Justia Public Benefits Opinion Summaries

Gayheart applied for Social Security disability insurance benefits in 2005 due to manifestations of anxiety, panic disorder, bipolar disorder, and depression. After an initial denial and three separate hearings, an administrative law judge (ALJ) found that the limitations caused by Gayheart’s impairments did not preclude him from performing a significant number of jobs available in the national economy and denied Gayheart’s application. Gayheart’s request for an administrative appeal was denied. The Report and Recommendation issued by the federal court’s assigned magistrate judge concluded that the ALJ’s decision was not supported by substantial evidence and that Gayheart should be awarded benefits. But the district court sustained the Commissioner’s objections and affirmed the ALJ’s decision. The Sixth Circuit reversed and remanded, holding that the ALJ failed to weigh the medical opinions according to 20 C.F.R. 404.1527. View "Gayheart v. Comm'r of Soc. Sec." on Justia Law

Plaintiffs, teaching hospitals, received Medicare payments to offset the costs associated with training "full-time equivalent" residents and intern physicians (FTEs). In 1997, Congress capped those payments in such a way that the number of FTEs the hospitals trained in 1996 would dictate the maximum reimbursement in all future years. Although the parties agreed that the 1996 data was not accurate, the Secretary believed that this predicate fact could not be corrected outside the three-year reopening window. The court held that the reopening regulation allowed for modification of predicate facts in closed years provided the change would only impact the total reimbursement determination in open years. Alternatively, the court agreed with the district court that the Secretary had acted arbitrarily in treating similarly situated parties differently. The court rejected the Secretary's claim that the Medicare Act, 42 U.S.C. 1395 et seq., would not allow the intermediary to change the 1996 GME resident count without changing the corresponding reimbursement amount, which all parties conceded would constitute a reopening of an "Intermediary determination." Accordingly, the court affirmed the judgment. View "Kaiser Foundation Hospitals v. Sebelius" on Justia Law

Plaintiffs, thirteenth North Carolina residents who lost access to in-home personal care services (PCS) due to a statutory change, brought suit challenging the new PCS program. The district court granted plaintiffs' motions for a preliminary injunction and class certification. Defendants appealed, raising several points of error. The court agreed with the district court's conclusion that a preliminary injunction was appropriate in this case. The court held, however, that the district court's order failed to comply with Federal Rule of Civil Procedure 65 because it lacked specificity and because the district court neglected to address the issue of security. Accordingly, the court remanded the case. View "Pashby v. Delia" on Justia Law

Full Life Hospice participates in the federal Medicare program. It sought reimbursement for hospice services provided to Medicare recipients from the Department of Health and Human Services (HHS). A fiscal intermediary, acting on behalf of HHS, later contested some of these reimbursements and demanded repayment of funds that it claimed were distributed in excess of a spending cap. Full Life unsuccessfully challenged HHS intermediary’s determination through an administrative appeal, which was denied as untimely. On appeal to the district court, the court found no basis to excuse Full Life's untimely challenge. Upon review, the Tenth Circuit agreed with the district court that it lacked subject matter jurisdiction because of Full Life's failure to file a timely administrative appeal. View "Full Life Hospice v. Sebelius" on Justia Law

The State appealed from the district court's order enjoining it from requiring plaintiff to submit to a suspicionless drug test pursuant to Section 414.0652 of the Florida Statutes, as a condition for receipt of government-provided monetary assistance for which he was otherwise qualified. Plaintiff applied for financial assistance benefits for himself and his son through Florida's Temporary Assistance for Needy Families program (TANF). The court held that the district court did not abuse its discretion in granting the preliminary injunction enjoining the State from enforcing the statute because the court concluded that the State had failed to establish a substantial special need to support its mandatory suspicionless drug testing of TANF recipients. View "Lebron v. Secretary, FL Dept. of Children and Families" on Justia Law

Petitioner appealed from the district court's judgment affirming the Commissioner's denial of his application for disability benefits. The court held that the ALJ erred in her treatment of plaintiff's claim that he suffered from fibromyalgia by failing to accord the proper weight to the opinion of plaintiff's treating physician, by misconstruing the record, and by failing to evaluate the claim in light of medically accepted diagnostic criteria. The court also held that the ALJ's determination that plaintiff could perform light work was not supported by substantial evidence, and that the ALJ further erred by not determining whether plaintiff's reaching limitation was non-eligible and would therefore require the testimony of a vocational expert. Accordingly, the court vacated and remanded for further proceedings. View "Selian v. Astrue" on Justia Law

Prasch worked as a mail carrier for the Postal Service until suffering a work-related injury, compensable under the Federal Employees’ Compensation Act. He received benefits from the Office of Workers’ Compensation Programs from December 2007 until October 2008. Prasch applied for disability retirement. OPM approved his application and deposited $14,640.27, representing retroactive retirement annuity payments from December 2007 through the approval of his application. OPM paid him another $5,869.60 in retirement annuity benefits before determining that Prasch had received FECA disability benefits from OWCP during the period that OPM was paying him retirement annuity benefits. Because governing statutes prohibit dual benefits, OPM adjusted the commencement date of Prasch’s retirement annuity and computed an overpayment of $14,703.62.and sent a proposed repayment schedule. Prasch requested a waiver of the repayment obligation, lower installments, or a compromise payment, but he did not ask for reconsideration of OPM’s decisions as to the existence of the overpayment or its amount. OPM affirmed its initial decision, finding that Prasch should have known that he could not receive dual benefits and rejecting his claim of financial hardship, but extended the time for repayment. The Merit Systems Protection denied an appeal. The Federal Circuit affirmed. View "Prasch v. Office of Pers. Mgmt." on Justia Law

Reimbursement providers for inpatient services rendered to Medicare beneficiaries is adjusted upward for hospitals that serve disproportionate numbers of patients who are eligible for Supplemental Security Income. The Centers for Medicare & Medicaid Services annually submit the SSI fraction for eligible hospitals to a “fiscal intermediary,” a Health and Human Services contractor, which computes the reimbursement amount and sends the hospitals notice. A provider may appeal to the Provider Reimbursement Review Board within 180 days, 42 U. S. C. 1395oo(a)(3). The PRRB may extend the period, for good cause, up to three years, 42 CFR 405.1841(b). A hospital timely appealed its SSI fraction calculations for 1993 through 1996. The PRRB found that errors in CMS’s methodology resulted in a systematic under-calculation. When the decision was made public, hospitals challenged their adjustments for 1987 through 1994. The PRRB held that it lacked jurisdiction, reasoning that it had no equitable powers save those granted by legislation or regulation. The district court dismissed the claims. The D. C. Circuit reversed. The Supreme Court reversed. While the 180-day limitation is not “jurisdictional” and does not preclude regulatory extension, the regulation is a permissible interpretation of 1395oo(a)(3). Applying deferential review, the Court noted the Secretary’s practical experience in superintending the huge program and the PRRB. Rejecting an argument for equitable tolling, the Court noted that for nearly 40 years the Secretary has prohibited extensions, except as provided by regulation, and Congress not amended the 180-day provision or the rule-making authority. The statutory scheme, which applies to sophisticated institutional providers, is not designed to be “unusually protective” of claimants. Giving intermediaries more time to discover over-payments than providers have to discover underpayments may be justified by the “administrative realities” of the system: a few dozen intermediaries issue tens of thousands of NPRs, while each provider can concentrate on its own NPR. View "Sebelius v. Auburn Reg'l Med. Ctr." on Justia Law

Roddy, born in 1964, suffers from several serious medical problems, including severe lower back pain attributable to degenerative disc disease. When her pain became unbearable, she stopped working and applied for disability insurance benefits. She was unsuccessful before the Social Security Administration. An administrative law judge found that there were jobs in the national economy within her capabilities, although she no longer could perform her old job as a shift manager at a Taco Bell restaurant. The district court affirmed. The Seventh Circuit vacated and remanded. The ALJ improperly discounted the opinion of a physician and improperly considered Roddy’s testimony about her ability to do housework. View "Roddy v. Astrue" on Justia Law

Harris served on active duty in the U.S. Army from 1963 to 1966 and from 1967 to 1970. In 1985, he had a VA Medical Center examination; an “Agent Orange” form associated with that examination indicates that Harris complained of “skin rashes on trunk and arms.” Another form, listing his service in Vietnam, is an “Application for Medical Benefits,” stated that it “will be used to determine your eligibility for medical benefits.” In 2002, Harris, pro se, sought service-connected disability compensation for contact dermatitis and latex allergy. The DVA regional office ultimately granted the claims and assigned an effective date of 2002. Harris sought an effective date of 1985. The Board held that the report of the Agent Orange Registry examination did not constitute a claim. The Veterans Court affirmed The Federal Circuit vacated, stating that pro se filings must be read liberally; the Veterans Court did not apply the proper legal standard for determining whether the Board had correctly determined the earliest applicable date for the claim. View "Harris v. Shinseki" on Justia Law