Justia Public Benefits Opinion Summaries

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Methodist Specialty Care Center was the only nursing facility for the severely disabled (NFSD) in Mississippi. NFSDs generally incur higher costs than other nursing facilities, and because of this, Methodist received a percentage adjustment to its new-bed-value (NBV) calculation when the Mississippi Division of Medicaid (DOM) determined how much it should reimburse Methodist for its property costs through the DOM’s fair-rental system. A NBV was intended to reflect what it would cost to put a new bed into service in a nursing facility today. Methodist had received a NBV adjustment of 328.178 percent added to the standard NBV every year since it opened in 2004 until State Plan Amendment (SPA) 15-004 was enacted. During the 2014 Regular Session, the Mississippi Legislature passed House Bill 1275, which authorized the DOM to update and revise several provisions within the State Plan; one such amendment changed Methodist's adjustment rate, and made the facility experience a substantial decrease in its NBV, while all other nursing facilities in the state received increases. Methodist appealed the DOM’s changes to its NBV that were enacted in SPA 15-004. After a hearing, an Administrative Hearing Officer (AHO) upheld the decreased percentage adjustment to Methodist’s NBV, but also determined the DOM had miscalculated Methodist’s NBV adjustment. The DOM had planned to calculate Methodist’s adjustment as 175 percent of the base NBV, but the AHO found that Methodist’s adjusted NBV should be calculated in the same manner as it was calculated preamendment - by taking 175 percent of the standard NBV and adding that value to the standard NBV. Methodist still felt aggrieved because its NBV adjustment rate had not been restored to the preamendment rate. Methodist appealed the DOM’s final decision to the Chancery Court. When the chancellor affirmed the DOM’s final decision, Methodist appealed to the Mississippi Supreme Court. After review, the Supreme Court found the DOM’s final decision was supported by substantial evidence, was not arbitrary or capricious, did not violate Methodist’s constitutional or statutory rights and that the DOM was acting within its power in reaching and adopting its final decision. View "Methodist Specialty Care Center v. Mississippi Division of Medicaid" on Justia Law

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Justice, employed as a workers’ compensation claims adjuster since 1991, fell at work in 2011 and injured her left knee. She later developed problems in her right knee, which was found to be a compensable consequence of the first injury. In 2012-2013 Justice had total bilateral knee replacement. Dr. Anderson, an orthopedic surgeon, testified that there was significant preinjury degeneration in both knees, that knee replacement was not required because of the meniscus tear, and that the fall “hasten[ed]” the need for knee replacement by “lighting up the underlying pathology.” Anderson apportioned 50 percent of the bilateral knee disability to the nonindustrial, preexisting degeneration. The workers’ compensation judge determined that Justice had sustained permanent partial disability of 48 percent, worth $59,110.00, stating that “the need for these surgeries was at least partially non-industrial. … the surgeries appear to have significantly increased [Justice’s] ability to walk and engage in weight-bearing activities. The judge stated that before the 2017 Hikida decision, he would have awarded permanent disability with 50% apportionment but that Hikida precluded apportionment. The Appeals Board affirmed. The court of appeal annulled the decision. Justice's permanent disability should have been apportioned between industrial and nonindustrial causes. Hikida, in which a medical treatment resulted in a new compensable consequential injury, is distinguishable. Here, there was unrebutted substantial medical evidence that Justice’s permanent disability was caused, in part, by preexisting pathology. Apportionment was required. Whether or not the workplace injury “directly caused” the need for surgery, the apportionment statutes demand that the disability be sorted among direct and indirect causal factors. View "County of Santa Clara v. Workers' Compensation Appeals Board" on Justia Law

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In 2012, Lozano gave birth to a baby. While still hospitalized, Lozano received a tetanus-diphtheria-acellular-pertussis (Tdap) vaccination. Two weeks later, Lozano reported a low-grade fever, body aches, and breast tenderness. Lozano’s symptoms persisted through visits to her physician and the emergency room. She developed abdominal pain, difficulty urinating, weakness, loss of balance, vision changes, neck pain, headache, vomiting, and dizziness. A brain MRI suggested that Lozano possibly had multiple sclerosis (MS), acute disseminated encephalomyelitis (ADEM), or vasculitis. Lozano’s symptoms improved with steroid treatment, following a working diagnosis of MS. After several months, a repeat MRI “showed dramatic improvement, suggesting that ADEM was a more likely etiology, which was confirmed through later serological findings.” Lozano’s doctors opine that ADEM is the likely explanation for her symptoms. Lozano sought compensation under the National Childhood Vaccine Injury Act, 42 U.S.C. 300aa. Lozano’s expert opined that Lozano’s ADEM was the result of her receipt of the Tdap vaccine. The special master granted Lozano’s petition, finding that her expert’s testimony and the supporting medical literature demonstrated that the Tdap vaccine can cause autoimmune diseases such as ADEM and that Lozano offered preponderant evidence of a proximate temporal relationship between the vaccine and her injury. The Claims Court and Federal Circuit upheld the award of a lump-sum payment of $1,199,216.86, finding that the decision was neither an abuse of discretion nor contrary to law and that the fact-findings were neither arbitrary nor capricious. View "Lozano v. Secretary of Health and Human Services" on Justia Law

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The First Circuit affirmed the order of the district court finding that Plaintiff was disabled as defined under 20 C.F.R. 404.1520 and awarding her benefits, holding that there was very strong evidence of Plaintiff's disability, without any contrary evidence, to justify an award of benefits. At age thirty-four, Plaintiff filed applications for Social Security Disability Benefits and Supplemental Security Income. The Commissioner of Social Security denied Plaintiff's applications. In an independent assessment of her claim, an ALJ agreed with the Commissioner's decision, finding that Plaintiff was not disabled as defined under the Social Security Act. A federal magistrate judge found that substantial evidence did not support the ALJ's denial of benefits and recommended reversing the Commissioner's decision and remanding the case for further development of the facts. The district court agreed with the magistrate judge's findings but bypassed the need for further fact-finding and awarded benefits. The First Circuit affirmed, holding that there was overwhelming evidence to support a finding of disability and an award of benefits and that a remand for further proceedings was unnecessary. View "Sacilowski v. Saul" on Justia Law

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The Mississippi Division of Medicaid (DOM) appealed a chancery court judgment ordering the DOM to reverse the adjustments for “Legend Drug” costs reported by Windsor Place Nursing Center, Inc., d/b/a Windsor Place Nursing & Rehab Center (Windsor) and Billdora Senior Care, Lexington Manor Senior Care, and Magnolia Senior Care (collectively Senior Care). The chancery court found that legend drug expenses incurred by these providers were properly reported on each of their Long Term Care (LTC) cost reports as an allowable cost and should have been taken into account the by DOM in determining the per diem rates for each provider. The DOM contends that its decision to disallow the legend drug expenses claimed by the providers in their required cost report for reporting years 2005, 2007, and 2008 was supported by substantial evidence, was not arbitrary or capricious, and was within its authority to decide. Therefore, the chancery court’s order must be reversed and the DOM’s decision must be reinstated. The Mississippi Supreme Court agreed with the DOM. "No where in the controlling statutes, the state plan, or Medicaid’s policy do we see language that lends itself to a construction taken by the providers that all prescription drug costs “not covered” by the Medicaid drug program means drug costs 'not paid for' by Medicaid. ... While the DOM may have failed to catch this in the past, legend drugs covered by Medicaid’s Drug Program are subject to direct reimbursement from Medicaid to the dispensing pharmacist, and constitute a non-allowable cost for the provider’s pier diem reimbursement report. And any action taken to the contrary by Medicaid is a violation of its rules and regulations." View "Mississippi Division of Medicaid v. Windsor Place Nursing Center, Inc. et al." on Justia Law

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After a bench trial, Xun Wang was convicted of two counts of Medicaid fraud, and one count of unauthorized practice of a health profession. Defendant earned a medical degree in her native China, and earned a Ph.D. in basic medical science in the United States. Notwithstanding her education in the United States and abroad, defendant was never licensed to practice in a health profession in the United States. The Michigan Department of the Attorney General’s Health Care Fraud Division discovered that a high volume of narcotics prescriptions were being written at the clinic for which she worked part time. In 2014, the department conducted an investigation, during which Drew Macon and Lorrie Bates, special agents with the department, separately went to the clinic while posing as patients with Medicaid benefits. Defendant saw both agents when they posed as patients, identified herself as clinic-owner Dr. Murtaza Hussain’s assistant, and took written notes of their medical histories. Defendant also performed physical examinations, answered their questions, and wrote prescriptions for both agents on a prescription pad that Hussain had previously signed, including a prescription for Ambien, a Schedule 4 controlled substance. The patients’ notes were entered into the clinic’s computer system and were electronically signed by Hussain; the notes indicated that both defendant and Hussain had seen the agents. The Medicaid processing system reflected that claims were submitted for both agents’ treatment and were paid to Hussain for a total of $260. The trial court sentenced her to concurrent terms of 365 days in jail for each conviction, which was suspended upon the successful completion of five years’ probation and the payment of $106,454 in fines and costs. The Michigan Supreme Court found after review that while the lower courts did nor err in determining there was sufficient evidence to convict defendant on unauthorized practice of a health profession, the evidence did not establish she was aware or should have been aware that the patients at issue were Medicaid beneficiaries and their treatment was substantially certain to cause the payment of a Medicaid benefit under the applicable statute. Therefore, defendant's convictions of Medicaid fraud were reversed. The matter was remanded back to the trial court for reconsideration of the fines assessed. View "Michigan v. Wang" on Justia Law

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The Eleventh Circuit vacated the district court's order affirming the Commissioner's denial of plaintiff's application for disability insurance benefits. The court held that the ALJ did not have the benefit of the court's decision in Schink v. Comm'r of Soc. Sec., 935 F.3d 1245 (11th Cir. 2019) (per curiam), which may alter the fourth step of the ALJ's disability analysis. Furthermore, the court agreed with plaintiff that the ALJ's hypothetical to the vocational expert did not sufficiently communicate plaintiff's limitations from bipolar disorder. View "Samuels v. Acting Commissioner of Social Security" on Justia Law

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Babcock joined the Michigan National Guard in 1970 and became a dual-status technician “a Federal civilian employee” who “is assigned to a civilian position as a technician” while maintaining membership in the National Guard, 10 U.S.C. 10216(a)(1); 32 U.S.C. 709(e). Babcock served as a National Guard pilot, held the appropriate military grade, wore a uniform that displayed his rank while working, and attended weekend drills. In 2004-2005, Babcock was deployed to Iraq on active duty. Babcock received military pay for his active-duty service and his inactive-duty training, including weekend drills. Otherwise, he received civil pay and participated in the Civil Service Retirement System (CSRS), 5 U.S.C. 5301. Babcock paid Social Security taxes on the wages for his active-duty service and his inactive-duty training from 1988 onwards, 42 U.S.C. 410(l)(1). He did not pay Social Security taxes on his wages for inactive-duty training before 1988 or on his civil-service wages. In 2009, Babcock retired and began receiving monthly CSRS payments and separate military retirement pay. For several years after his retirement, Babcock flew medical-evacuation helicopters for hospitals. This private-sector income was subject to Social Security taxes. Babcock fully retired in 2014. The government reduced his Social Security benefits under the Windfall Elimination Provision (WEP) because of his CSRS pension. Babcock cited a WEP exception for payments “based wholly on service as a member of a uniformed service.” While Babcock's case was pending, the Eleventh Circuit rejected the Eighth Circuit’s contrary analysis and held that the uniformed-services exception does not apply to dual-status technicians. The Sixth Circuit subsequently agreed that a federal civil-service pension based on work as a National Guard dual-status technician does not qualify as “a payment based wholly on service as a member of a uniformed service.” View "Babcock v. Commissioner of Social Security" on Justia Law

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The First Circuit issued this narrow opinion in response to the Commonwealth of Massachusetts's appeal from the district court's denial of its "Motion Regarding Substantial Compliance and To Terminate Monitoring and Court Supervision" and reversed, holding that the district court's analysis was flawed. The underlying suit was long-running class-action litigation concerning the Commonwealth of Massachusetts's compliance with federal statutory requirements for provision of services to a plaintiff class of Medicaid-eligible children with serious emotional disturbances. The district court found the Commonwealth liable for violating Medicaid provisions as to "reasonable promptness" and "early and periodic screening, diagnosis, and treatment" services. The court then issued remedial orders and a court monitor was appointed. Later the Commonwealth filed the motion at issue. Plaintiffs agreed that the court could terminate monitoring and reporting over the portions of the judgment the Commonwealth was in substantial compliance with. The district court denied the motion in its entirety. The First Circuit reversed, holding that the district court's analysis was flawed from the outset. View "Rosie D. v. Baker" on Justia Law

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Plaintiff-Appellants were eleven rural hospitals (the “Hospitals”) who challenged the methodology the U.S. Secretary of Health and Human Services (the “Secretary”) used to calculate their Medicare reimbursements. After the publication of the FY 2010 Final Rule, the Hospitals took issue with the Secretary’s methodology for calculating the hospital-specific rate for new base years. And dissatisfied with their reimbursements under that methodology, the Hospitals filed administrative appeals with the Provider Reimbursement Review Board, an independent panel authorized to hear appeals from the Secretary’s final determinations. The Hospitals then sued the Secretary in the district court, arguing: (1) the Secretary applied the same cumulative budget-neutrality adjustment twice—once by using inflated normalized diagnosis-related group weights as a divisor in step two and then again in step four; (2) the Secretary’s methodology yielded different payments than “would have been made had [he] . . . applied the budget-neutrality adjustments to the DRG weights themselves;" and (3) the Secretary acted arbitrarily and capriciously by not calculating the hospital-specific rate for new base years “based on 100 percent” of a hospital’s base-year “target amount." The district court held it would “not second-guess the Secretary’s policy” just because there may have been “other ways of calculating payments.” And so the court denied the Hospitals’ summary-judgment motion, granted the Secretary’s cross-motion, and entered final judgment.The Tenth Circuit Court of Appeals, in reviewing the Hospitals’ arguments, found that their arguments rested on "flawed assumptions. And the Secretary has long understood his methodology and explained it to the public." The Court concurred with the district court and affirmed its judgment. View "Hays Medical Center et al. v. Azar" on Justia Law