with an autism-spectrum disorder, was receiving applied behavior analysis (“ABA”), a type of autism-related service, in his home. ABA was covered by his family’s insurance policy with Appellee Independence Blue Cross. Appellant’s family requested that Blue Cross cover similar ABA services to be provided at Appellant’s elementary school in 2009. The insurer denied the request, pointing to a place-of-service exclusion in the policy which specified that no services would be covered if the care was provided at certain types of locations, including schools. This decision was unsuccessfully appealed internally. The dispute was then submitted to an independent external review agency appointed by the Pennsylvania Department of Insurance. In December 2009, that agency upheld the denial based on the policy’s place-of-service exclusion. Meanwhile, the General Assembly passed Act 62 of 2008, which, inter alia, required that health insurance policies provide coverage for the treatment of autism spectrum disorders. In 2010, Appellant filed suit seeking declaratory and injunctive relief in the form of a ruling that the policy’s place-of-service exclusion is null and void under Act 62, as well as an order directing the insurer to cover Appellant’s medically necessary treatments. Blue Cross filed responsive pleadings and Appellant requested judgment on the pleadings. The court ultimately rejected the argument that the policy’s place-of-service exclusion was a general exclusion as contemplated by Section 764h(c). Thus, it held that, under Section 764h(a), Blue Cross was required to provide coverage for school-based ABA services during the relevant time period. The common pleas court ordered the insurer to “take action consistent with this decision.” On appeal, the Superior Court, sua sponte, questioned whether the common pleas court should have entertained the appeal under Act 62. The Pennsylvania Supreme Court allowed review to consider whether individuals diagnosed with autism spectrum disorders have the right to judicial review of a denial of insurance coverage, considering the language of Act 62. "Here, we are faced with a situation in which a litigant sought a declaration of his rights under a legislative enactment, a task over which the common pleas court could have exercised jurisdiction, pursuant to the Declaratory Judgments Act, in response to the correct form of pleading. Furthermore, the complaint’s asserted basis for jurisdiction was deficient only because of the confusion created by an apparent drafting mistake by our General Assembly. Neither the court nor the defendant Insurer realized that anything was amiss in this regard and, if they had, Appellant could presumably have made any necessary formal corrections. Under these circumstances, we conclude that the common pleas court was permitted to reach the substantive claim forwarded in Appellant’s pleadings. It follows that the intermediate court should not have reversed the order of that court by sua sponte pointing to the language of Section 764h(k)(2) as a bar to Appellant’s ability to seek relief in a judicial forum, without first evaluating whether the common pleas court’s assessment of the substantive question could be justified on some other basis." View "Burke v. Independence Blue Cross" on Justia Law

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The issue this case presented to the Pennsylvania Supreme Court centered on the interpretation of Sections 6152(a)(1) and (a)(2)(i) of the Medical Records Act ("MRA,"42 Pa.C.S. secs. 6151-6160), which requires businesses such as appellee MRO Corporation, which reproduces medical records for patients and their representatives, to limit their copying charges to their estimated actual and reasonable expenses of reproducing requested charts or records (subject to a statutory ceiling rate), or whether such businesses may simply charge the statutory ceiling rate. Appellant asked the Court to review the Superior Court's finding that, where a medical records reproducer fails to disclose and charge its estimated actual and reasonable expenses and instead charges the MRA's ceiling rates which the records requestor then pays, the defenses of "voluntary payment" and "prior approval" bars the records requestor from maintaining a breach of contract claim to recoup alleged overpayments. MRO did not dispute that the MRA requires the records reproducer to disclose to the requestor “the estimated actual and reasonable expenses” of reproduction. But, MRO argues that the "expenses" so disclosed do not represent actual costs of reproduction; rather, MRO argues that "expenses" refers to the cost to the party making the request, and that expense is determined by the pricing schedule. In MRO's view, the pricing schedule establishes the "expense" to be estimated and then passed on to the requestor. "MRO's construction of the Act is intricate and ingenious in some respects, and it articulates what may be a rational and legitimate approach to the general question of how best and fairly to regulate the expenses of securing medical records." However, the Supreme Court did not believe that the structure and plain language of the provisions of the Act at issue here supported MRO's construction. The Supreme Court reversed the Superior Court and remanded the matter to the trial court for further proceedings. View "Wayne M. Chiurazzi Law, Inc., et al. v. MRO Corporation" on Justia Law

Posted in: Health Law

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This case was among a number of civil actions brought by state attorneys general against pharmaceutical companies challenging the propriety of prescription drug pricing, as it impacted third-party reimbursement for brand-name drug purchases subsidized by government social welfare programs. The Commonwealth focused its claims upon alleged overpayments tied to the use of an industry benchmark figure (average wholesale price, or "AWP") in government reimbursement formulas. While many issues of concern were raised about the Commonwealth’s approach to this litigation and the judgment it has obtained, the Pennsylvania Supreme Court overturned the monetary component of that judgment grounded on the Commonwealth’s failure to offer a rational accounting for the billion dollars in rebate monies which Commonwealth agencies received from the drug manufacturers it sued. View "Pennsylvania v. TAP Pharmaceutical Products, Inc." on Justia Law