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The Eighth Circuit affirmed the denial of social security disability benefits to claimant, holding that the denial of benefits was supported by substantial evidence. The court held that the ALJ did not err in determining claimant's Residual Functional Capacity and did not err in determining that the medical records did not support the limitations stated by her treating physician. The court also held that the ALJ did not err by discrediting the physician's testimony to the extent that it exceeded the supported limitations. View "Despain v. Berryhill" on Justia Law

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The Eighth Circuit affirmed the denial of disability insurance benefits to claimant. The court held that the agency was justified in reopening claimant's case based on new and material information; there was no due process violation and claimant had adequate notice that the reopened proceedings could result in a determination that she was not disabled; res judicata did not bar the Commissioner from revising a determination; substantial evidence supported the ALJ's determination that claimant was not disabled from 2012 onward; claims of witness and evidentiary errors rejected; the ALJ did not err in determining that claimant could perform her past relevant work; and there was no error in the ALJ's statement regarding claimant's residual functional capacity (RFC) to the vocational expert where substantial evidence supported the omission of certain limitations from her RFC. View "Schwandt v. Berryhill" on Justia Law

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The Second Circuit held that the district court properly deferred to the decision of the New York State Review Officer (SRO), which concluded that student W.E. was not denied a free and appropriate public education (FAPE) for the eighth grade school year and that Northwood School was not an appropriate unilateral private school placement for the ninth grade school year. Accordingly, the court affirmed the district court's November 2016 judgment and order in part. To the extent that the district court failed to accord appropriate deference to the SRO's conclusion that Northwood did not provide W.E. specially designed instruction so as to constitute an appropriate private school placement for the tenth grade school year, the court reversed in part the district court's opinion and vacated the award of tuition reimbursement to plaintiffs for that school year. The court also affirmed a July 2017 opinion and order granting the district court's grant of summary judgment and vacating the award of compensatory education for the eighth grade year. View "W.A.v. Hendrick Hudson Central School District" on Justia Law

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The Medicare program offers additional payments to institutions that serve a “disproportionate number” of low-income patients, 42 U.S.C. 1395ww(d)(5)(F)(i)(I), calculated using the hospital’s “Medicare fraction.” The fraction’s denominator is the time the hospital spent caring for patients entitled to Medicare Part A benefits; the numerator is the time the hospital spent caring for Part-A-entitled patients who were also entitled to income support payments under the Social Security Act. Medicare Part C (Medicare Advantage) was created in 1997. Part C, beneficiaries may choose to have the government pay their private insurance premiums rather than pay for their hospital care directly. Part C enrollees tend to be wealthier than Part A enrollees, so counting them makes the fraction smaller and reduces hospitals’ payments. In 2014, the Medicare website indicated that fractions for fiscal year 2012 included Part C patients. Hospitals sued, claiming violation the Medicare Act’s requirement to provide public notice and a 60-day comment period for any “rule, requirement, or other statement of policy . . . that establishes or changes a substantive legal standard governing . . . the payment for services.” The Supreme Court affirmed the D.C. Circuit in agreeing with the hospitals. The government has not identified a lawful excuse for neglecting its statutory notice-and-comment obligations. The 2014 announcement established or changed a “substantive legal standard” not an interpretive legal standard. The Medicare Act and the Administrative Procedures Act do not use the word “substantive” in the same way. The Medicare Act contemplates that “statements of policy” can establish or change a “substantive legal standard." Had Congress wanted to follow the APA in the Medicare Act and exempt interpretive rules and policy statements from notice and comment, it could have cross-referenced the APA exemption, 5 U.S.C. 553(b)(A). View "Azar v. Allina Health Services" on Justia Law

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Medicare pays for doctors’ home visits if a patient is homebound. Mobile Doctors offered physician services to homebound Medicare beneficiaries, hiring doctors who assigned their Medicare billing rights to the company. Upon receipt of payment, Mobile would pay the physician-employee a percentage of what Mobile received from billing Medicare. Many of Mobile’s patients did not actually qualify as homebound. Some doctors signed certifications for additional unneeded treatment from companies that provided at-home nursing or physical therapy services—companies that had referred the patients to Mobile. Mobile submitted Medicare codes for more serious and more expensive diagnoses or procedures than the provider actually diagnosed or performed. Mobile instructed physicians to list at least three diagnoses in the patient file; if the doctors did not list enough, a staff member added more. Mobile only paid the physicians if they checked at least one of the top two billing codes. Doctors who billed for the higher of the top two codes were paid more. Mobile also paid for “standing orders” for testing, although Medicare prohibits testing done under standing orders. Daneshvar joined Mobile as a physician in 2012. After following Mobile’s policies Daneshvar was convicted of conspiracy to commit healthcare fraud but found not guilty of healthcare fraud; he was sentenced to 24 months' imprisonment. The Sixth Circuit affirmed. Daneshvar’s trial was fair; none of the district court’s rulings during that proceeding should be reversed. There was no reversible error with his sentencing. View "United States v. Daneshvar" on Justia Law

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The Second Circuit vacated the district court's decision affirming the Commissioner's denial of social security disability benefits. The court held that the ALJ failed to comply with the procedural mandates of the treating physician rule where it explicitly failed to consider the first Burgess factor before assigning "little weight" to the opinion of plaintiff's treating psychiatrist. Furthermore, there was a lack of other "good reasons" to support that decision. Accordingly, the court remanded for the ALJ to reconsider plaintiff's claim for disability benefits consistent with the procedural mandates of the Social Security Act and this court. View "Estrella v. Berryhill" on Justia Law

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The Social Security Act permits judicial review of “any final decision . . . after a hearing” by the Social Security Administration (SSA), 42 U.S.C. 405(g). Claimants for Title XVI supplemental security income disability benefits must generally proceed through a four-step process before federal-court review: seek an initial determination of eligibility; seek reconsideration; request a hearing before an administrative law judge (ALJ); and seek review of the ALJ’s decision by the Appeals Council within 60 days of receiving the ALJ’s ruling. If the claimant misses that deadline and cannot show good cause for doing so, the Appeals Council dismisses the request. Smith’s claim for disability benefits was denied on initial determination, upon reconsideration, and on the merits by an ALJ. The Appeals Council dismissed Smith’s request for review as untimely. Smith sought judicial review of the dismissal. The Sixth Circuit affirmed dismissal for lack of jurisdiction, holding that the Appeals Council’s dismissal of an untimely petition is not a “final decision.” A unanimous Supreme Court reversed. An Appeals Council dismissal on timeliness grounds after a claimant has had an ALJ hearing on the merits qualifies as a “final decision . . . made after a hearing” under section 405(g). The Appeals Council’s dismissal is the final stage of review, 20 CFR 416.1472; Smith obtained the kind of hearing that section 405(g) most naturally suggests. The dismissal is not merely collateral but an end to a proceeding in which a substantial factual record has been developed. The Court noted that “Congress designed [the statute as a whole] to be ‘unusually protective’ of claimants” and “the strong presumption that Congress intends judicial review of administrative action.” View "Smith v. Berryhill" on Justia Law

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A husband and wife appealed denials of their Permanent Fund Dividends (PFDs) for 2014 and 2015. The husband’s 2014 PFD application was denied because he had been absent from the state for more than five years, creating a presumption of nonresidence that he was unable to rebut. The wife’s application was denied because her PFD eligibility as an accompanying military spouse depended on her husband’s. After the denials were affirmed by an Administrative Law Judge (ALJ), the couple appealed to the superior court. While this appeal was pending they both applied for 2015 PFDs and were again denied. The husband’s 2015 application was denied because his residency for PFD purposes was severed in the 2014 PFD proceedings and he had not reestablished it. The wife’s application was again denied because of her accompanying-spouse status. They appealed the 2015 denials too; the superior court consolidated the 2014 and 2015 cases and affirmed both denials. The Alaska Supreme Court determined neither spouse met the residency requirements to qualify for either a 2014 or a 2015 PFD under the plain language of the applicable statute. The Court therefore affirmed the ALJs’ decisions. View "Jones v. Alaska, Department of Revenue" on Justia Law

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At issue in this case was whether a school district may be permitted to avoid its responsibility to provide special education and related services to an eligible student to fund the placement of a child with severe disabilities in a residential treatment center, where that placement was necessary to enable the child to access a meaningful educational benefit, because the child's adoptive parents happened also to have funding available for that residential placement through a noneducational governmental agency program. The Court of Appeal held that the Los Angeles County Department of Children and Family Services (DCFS) is not a "public agency, other than an educational agency" under Education Code section 56155; DCFS did not "place" the student in the Sonoma facility by providing Adoptive Assistance Program (AAP) assistance; and therefore Education Code section 56156.4, subdivision (a), did not provide the school district with an exception to the rule that the school district of the parents' residence is responsible for the costs of a disabled student's education. The court also disapproved of the Office of Administrative Hearings's decision in Parent v. Elk Grove Unified Sch. Dist., to the extent it is inconsistent with this decision. Therefore, the court held that the school district was responsible for the cost of the parents' transportation relating to the student's placement in the Sonoma facility. The court reversed and remanded. View "B.H. v. Manhattan Beach Unified School District" on Justia Law

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Three plaintiffs' cases were consolidated for review; the plaintiffs were elderly women receiving long-term care in nursing homes. In each case, the “institutionalized spouse,” began receiving long-term care at a nursing home at her own expense. One to two months later, each plaintiff’s husband, a “community spouse,” created an irrevocable trust that was solely for his own benefit (a “solely for the benefit of,” or “SBO,” trust). The couples then transferred a majority of their individual and marital property to each SBO trust or its trustee, giving up any claim of title to that property. Distributions or payments from each SBO trust were to be made on an actuarially sound basis and solely to or for the benefit of the community spouse. The distribution schedule required that each trustee distribute the income and resources held by the trust to each community spouse at a rate that would deplete the trust within the community spouse’s expected lifetime. A short time after each SBO trust was formed, each institutionalized spouse applied for Medicaid benefits. The Department of Health and Human Services and its director (collectively, the Department) determined that each institutionalized spouse did not show the requisite financial need because the value of the trust assets put their countable resources above the monetary threshold, and it denied each application. In each case, the plaintiff unsuccessfully contested the Department’s decision in an administrative appeal, but each decision was then reversed on appeal at the circuit court. On appeal in the Court of Appeals, all three cases were consolidated, and the Department’s denial decisions were reinstated. The Michigan Supreme Court concluded that the Court of Appeals erred in its interpretation of the controlling federal statutes, which caused the Court of Appeals to improperly reinstate the Department’s denial decisions. Because the administrative hearing decision in each case suffered from "the same faulty reasoning" used by the Court of Appeals, the Court surmised that legal error may have caused the administrative law judges (ALJs) to forgo a more thorough review of the Medicaid applications at issue or to disregard other avenues of legal analysis. Therefore, rather than order that the Medicaid applications be approved at this time, the Court vacated the hearing decision of the ALJ in each case and remanded these cases to the appropriate administrative tribunal for any additional proceedings necessary to determine the validity of the Department’s decision to deny plaintiffs’ Medicaid applications. View "Hegadorn v. Dept. of Human Services" on Justia Law