Justia Public Benefits Opinion Summaries

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

Social security survivors' benefits are a thing of value of the United States that can support a conviction under 18 U.S.C. 641. Viewed in the light most favorable to the government, the Fourth Circuit concluded that substantial evidence supported defendant's conviction for theft of government property beyond a reasonable doubt. In this case, the jury could reasonably infer from two denied benefits applications that defendant had a motive to file under a different benefits program to again attempt to obtain benefits to which he was not entitled. Finally, the district court's trial management was reasonable and far from an abuse of discretion. Accordingly, the court affirmed the judgment. View "United States v. Kiza" on Justia Law

Plaintiff was a registered sex offender when he was admitted to the state rental assistance program. Thereafter, the legislature promulgated section 17b-812-13(9) of the Regulations of Connecticut States Agencies, which makes sex offender registration a ground for termination or denial of rental program assistance. The Commissioner of Housing (Commissioner) subsequently terminated Plaintiff’s rental program benefits. Plaintiff took an administrative appeal of the Commissioner’s decision to the trial court, which concluded that the Commissioner’s application of section 17b-812-13(9) was not retroactive and therefore did not exceed the authority granted to the Commissioner by the legislature. The Supreme Court reversed, holding (1) the Commissioner applied section 17b-812-13(9) of the regulations retroactively in this case by imposing a new obligation on Plaintiff’s sex offender status that terminated his rental program assistance; and (2) such retroactive application of the regulation was not statutorily authorized, and therefore, the trial court erred in dismissing Plaintiff’s administrative appeal. View "Shannon v. Comm’r of Housing" on Justia Law

In 2009 Crespo applied for Supplemental Security Income benefits for his mother, representing that she lived with him in Illinois and that he took care of her. He served as her representative payee. By signing the form, Crespo acknowledged that he could be held liable for any improper overpayments he caused. Crespo’s mother was not entitled to those benefits because she lived in Puerto Rico (20 C.F.R. 416.215), which Crespo hid from the Social Security Administration by falsely representing, in three subsequent reports as representative payee, that she lived with him. Airline records established that she resided in Puerto Rico; his mother was serving as representative payee for her own mother’s retirement benefits, declaring herself a resident of Puerto Rico. An ALJ imposed a $114,956 civil penalty on Crespo for misrepresentation. The Departmental Appeals Board of the Department of Health and Human Services dismissed his appeal as untimely. The Seventh Circuit affirmed. The Board did not abuse its discretion in rejecting Crespo’s untimely appeal and finding good cause lacking. Appeals are due 30 days after the ALJ’s initial decision is deemed served. A copy of the regulation is included when the decision is delivered. Crespo offered no reason why he did not request an extension. View "Crespo v. Colvin" on Justia Law

The Louisiana Supreme Court granted certiorari to determine whether the Sledge Jeansonne Louisiana Insurance Fraud Prevention Act, and the Louisiana Unfair Trade Practice and Consumer Protection Act, could be applied retroactively to defendant’s criminal misconduct which occurred prior to the effective dates of these statutes. Defendant Lynn Foret, a medical doctor who specialized in orthopedic surgery, pled guilty in federal court to one count of health care fraud, for criminal acts that occurred between 2003 and 2009. The trial court granted Dr. Foret’s declinatory exceptions, dismissing with prejudice, the State's action for penalties under the Sledge Jeansonne Act and dismissed with prejudice causes of action under the Louisiana Unfair Trade Practices Act. The court of appeal affirmed the trial court’s rulings, finding that the conduct regulated by the substantive statute was the underlying fraud, rather than the subsequent guilty plea. Therefore, even though the State's cause of action could not have accrued until Dr. Foret pled guilty, application of the Acts nonetheless attached new consequences to his criminal misconduct, which occurred before the Acts became effective. One judge on the appellate panel dissented, reasoning the plain language of the Sledge Jeansonne Act demonstrated it was the guilty plea that gave the State Attorney General the authority to act, not the criminal activity, and because the guilty plea was entered after the effective date of the statute, its application herein would be prospective, not retroactive. The State appealed to the Supreme Court, arguing that the Sledge Jeansonne Act was not an impermissible retroactive application of the law. After review, the Supreme Court held that both the Sledge Jeansonne Act and Louisiana Unfair Trade Practice and Consumer Protection Act operated prospectively only, applying to causes of action arising after the effective date of each Act. The Court affirmed the court ofappeal ruling finding that the statutes at issue could not be retroactively applied to this defendant’s past criminal conduct. View "Louisiana v. Foret" on Justia Law

In 2008, Javidan shadowed Shahab, who was involved with fraudulent home-health agencies. Javidan, Shahab, and two others purchased Acure Home Care. Javidan managed Acure, signing Medicare applications and maintaining payroll. She had sole signature authority on Acure’s bank account and, was solely responsible for Medicare billing. Javidan illegally recruited patients by paying “kickbacks” to corrupt physicians and by using “marketers” to recruit patients by offering cash or prescription medications in exchange for Medicare numbers and signatures on blank Medicare forms. Javidan hired Meda as a physical therapist. Meda signed revisit notes for patients that he did not visit. He told Javidan which patients were not homebound and which demanded money for their Medicare information. The government charged both with health care fraud conspiracy (18 U.S.C. 1347) and conspiracy to receive kickbacks (18 U.S.C. 371). At trial, Javidan testified that she did not participate in and was generally unaware of Acure’s fraudulent business practices. Meda called no witnesses. Javidan and Meda were sentenced to terms of 65 and 46 months of imprisonment, respectively. The Sixth Circuit affirmed, rejecting Meda’s claims that his conviction violated the Double Jeopardy Clause and that he was subjected to prosecutorial vindictiveness for refusing to plead guilty and requesting a jury trial in prior case and Javidan’s claims of improper evidentiary rulings and sentence calculation errors. View "United States v. Javidan" on Justia Law

Mowlana, a native of Somalia, was admitted to the United States as a refugee in 2000 and became a lawful permanent resident in 2002. He was ordered removed from the U.S. after the Board of Immigration Appeals concluded that he had been convicted of an aggravated felony. The Board cited Mowlana’s prior conviction under 7 U.S.C. 2024(b), which forbids the knowing use, transfer, acquisition, alteration, or possession of benefits in a manner contrary to the statutes and regulations of the Supplemental Nutrition Assistance Program (food stamps). The Eighth Circuit dismissed his petition for review, agreeing that his offense was an aggravated felony, 8 U.S.C. 1227(a)(2)(A)(iii). View "Mowlana v. Holder" on Justia Law

Defendant Christopher Boisvert appealed his conviction for welfare fraud. Defendant was the father of Carrie Gray's two children. He and Gray moved into a Bristol apartment in 2009 or 2010. Defendant's name was removed from the lease at some point prior to late 2010. On December 31, 2010, defendant filed an application for public assistance. On January 14, 2011, he met with a department of health and human services representative and stated that he was homeless and had no resources; he was certified to receive benefits. Defendant was recertified for benefits at six-month intervals, and again reported in June 2011 and December 2011 that he was homeless. Between December 2010 and March 2012, Gray received medical, food stamp, and cash public assistance. The total amount of assistance that she received was calculated based upon a household consisting only of Gray and her children. She would not have been eligible for the same level of benefits if defendant had disclosed that he was living in the apartment. At some point, the special investigations unit of the department of health and human services received an allegation of welfare fraud concerning Gray. After interviewing witnesses and reviewing records provided by Gray and defendant, the investigator concluded that the case should be referred to the county attorney's office. Defendant was subsequently indicted on one count of welfare fraud. Because it was alleged that the value of the fraudulently obtained payments exceeded $1,000, the offense was classified as a class A felony. The case went to trial, and at the close of the State's case, defendant moved to dismiss the charge, arguing that the State had failed to present sufficient evidence that he was living with Gray during the relevant time period. The trial court denied the motion, and the jury found defendant guilty. This appeal followed. He argued on appeal to the Supreme Court that the Superior Court erred by denying: (1) defendant's motion to dismiss that challenged the sufficiency of the evidence; and (2) his request to give an accomplice liability jury instruction. Finding no reversible error, the Supreme Court affirmed. View "New Hampshire v. Boisvert" on Justia Law

Lemons applied for social security disability benefits after being diagnosed with a pain disorder caused by inflammation of a membrane that surrounds the nerves of the spinal cord. An ALJ awarded benefits and Lemons began receiving $802 per month. The ALJ, advised that Lemons’s condition was expected to improve, recommended follow-up review. The Administration failed to conduct the review and never contacted Lemons until it received an anonymous letter, including photographs of Lemons engaged in various activities. Investigators conducted surveillance. The Administration initiated review. Lemons responded that she could not pick up anything over 20 pounds nor sit more than 30 minutes without causing increased pain. The Administration discontinued benefits. Lemons appealed and chose to continue benefits during the process. Investigators met with Lemons’s treating physician, and showed her surveillance videos; the doctor revised her assessment and concluded that Lemons could perform some work. A cessation of benefits decision recorded a finding of “Fraud or Similar Fault.” Lemons was convicted of making a false statement, 18 U.S.C. 1001, and theft of government funds, 18 U.S.C. 641. The district court calculated a guidelines range of 27-33 months’ imprisonment, based on an intended loss totaling $284,018.64, varied downward, and sentenced Lemons to 12 months and one day. The Eighth Circuit affirmed. View "United States v. Lemons" on Justia Law

The Medocks’ company, MAS, transported patients to kidney dialysis for Medicare reimbursement. Reimbursement of non-emergency ambulance transport is allowed only if medically necessary for bedridden patients; both a driver and an EMT must accompany any such passenger. Certification of medical necessity (CMN) must be signed by a doctor. A “run sheet” is reviewed by a Medicare contractor other than the ambulance company, such as AdvanceMed, to reduce fraud. AdvanceMed identified MAS as a high biller in Tennessee for dialysis ambulance transport and audited MAS. MAS’s records were missing some CMNs. Covert surveillance resulted in videotapes of patients walking, riding in the front seat, being double-loaded, being driven by single-staffed ambulances, or being transported by wheelchair. MAS had billed the transports as single-passenger and “stretcher required.” Executing a search warrant at the Medlocks’ home, agents seized CMNs and run tickets; some had been altered or forged. The Sixth Circuit reversed a conviction for aggravated identity theft, 18 U.S.C. 1028A, agreeing that misrepresentations that certain beneficiaries were transported by stretcher did not constitute a “use” of identification, but affirmed health-care fraud convictions, rejecting arguments that the court should have instructed the jury that Medicare, not merely a prudent person, was the relevant decision-maker; that Medicare would have reimbursed MAS without their misrepresentations; and that refusal to sever a defendant was prejudicial. View "United States v. Medlock" on Justia Law