Justia Public Benefits Opinion Summaries

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When Plaintiff-appellant Linda Smith purchased a prescribed continuous blood glucose monitor (CGM) and its necessary supplies between 2016 and 2018, she sought reimbursement through Medicare Part B. Medicare administrators denied her claims. Relying on a 2017 ruling issued by the Centers for Medicare and Medicaid Services (CMS), Medicare concluded Smith’s CGM was not “primarily and customarily used to serve a medical purpose” and therefore was not covered by Part B. Smith appealed the denial of her reimbursement claims through the multistage Medicare claims review process. At each stage, her claims were denied. Smith then sued the Secretary of the Department of Health and Human Services in federal court, seeking monetary, injunctive, and declaratory relief. Contending that her CGM and supplies satisfied the requirements for Medicare coverage. Instead of asking the court to uphold the denial of Smith’s claims, the Secretary admitted that Smith’s claims should have been covered and that the agency erred by denying her claims. Rather than accept the Secretary’s admission, Smith argued that the Secretary only admitted error to avoid judicial review of the legality of the 2017 ruling. During Smith’s litigation, CMS changed its Medicare coverage policy for CGMs. Prompted by several adverse district court rulings, CMS promulgated a formal rule in December 2021 classifying CGMs as durable medical equipment covered by Part B. But the rule applied only to claims for equipment received after February 28, 2022, so pending claims for equipment received prior to that date were not covered by the new rule. Considering the new rule and the Secretary’s confession of error, the district court in January 2022 remanded the case to the Secretary with instructions to pay Smith’s claims. The district court did not rule on Smith’s pending motions regarding her equitable relief claims; instead, the court denied them as moot. Smith appealed, arguing her equitable claims were justiciable because the 2017 ruling had not been fully rescinded. The Tenth Circuit agreed with the Secretary that Smith’s claims were moot: taken together, the December 2021 final rule and the 2022 CMS ruling that pending and future claims for CGMs would be covered by Medicare deprived the Tenth Circuit jurisdiction for further review. View "Smith v. Becerra" on Justia Law

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In 2006, LaBonte went absent without leave (AWOL) from the Army for six months. He voluntarily returned to his base, pleaded guilty to desertion in a court-martial proceeding, and received a Bad Conduct Discharge. In 2012, LaBonte was diagnosed with post-traumatic stress disorder (PTSD), stemming from his combat service in Iraq. In 2014, he was found eligible for VA benefits for service-connected PTSD, traumatic brain injury, depression, headaches, back pain, tinnitus, a painful scar, and ulcers. In 2016, LaBonte received a 100% service-connected disability rating.In 2015, LaBonte applied to the Army Board for Correction of Military Records (ABCMR), seeking retroactive medical retirement. He alleged that, while in the Army, he had permanent disabilities incurred during service that rendered him unfit for service before his absence without leave. In 2020, on remand, ABCMR again denied LaBonte’s claim. The Claims Court dismissed an appeal, finding that, in order for ABCMR to grant LaBonte disability retirement, it would have to correct LaBonte’s DD-214 Form to show that he was separated due to physical disability rather than due to a court-martial conviction and that 10 U.S.C. 1552(f), prohibited such a correction. The Federal Circuit reversed. ABCMR was not required to change LaBonte’s DD-214 in order to grant him disability retirement. The 214 is a record of events, not intended to have any legal effect on the termination of a soldier’s service. View "LaBonte v. United States" on Justia Law

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Plaintiffs worked for MBO and Trustmark, which provide medical billing and debt‐collection services to healthcare providers. After they raised concerns about their employers’ business practices, the plaintiffs were fired. They sued MBO, Trustmark, and MBO's client, the University of Chicago Medical Center (UCMC), under the False Claims Act, 31 U.S.C. 3729. Regulations specify that Medicare providers seeking reimbursement for “bad debts” owed by beneficiaries must first make reasonable efforts to collect those debts. The plaintiffs claim that UCMC knowingly avoided an obligation to repay the government after it effectively learned that it had been reimbursed for non-compliant debts; MBO and Trustmark caused the submission of false claims to the government. Each plaintiff also claimed retaliation.The Seventh Circuit affirmed the dismissal of the complaint, in part. The district court properly dismissed the claim against UCMC, which neither had an established duty to repay the government nor acted knowingly in avoiding any such duty. The direct false claim against MBO was also correctly dismissed. The complaint failed to include specific representative examples of non-compliant patient debts, linked to MBO, for which reimbursement was sought. The court reversed in part; the complaint includes specific examples of patient debts involving Trustmark. Two plaintiffs alleged facts that support the inference that they reasonably believed their employers were causing the submission of false claims. View "Sibley v. University of Chicago Medical Center" on Justia Law

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MSPA Claims 1 LLC—the assignee of a now-defunct Medicare Advantage Organization—sued Tower Hill Prime Insurance Company to recover a reimbursable payment. The district court granted Tower Hill’s motion for summary judgment because it determined that MSPA Claims 1’s suit was untimely.The Eleventh Circuit affirmed. The court explained that because it is at least “plausible” that the term “accrues” in Section 1658(a) incorporates an occurrence rule—in fact, and setting presumptions aside, the court wrote that it thinks that’s the best interpretation—that is how the court interprets it. Therefore, MSPA Claims 1’s cause of action accrued in 2012 when MSPA Claims 1’s assignor, Florida Healthcare, paid D.L.’s medical bills and became entitled to reimbursement through the Medicare Secondary Payer Act. Because that was more than four years before MSPA Claims 1 filed suit in 2018, its suit is not timely under 28 U.S.C. Section 1658(a). View "MSPA Claims 1, LLC. v. Tower Hill Prime Insurance Co." on Justia Law

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An Administrative Law Judge (“ALJ”) denied Plaintiff benefits based on the testimony of a vocational expert (“VE”) that there were an estimated 72,000 “Table worker,” 65,000 “Assembler,” and 32,000 “Film touch up inspector” jobs in the national economy that claimant could perform. After the ALJ issued her decision, claimant’s attorney submitted to the Social Security Administration (“SSA”) Appeals Council different estimates for those same jobs, allegedly using the same software program used by the VE. The Appeals Council considered the new evidence but denied claimant’s request for review.The Ninth Circuit reversed the district court’s decision granting summary judgment to the Commissioner of Social Security and affirming the denial of Plaintiff’s claim for Supplemental Security Income (“SSI”) benefits, and remanded to the district court with directions that the case be remanded to the agency for further proceedings. The court held that under Buck v. Berryhill, 869 F.3d 1040 (9th Cir. 2017), remand was required to allow the ALJ to address claimant’s evidence of widely discrepant job number estimates.The claimant estimated—using SkillTRAN Job Browser Pro and the same DOT codes the VE had used—that there were 2,957 table worker, 0 assembler, and 1,333 film tough-up inspector jobs in the national economy. The discrepancy between the VE and the claimant’s estimates was comparable to the discrepancy in Buck. View "TYRONE WHITE V. KILOLO KIJAKAZI" on Justia Law

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The Seventh Circuit affirmed the judgment of the district court denying Heart of CarDon, LLC's motion for judgment on the pleadings in this interlocutory appeal concerning section 1557 of the Patient Protection and Affordable Care Act, holding that T.S. was a proper plaintiff against CarDon under section 1557, and his suit may continue on that basis.CarDon was a healthcare provider that was reimbursed by Medicare and Medicaid for its serves. CarDon provided health insurance to its employees and their depends through a self-funded employee benefits plan. T.S., a dependent who had autism, brought this action alleging that the plan's exclusion of coverage for autism treatment violated section 1557. CarDon moved for judgment on the pleadings, arguing that only a recipient of CarDon's healthcare services was a permissible plaintiff under section 1557. The district court denied the motion. The Seventh Circuit affirmed, holding that T.S. plausibly alleged an interest that comes within the zone of interests section 1557 seeks to protect. View "T.S. v. Heart of CarDon, LLC" on Justia Law

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Robert Procive appealed when a district court dismissed his appeal of an Administrative Law Judge’s order that denied his claim for Workforce Safety and Insurance (“WSI”) benefits. Procive submitted his first claim in 2020, alleging he suffered carpal tunnel syndrome due to injuries to both wrists, elbows, and shoulders resulting from repetitive digging, hammering and driving stakes, steel posts, and iron rods into the ground. He claimed his original injury occurred in western North Dakota, and he notified his employer of his injury in November 2004 and October 2016. WSI accepted liability for Procive’s right carpal tunnel injury, but denied for the left. Later WSI issued its order reversing its acceptance of liability for the right carpal tunnel, finding Procive willfully made false statements about whether he had prior injuries or received treatment. WSI ordered Procive to repay past benefits he received. After a hearing the ALJ affirmed WSI’s decisions denying coverage. Procive appealed to the district court in Stutsman County. WSI moved to dismiss the appeal, arguing the district court lacked subject matter jurisdiction because Procive was required to file his appeal in the county where the injury occurred or the county where he resided. To this, the North Dakota Supreme Court affirmed, finding the district court did not have jurisdiction. View "Procive v. WSI" on Justia Law

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Plaintiff hospices exceeded their aggregate caps in the 2013 fiscal year, and three Silverado hospices also exceeded their aggregate caps in the 2014 fiscal year. Plaintiffs appealed their cap determinations to the Provider Reimbursement Review Board (“PRRB”), arguing that their MAC had failed to calculate the aggregate cap using the “actual net amount of payment received by the hospice provider.” The Ninth Circuit affirmed the district court’s summary judgment in favor of the government.   The court held that CMS correctly concluded that the Budget Control Act required it to reduce the total annual amounts paid to hospices, not only the periodic reimbursements, and that the agency’s chosen method for implementing sequestration was consistent with the Medicare statute. The court further held that the agency was not required to undertake notice-and-comment rulemaking before implementing the Budget Control Act’s sequestration mandate. The agency’s sequestration method, as reflected in the TDL and the PRRB’s decisions, did not amount to the “establish[ment]” or “change[]” of a substantive legal standard governing payment for services under Medicare, within the meaning of 42 U.S.C. Section 1395hh. Rather, Congress enacted the Budget Control Act’s sequestration requirements, and the President implemented sequestration when the statutory conditions were triggered. View "SILVERADO HOSPICE, INC. V. XAVIER BECERRA" on Justia Law

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Grant Bauserman, Karl Williams, and Teddy Broe, on behalf of themselves and all others similarly situated, brought a putative class action in the Michigan Court of Claims against the Unemployment Insurance Agency, alleging that the Agency violated their due-process rights, and that the Agency also engaged in unlawful collection practices. Plaintiffs, who were all recipients of unemployment compensation benefits, specifically alleged defendant had used an automated fraud-detection system, the Michigan Integrated Data Automated System (MiDAS), to determine that plaintiffs had received unemployment benefits for which they were not eligible and then garnished plaintiffs’ wages and tax refunds to recover the amount of the alleged overpayments, interest, and penalties that defendant had assessed without providing meaningful notice or an opportunity to be heard. Among other remedies for this constitutional violation, plaintiffs sought monetary damages. Although the Michigan Supreme Court had never specifically held that monetary damages were available to remedy constitutional torts, the Court now held that they were. “Inherent in the judiciary’s power is the ability to recognize remedies, including monetary damages, to compensate those aggrieved by the state, whether pursuant to an official policy or not, for violating the Michigan Constitution unless the Constitution has specifically delegated enforcement of the constitutional right at issue to the Legislature or the Legislature has enacted an adequate remedy for the constitutional violation. Because enforcement of Const 1963, art 1, § 17 has not been delegated to the Legislature and because no other adequate remedy exists to redress the alleged violations of plaintiffs’ rights, we agree that plaintiffs have alleged a cognizable constitutional-tort claim for which they may recover money damages and we agree with the lower courts that defendant was properly denied summary disposition.” View "Bauserman v. Unemployment Insurance Agency" on Justia Law

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After voluntarily leaving his job due to back problems, Plaintiff applied for disability insurance benefits. The Social Security Administration found that he was not disabled and denied his application. Plaintiff sought judicial review and the district court1 affirmed. He appealed, arguing that the agency’s decision was not supported by substantial evidence.   The Eighth Circuit affirmed, explaining that when reviewing the denial of disability insurance benefits, the court decides whether the findings are supported by substantial evidence on the record as a whole. Here, Plaintiff claims that his treating physician’s opinion was entitled to deference. However, the court explained, that under the current regulations, however, treating physicians are not entitled to special deference. And although Plaintiff may disagree with the ALJ’s conclusion, it is supported by substantial evidence on the record as a whole. View "Jason Bowers v. Kilolo Kijakazi" on Justia Law