by
Gumila, the head of clinical operations for a company that provided home medical care to the elderly, was convicted of 21 counts of health-care fraud, 18 U.S.C. 1347 and three counts of making a false statement in a health-care matter, 18 U.S.C. 1035. There was testimony from more than 20 witnesses and documentary evidence establishing that Gumila regularly overruled physicians who wanted to discharge patients and instructed employees to bill services at unjustifiably high rates, to claim that patients were homebound even when they weren’t, and to order skilled-nursing services even if no doctor had ever examined the patient. The government estimated Medicare’s financial loss: approximately $2.375 million for unnecessary and upcoded home visits; $9.45 million for unnecessary skilled-nursing services that did not meet Medicare’s requirements; and $3.779 million for oversight services that did not qualify for payment or were never performed. The guidelines range was 151-188 months in prison. Gumila argued that the loss should be limited to payments for the eight patients specifically mentioned in the indictment ($14,449). The judge concluded that the government was not required to present specific evidence to prove the fraudulent nature of each individual transaction contributing to the total loss, determined that the loss estimate was reasonable, imposed a sentence of 72 months, and ordered Gumila to pay $15.6 million in restitution. The Seventh Circuit affirmed, upholding the loss calculation and the prison term as substantively unreasonable. View "United States v. Gumila" on Justia Law

by
In 2005, the State of Mississippi filed suit against more than eighty prescription drug manufacturers alleging, among other things, that each committed common-law fraud and violations of the Mississippi Consumer Protection Act. The allegations primarily focused on whether the prescription-drug manufacturers inflated reported prices, which caused the Mississippi Division of Medicaid to reimburse pharmacies at inflated rates. The cases were eventually severed; this appeal involved only Watson Laboratories, Inc., Watson Pharma Inc., and Watson Pharmaceuticals, Inc. (collectively “Watson”). Following a bench trial, the Chancery Court concluded that Watson had committed common-law fraud and had violated the Mississippi Consumer Protection Act. As a result, the chancery court awarded the State a total of $30,262,052 in civil penalties, compensatory damages, and punitive damages. The chancery court also awarded post-judgment interest of three percent on the compensatory and punitive damages. Watson appealed, challenging the chancery court’s decision; the State also filed a cross-appeals relating to damages. After review, the Mississippi Supreme Court affirmed the chancery court’s judgment in favor of Mississippi Medicaid. Further, the Court affirmed the ruling on the State’s cross-appeal. View "Watson Laboratories, Inc. v. Mississippi" on Justia Law

by
Gerstner, age 27, applied for disability insurance benefits and supplemental security income was denied. An administrative law judge found that she was severely impaired by anxiety, bipolar disorder, panic disorder, depression, and fibromyalgia but that these impairments were not disabling, and denied benefits. The Seventh Circuit vacated the denial as not supported by substantial evidence. The ALJ fixated on select portions of the treating psychiatrist’s treatment notes, inadequately analyzed his opinions, and overlooked the extent to which those opinions were consistent with the diagnoses and opinions of other medical sources who treated Gerstner. ALJs must consider psychologists’ and nurse practitioners’ opinions on the severity of a patient’s impairments. In discrediting Gerstner’s testimony, the ALJ overstated findings from three diagnostic tests and misunderstood the nature of her fibromyalgia pain. Fibromyalgia pain cannot be measured with objective tests aside from a trigger-point assessment. View "Gerstner v. Berryhill" on Justia Law

by
The Ninth Circuit affirmed the denial of Social Security Disability Insurance (SSDI) benefits and the partial denial of Supplemental Security Income (SSI) benefits. The panel held that the ALJ did not err by finding plaintiff's disability onset date without calling on a medical advisor at the hearing. In this case, the record was adequate even before plaintiff saw a mental health specialist and no reasonable medical expert could have inferred that her disability began before May 2010. Therefore, Social Security Ruling 83-20 did not require the ALJ to consult a medical advisor before determining plaintiff's disability onset date. View "Wellington v. Berryhill" on Justia Law

by
Cullinan unsuccessfully sought Disability Insurance Benefits and Supplemental Security Income based on several impairments, most of which arose after she suffered a stroke: anxiety, depression, peripheral blindness in one eye, diabetes, obesity, and sleep apnea. An administrative law judge determined that although Cullinan has several impairments, she is not disabled. The Seventh Circuit vacated. The ALJ’s decision to discredit Cullinan’s testimony and that of her treating psychologist was unsupported by the record because the ALJ’s examples of Cullinan’s daily activities and social interactions did “not remotely describe a ‘very active’ lifestyle.” The ALJ did not adequately explain the conclusion that the doctor’s notes were inconsistent with his opinion and did not consider Cullinan’s daily extended naps and frequent debilitating headaches in determining her residual functional capacity. No evidence contradicted Cullinan’s testimony about those limitations. The vocational expert said that needing to take a two-hour nap every day would rule out all work. The ALJ has the burden to develop the record and assess whether symptoms are disabling. View "Cullinan v. Berryhill" on Justia Law

by
Ebanks sought veterans benefits for service-connected posttraumatic stress disorder, hearing loss, and arthritis. His claim for an increased disability rating was denied by the VA Regional Office (RO) in October 2014; in December he sought Board of Veterans Appeals review, with a video-conference hearing (38 U.S.C. 7107). Two years later, the Board had not scheduled a hearing. Ebanks sought a writ of mandamus. The Veterans Court denied relief. While his appeal was pending, the Board held his hearing in October 2017. The Federal Circuit vacated, finding the matter moot so that it lacked jurisdiction. The delay is typical and any Board hearings on remand are subject to expedited treatment under 38 U.S.C. 7112. Congress has recently overhauled the review process for RO decisions, so that veterans may now choose one of three tracks for further review of an RO decision, Given these many contingencies, Ebanks has not shown a sufficiently reasonable expectation that he will again be subjected to the same delays. Even if this case were not moot, the court questioned “the appropriateness of granting individual relief to veterans who claim unreasonable delays in VA’s first-come-first-served queue.” The “issue seems best addressed in the class-action context,.” View "Ebanks v. Shulkin" on Justia Law

by
The Fifth Circuit affirmed the district court's denial of social security disability benefits to plaintiff. The court held that the ALJ's decision not to follow the VA's 100% disability rating determination was supported by substantial evidence where the court considered, but ultimately rejected the VA's findings, in part because the VA relied heavily on a one-time evaluation by a doctor who had not formed a treating relationship with plaintiff. The court explained that reports by two state-agency consultants cut against the VA's determination, and it was emphatically the ALJ's province to weigh the evidence and decide among these competing accounts. The court rejected plaintiff's remaining claims. View "Garcia v. Berryhill" on Justia Law

by
The First Circuit affirmed the district court’s dismissal of Plaintiffs’ suit challenging the Social Security Administration’s (SSA) termination of tier disability benefits for lack of subject matter jurisdiction based on Plaintiffs’ failure to have exhausted their administrative remedies. After the SSA terminated the disability benefits that Plaintiffs had been receiving, Plaintiffs challenged that decision administratively. Before they had exhausted the administrative review process, however, Plaintiffs filed suit in federal court seeking various kinds of relief based presumably on the same grounds as the claims that had presented to the SSA in seeking to continue to receive their benefits. The district court granted the government’s motion to dismiss for lack of subject matter jurisdiction, concluding that Plaintiffs failed to exhaust their administrative remedies. The First Circuit affirmed, holding that Plaintiffs failed to show that they could not obtain a restoration of their benefits through the administrative review process, despite evidence suggesting that they would have a substantial chance of doing so. View "Justiniano v. Social Security Administration" on Justia Law

by
The North Dakota Department of Human Services appealed a district court judgment reversing the Department's order deciding Altru Specialty Services, doing business as Yorhom Medical Essentials, received overpayments for medical equipment supplied to Medicaid recipients and ordering recoupment. The North Dakota Supreme Court concluded the district court did not have jurisdiction and the appeal should have been dismissed because Yorhom failed to satisfy statutory requirements for perfecting an appeal. View "Altru Specialty Services, Inc. v. N.D. Dep't of Human Services" on Justia Law

by
The "credit-as-true rule" permits, but does not require, a direct award of benefits on review but only where the ALJ has not provided sufficient reasoning for rejecting testimony and there are no outstanding issues on which further proceedings in the administrative court would be useful. The Ninth Circuit affirmed the district court's decision to remand for further administrative proceedings in a claimant's action seeking Title II disability insurance benefits. The panel clarified the district court's remand order, instructing the district court to remand to the ALJ consistent with the requirements pursuant to Treichler v. Comm'r of Soc. Sec. Admin., 775 F.3d 1090, 1101-02 (9th Cir. 2014), with an open record on the issue of claimant's fatigue related to his capacity to undertake full time employment. On remand, claimant shall be permitted to cross-examine the Commissioner's medical consultants, but only to the extent such cross-examination concerns the issue of claimant's fatigue. View "Leon v. Berryhill" on Justia Law