Justia Public Benefits Opinion Summaries

On July 11, 2013, the Idaho Department of Labor (“IDOL”) mailed an eligibility determination for unemployment benefits (the “2013 determination”) to William Wittkopf. This determination found Wittkopf underreported his wages for several weeks, which resulted in an overpayment in unemployment benefits. As a result, Wittkopf was: (1) ordered to repay the overpayment; (2) ineligible for any unemployment benefits for a fifty-two week period; and (3) assessed a civil penalty. Additionally, Wittkopf was told that he would remain ineligible for unemployment benefits until all amounts were repaid. Pursuant to Idaho Code section 72– 1368(3) the last day for Wittkopf to file a protest to the 2013 determination was July 25, 2013, which he failed to do. IDOL attempted to collect on the 2013 determination over the next year without success. Subsequently in early 2016, Wittkopf filed for Chapter 7 bankruptcy. The debt he owed to the state of Idaho was included in his bankruptcy and was discharged by order of the Bankruptcy Court. In September 2016, Wittkopf began filing new claims for unemployment benefits with IDOL because he worked a seasonal job and was not receiving any income in the winter months. After not receiving benefits for several weeks, Wittkopf called IDOL which informed him he was ineligible for unemployment benefits because he had failed to pay back his overpayment, civil penalty, and interest he owed IDOL, even though those amounts were discharged in bankruptcy. Wittkopf mailed a letter to IDOL protesting the denial of his unemployment benefits. Wittkopf claimed in this letter that he was eligible for unemployment benefits because his bankruptcy discharged any amount he owed to IDOL. An Appeals Examiner construed Wittkopf’s 2016 letter as a protest of the 2013 determination. Two days later the Appeals Examiner issued a written decision finding there was no jurisdiction to hear Wittkopf’s protest because it was not filed within fourteen days of when it was issued on July 25, 2013, as required by Idaho Code section 72-1368. On November 3, 2016, Wittkopf appealed the Appeals Examiner’s decision to the Industrial Commission. On January 27, 2017, the Industrial Commission affirmed the Appeals Examiner’s decision. The Idaho Supreme Court determined the Industrial Commission erred in affirming the examiner without having determined first whether: (1) the bankruptcy discharge voided IDOL's 2013 determination; (2) whether the discharge operated as an injunction against any effort to collect, recover or offset the 2013 debt; and if yes, (3) why the Department's denial of current benefits on the basis of the 2013 debt wasn't a violation of the injunction. The matter was remanded back to the Industrial Commission for further proceedings. View "Wittkopf v. Idaho Dept of Labor" on Justia Law

This case was a qui tam action alleging violations of the False Claims Act (“FCA”) involving fraudulent reimbursements under the Medicare Act. Plaintiff Gerald Polukoff, M.D., was a doctor who worked with Defendant Sherman Sorensen, M.D. After observing some of Sorensen’s medical practices, Polukoff brought this FCA action, on behalf of the United States, against Sorensen and the two hospitals where Sorensen worked (collectively, “Defendants”). Polukoff alleged Sorensen performed thousands of unnecessary heart surgeries and received reimbursement through the Medicare Act by fraudulently certifying that the surgeries were medically necessary. Polukoff further alleged the hospitals where Sorensen worked were complicit in and profited from Sorensen’s fraud. The district court granted Defendants’ motions to dismiss, reasoning that a medical judgment could not be false under the FCA. The Tenth Circuit reversed and remanded, holding that a doctor’s certification to the government that a procedure is “reasonable and necessary” is “false” under the FCA if the procedure was not reasonable and necessary under the government’s definition of the phrase. View "Polukoff v. St. Mark's Hospital" on Justia Law

In this interlocutory appeal, the Supreme Court held that sovereign immunity barred the counterclaims filed by Defendants against the State and that it lacked interlocutory jurisdiction to address the trial court’s dismissal of the Defendants’ third-party claims.The State brought this enforcement action under the Texas Medicaid Fraud Prevention Act, alleging that Defendants - several dentists and their professional associations and employees - fraudulently obtained Medicaid payments for providing dental and orthodontic treatments to children. Defendants asserted counterclaims and third-party claims alleging that the State and its contractor mismanaged the payment-approval process and misled Defendants regarding the requirements imposed by the Texas Medical Program. The trial court granted the State’s plea to the jurisdiction against the counterclaims and motion to dismiss the third-party claims. Defendants filed this interlocutory appeal. The court of appeals affirmed the trial court’s order dismissing Defendants’ counterclaims and concluded that it lacked jurisdiction over the order dismissing the third-party claims. The Supreme Court affirmed, holding (1) sovereign immunity barred the counterclaims, and (2) this Court lacked interlocutory jurisdiction to address the order dismissing the third-party claims. View "Nazari v. State" on Justia Law

Plaintiffs were 23 federally qualified health centers (FQHC’s) and rural health clinics (RHC’s) that served medically underserved populations (the Clinics). The dispute before the Court of Appeal centered on coverage for adult dental, chiropractic, and podiatric services the FQHC’s and RHC’s provided to Medi-Cal patients for a period between 2009 and 2013. Prior to July 1, 2009, the Department processed and paid claims for these services. In 2009, in a cost-cutting measure due to budget problems, the Legislature enacted Welfare and Institutions Code section 14131.101 to exclude coverage for these services (and others) “to the extent permitted by federal law.” After the Department stopped paying claims for these services, various FQHC’s and RHC’s challenged the validity of section 14131.10, claiming it conflicted with federal Medicaid law. In California Assn. of Rural Health Clinics v. Douglas, 738 F.3d 1007 (9th Cir. 2013), the Ninth Circuit held section 14131.10 was invalid to the extent it eliminated coverage for these services when provided by FQHC’s and RHC’s because the federal Medicaid Act imposed on participating states the obligation to cover these services by these providers. In response to CARHC, the Department announced it would reimburse FQHC’s and RHC’s for these services for dates of service only on or after September 26, 2013, the date of the Ninth Circuit’s mandate. Seeking reimbursement for services provided prior to September 26, 2103, the Clinics petitioned for a writ of mandate to compel the Department to accept, process, and pay claims for these services for the period July 1, 2009, to September 26, 2013. The trial court granted the petition in part and entered judgment for the Clinics. The Department appeals. Characterizing the Clinics’ writ petition as a suit for damages, it contended: (1) sovereign immunity barred the Clinics’ claims for retroactive payment; (2) the CARHC decision was retroactive because the Medicaid Act is spending clause legislation and its terms were not sufficiently clear as to the requirement to cover adult dental, chiropractic, and podiatric services provided by FQHC’s and RHC’s; and (3) retroactive relief violated the separation of powers doctrine because it forces the Legislature to appropriate money. The Court of Appeal disagreed with the Department’s characterization of the Clinics’ lawsuit. "Rather than a suit for damages, the lawsuit seeks an order to compel performance of a mandatory duty and did not result in a money judgment. Under well-settled California law, such a mandamus proceeding is not barred by sovereign immunity. The Department’s contentions based on spending clause legislation and separation of powers are new arguments raised for the first time on appeal. We exercise our discretion to consider only the spending clause argument. We reject it because the Department has not shown its obligations under Medicaid law, as determined by CARHC, came as a surprise. The separation of powers argument raises factual issues about appropriations that should have been presented in the trial court and we decline to consider this new argument." Accordingly, the Court affirmed the judgment. View "American Indian Health etc. v. Kent" on Justia Law

In this discretionary appeal, we consider whether Appellant, the Pennsylvania State Police (“PSP”), is entitled to subrogation of benefits that a trooper – who was injured in a motor vehicle accident – was eligible to receive under the Workers’ Compensation Act (“WCA”) against the trooper’s recovery from a third-party tortfeasor pursuant to the Motor Vehicle Financial Responsibility Law (“MVFRL”). In 2011, Pennsylvania State Trooper Joseph Bushta (“Claimant”) was on duty when his police vehicle was hit by a tractor-trailer. As a result of the collision, Claimant suffered various cervical, thoracic, and lumbar injuries which required medical treatment and physical therapy, and which resulted in Claimant’s inability to perform his job duties for approximately 16 months. PSP, a self-insured public employer, issued a notice of compensation payable (“NCP”) indicating a weekly compensation rate of $858.08 under the WCA. The Pennsylvania Supreme Court determined that all of the benefits Claimant received were Heart and Lung benefits, not WCA benefits. Thus, pursuant to the MVFRL, PSP does not have a right of subrogation against Claimant’s settlement with the third-party tortfeasors. View "Penn. State Police v. WCAB (Bushta)" on Justia Law

Twelve Medicaid-participating hospitals (“Hospitals”) challenged the Department of Medicaid’s (“DOM’s”) recalculation of their Medicaid outpatient rates for fiscal year 2001. The chancery court affirmed the opinion of the DOM, finding that “DOM interpreted its own regulation – the State Plan, which is its contract with the federal government and which it is required to follow to receive federal funds to require Medicaid to calculate the cost to charge ratio by using Medicare Methodology, which at that time was using a blended rate.” The Mississippi Supreme Court found the plain language of Attachment 4.19-B of the State Plan provided a cost-to-charge-ratio formula for calculating outpatient rates. Laboratory and radiology charges were to be excluded from this formula, because they were reimbursed on a fee-for-service basis. DOM’s inclusion of radiology and laboratory services in the charges and substitution of costs with Medicare blended payment amounts was a clear violation of the State Plan. Therefore, the Court reversed the judgments of DOM and the chancery court. Consistent with its opinion, the Court remanded and ordered the Executive Director of DOM to recalculate the Hospitals’ cost-to-charge ratio using the Hospital’s submitted costs in their cost reports, excluding laboratory and radiology services, and reimbursing the Hospitals the appropriate amounts determined by using the State Plan. View "Crossgates River Oaks Hospital v. Mississippi Division of Medicaid" on Justia Law

The Supreme Court affirmed the district court’s grant of summary judgment in favor of Defendants, holding that Plaintiffs' claims were either moot or failed to state a claim as a matter of law.The hospital at which an injured child received medical care sought to secure payment for that care by asserting liens against the child’s interest in the tort claim against the driver of the car that struck the child. The child and his mother brought claims against the hospital owner and its payments vendor, arguing that the liens violated Medicaid law. When the liens were released, the district court granted summary judgment in favor of Defendants. The Supreme Court affirmed on the principles of mootness and Plaintiffs’ failure to state a claim as a matter of law. View "Shaffer v. IHC Health Services, Inc." on Justia Law

The Supreme Court affirmed the district court’s grant of summary judgment in favor of Defendants, holding that Plaintiffs' claims were either moot or failed to state a claim as a matter of law.The hospital at which an injured child received medical care sought to secure payment for that care by asserting liens against the child’s interest in the tort claim against the driver of the car that struck the child. The child and his mother brought claims against the hospital owner and its payments vendor, arguing that the liens violated Medicaid law. When the liens were released, the district court granted summary judgment in favor of Defendants. The Supreme Court affirmed on the principles of mootness and Plaintiffs’ failure to state a claim as a matter of law. View "Shaffer v. IHC Health Services, Inc." on Justia Law

The trial court did not err in dismissing Plaintiffs’ action for lack of subject matter jurisdiction due to Plaintiffs’ failure to exhaust administrative remedies in seeking damages for denied Medicaid reimbursement claims.The court of appeals reversed the trial court’s order, ruling that the trial court erred in dismissing Plaintiffs’ complaint without resolving certain factual issues and that Plaintiffs sufficiently demonstrated that it would be futile to pursue administrative remedies. The Supreme Court reversed, holding that the court of appeals erred in reversing the dismissal of Plaintiffs’ claims where Plaintiffs failed to exhaust their administrative remedies prior to filing suit and failed to demonstrate futility of the available remedies at this time. View "Abrons Family Practice & Urgent Care, PA v. North Carolina Department of Human Services" on Justia Law

In November 2014, the Board of Veterans’ Appeals denied Bly’s request for service connection for bilateral hearing loss. Bly appealed to the Veterans Court. After his opening brief was filed, Bly and the government filed a joint motion for partial remand. The Veterans Court granted the motion, citing to Rule 41(b) of the Veterans Court’s Rules of Practice and Procedure, and noting that “this order is the mandate of the Court.” Bly applied for attorneys’ fees and expenses under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412, 31 days later. Remand orders from the Veterans Court may entitle veterans to EAJA fees and expenses. Under 28 U.S.C. 2412(d)(1)(B), such EAJA applications must be made “within thirty days of final judgment in the action.” The Veterans Court reasoned that its judgment became final immediately because the order remanded the case on consent and stated that it was the mandate of the court. The Federal Circuit vacated the denial of his application, reasoning that the consent judgment at issue became “not appealable” 60 days after the entry of the remand order under 38 U.S.C. 7292(a). View "Bly v. Shulkin" on Justia Law