Justia Public Benefits Opinion Summaries

The VA determined that West, a Viet Nam veteran, was eligible for a disability pension. Two days later West died. Four days later—without knowing that West had died—the government sent West a check for $8,660--his pension benefit retroactive to June 2013. In March 2014, a Kentucky probate court appointed West’s ex-wife, Brenda, as the Estate's executor. Brenda endorsed the VA check, the estate’s only cash asset, and deposited it into an escrow account. After three months, the VA determined that West’s estate was not entitled to the money, 38 U.S.C. 5121(a), and directed the bank to wire the $8,660 back to the U.S. Treasury. The bank complied. The Estate did not learn until later that its account had been drained of funds. More than 18 months later, the Estate obtained a Kentucky probate court order requiring the government to return the funds. The government removed the matter to the district court, which remanded the matter back because the $8,660 was already subject to the probate court’s jurisdiction. The Estate unsuccessfully sought attorneys’ fees. The Sixth Circuit reversed the remand order; the dispute can be litigated only under the procedure set forth in the Veterans’ Judicial Review Act, 102 Stat 4105. The court noted “concerns about the government’s expropriation of the Estate’s funds without any advance notice or process.” View "Estate of West v. United States Department of Veterans Affairs" on Justia Law

In 2000, Kaminski fell down a flight of stairs, suffering a head wound that caused a traumatic brain injury and a seizure disorder. He applied under the Social Security Act for disability insurance benefits and supplemental security income 13 years later. The Social Security Administration denied his applications; the district court upheld the denial. The Seventh Circuit reversed, finding that the administrative law judge improperly rejected his treating physician’s opinions. The treating physician’s opinions and the testimony of the vocational expert together show that Kaminski is disabled. View "Kaminski v. Berryhill" 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 2010, Earley applied for disability benefits, 42 U.S.C. 423(d)(2)(A), 1382c(a)(3)(B) . In 2012, an ALJ rejected the application on the ground that Earley, who suffered from fibromyalgia, mild carpal tunnel syndrome, panic disorder, degenerative disk disease, and major depression, did not have a covered disability. She applied again for a new period of time. The same ALJ denied her benefits, citing Sixth Circuit precedent (Drummond) as requiring him to give preclusive effect to the work-capacity finding he had made during the first proceeding absent “new and material evidence documenting a significant change in the claimant’s condition.” The district court reversed, concluding that the Drummond “principles of res judicata” apply only when they favor an individual applicant, not the government. The Sixth Circuit disagreed. The key principles protected by Drummond—consistency between proceedings and finality with respect to resolved applications—apply to individuals and the government but do not prevent the agency from giving a fresh look to a new application containing new evidence or satisfying a new regulatory threshold that covers a new period of alleged disability while being mindful of past rulings and the record in prior proceedings. View "Earley v. Commissioner of Social Security" 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

The First Circuit affirmed the district court’s order upholding an administrative law judge’s (ALJ) denial of Appellant’s application for Social Security Disability Insurance Benefits and Supplemental Security Income. The Court held (1) even if this Court reviews the ALJ’s ruling on the understanding that it must apply a certain Social Security Ruling in reviewing the ALJ’s ruling, the ALJ’s determination that Appellant was not disabled still must be upheld; (2) substantial evidence supported the ALJ’s determination that Appellant’s ability to carry out certain daily activities undermined his contention that he was unable to perform light work; and (3) Appellant’s remaining allegations of error were without merit. View "Coskery v. Berryhill" on Justia Law

Acree served on active duty in the Navy from 1985-1989 and 2007-2008. He was deployed to Iraq and received Seabee Combat Warfare Medals. Acree was diagnosed with post-traumatic stress disorder (PTSD) while serving in Iraq. After leaving the service, Acree filed several claims for service-connected disability benefits and appealed 11 claims to the Board of Veterans’ Appeals. A representative from the Disabled American Veterans (DAV) organization was present with Acree at the board hearing. Acree said “yes” when asked to withdraw seven issues. The board listed the four issues that would be discussed and would “continue to be in appellate status” and asked the DAV representative whether it had “correctly identified the issues.” The representative responded: “Yes.” The board remanded four and dismissed seven claims. Acree appealed, arguing that a veteran’s withdrawal of a claim “is not effective unless the withdrawal ‘is explicit, unambiguous, and done with a full understanding of the consequences’” and that since he “ha[d] a long history of taking psychotropic medications,” the hearing officer should have inquired as to his capacity to appreciate the consequences of dismissing the claims. The Veterans Court affirmed, citing the hearing transcript. The Federal Circuit vacated. Precedent (DeLisio) explicitly states that a withdrawal is effective only if undertaken with “a full understanding of the consequences of such action on the part of the [veteran].” The Veterans Court was required to make that determination even though a DAV representative was present. View "Acree v. O'Rourke" on Justia Law

The district court properly placed the burden of proof on a grocery store (Store) in this action brought by Plaintiffs alleging that the Store unlawfully trafficked in Supplemental Nutrition Assistance Program (SNAP) benefits.The Food and Nutrition Service (FNS), the bureau within the United States Department of Agriculture (USDA) charged with administering the SNAP regime, concluded that the Store had engaged in trafficking and permanently disqualified the Store from SNAP participation. The Store brought an action in Maine’s federal district court challenging the agency’s final decision. The district court granted summary judgment for the USDA. The First Circuit affirmed, holding (1) the burden of proof is imposed on the claimant - here, the Store; and (2) no rational fact-finder could conclude that the Store had demonstrated by a preponderance of the evidence that the finding of trafficking was incorrect. View "Irobe v. United States Department of Agriculture" on Justia Law

Burris’s father served on active duty in Vietnam, 1969-1971, and was granted a permanent and total disability rating for schizophrenia effective 2000. Because of his father’s disability, Burris was eligible to receive Dependents’ Educational Assistance (DEA) benefits. In October 2010, Burris, then 35-years old, elected to receive retroactive benefits for a period 2002-2010. During a portion of that period, Burris was enrolled as an undergraduate student. Burris’s studies were interrupted in 2005 when his mother unexpectedly passed away. Burris became the primary caretaker for his father, who suffered from prostate cancer. Burris was unable to attend school until his DEA eligibility had expired. The VA denied Burris’s request for an extension of his eligibility period, citing VA regulations that prohibit extensions for dependents “beyond age 31,” 38 C.F.R. 21.3041(g)(1), (g)(2), 21.3043(b), and refused to reimburse Burris for educational expenses incurred 2002-2004 because DEA benefits cannot be paid for expenses incurred more than one year prior to the application date. The Board of Veterans’ Appeals and Veterans Court affirmed the denial of equitable relief. The Federal Circuit affirmed. The Veterans Court lacks jurisdiction to grant equitable relief in these circumstances, 38 U.S.C. 7261. View "Burris v. Wilkie" 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