Justia Public Benefits Opinion Summaries

Plaintiff filed several suits against healthcare groups on behalf of the United States, claiming violation of the Medicare Secondary Payer Act, 42 U.S.C. 1395y(b). No court has ever found that the MSP is a qui tam statute, permitting private attorneys general to sue on behalf of the United States. The Sixth Circuit found plaintiff was on notice of the frivolous nature of his filings from their inception in the Tennessee district courts and remanded for a show-cause hearing on why sanctions should not issue. The district court awarded sanctions to two defendants in amounts of $131,158.50 and $145,431.19. The Sixth Circuit affirmed, but denied an award for the appeal.

West Virginia sued pharmaceutical manufacturers, claiming that the defendants artificially inflated the reimbursement values of certain drugs, in violation of the West Virginia Consumer Credit and Protection Act, W. Va. Code 46A-1-101, and a state statute prohibiting fraud and abuse in the Medicaid program. The complaint alleged that the defendants inflated the average wholesale price of certain drugs and caused the state to pay an artificially inflated amount of reimbursement for the drugs. One company agreed to pay West Virginia $850,000. After learning of the settlement in 2007, the federal Centers for Medicare & Medicaid Services notified West Virginia of a disallowance in federal funding for the state’s Medicaid program for failure to credit the federal government its share of the settlement proceeds. The Appeals Board sustained the disallowance. The district court upheld the decision. The Fourth Circuit affirmed, rejecting an argument the Medicaid Act, 42 U.S.C. 1396b(d)(2)(A), authorizes a disallowance only when the state has recovered from a "provider."

Plaintiff Laurie Harper appealed a district court's order that affirmed the denial of her disability benefits. Plaintiff alleged her disability was based on fibromyalgia and depression. The Social Security Administration denied her applications initially and on reconsideration. The Administrative Law Judge determined that she was not "disabled" within the meaning of the Social Security Act. Upon review of the testimony of the expert witnesses and the record of the Commission's analysis of her case, the Tenth Circuit found sufficient evidence to support Ms. Harper's claim of disability in this case. The Court reversed the district court's order and remanded the case to the Commissioner for further proceedings.

The World War II veteran died in 2004, during litigation of whether a hip injury was service-related. The VA dismissed a pending appeal as moot and rejected the widow's request to be substituted. The Federal Circuit reversed. The widow filed her own claim for accrued benefits. The motion to substitute was denied, but the widow was awarded accrued benefits and sought $87,802.17 in attorney fees and expenses under the Equal Access to Justice Act, 28 U.S.C. 2412. The veterans' court determined that the widow had the right, as representative of the estate, to recover fees for attorney hours expended prior to his death, but had no right to recover fees for work performed after her husband’s death. The Federal Circuit reversed, stating that attorney work performed after the veteran's death was directly related to his claim; it was his claim, not the widow's claim, that was being litigated.

This appeal involved a putative class action filed by three Pennsylvania Medicaid beneficiaries subject to the Pennsylvania Department of Public Welfare's (DPW) liens against future settlements or judgments. At issue was whether state agencies responsible for administering the Medicaid program have the authority to assert such liens and, if so, whether Pennsylvania's statutory framework was consistent with the Supreme Court's decision in Arkansas Department of Health and Human Services v. Ahlborn. The court examined the text, structure, history, and purpose of the Social Security Act, 42 U.S.C. 301 et seq., and held that liens limited to medical costs were not prohibited by the anti-lien and anti-recovery provisions of the Act, 42 U.S.C. 1396p(a)-(b). Accordingly, the court upheld Pennsylvania's longstanding practice of imposing such liens. The court also held that Pennsylvania's current statutory framework, which afforded Medicaid recipients a right of appeal from the default allocation, was a permissible default apportionment scheme.

The District of Columbia filed this suit to recover its attorneys' fees from a lawyer who brought an administrative complaint against the District on behalf of a student with special educational needs under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400(d)(1)(A). At issue was whether the District was a "prevailing party" under the IDEA in this suit. The court held that the facts in this case followed closely in the wake of the court's precedent in District of Columbia v. Straus where that court held that the district was not a "prevailing party" where its own change of position was what had mooted the dispute, causing the case to be dismissed. Therefore, the court held that the District, in this case, was not a "prevailing party" where the District of Columbia Public Schools (DCPS) authorized an independent comprehensive psychological evaluation for the student, which mooted the only issue before the hearing officer. Accordingly, the district court's grant of summary judgment ordering the lawyer to pay attorneys' fees was reversed.

This case stemmed from the discovery in an unrelated case that the Center for Medicare & Medicaid Services ("CMS") had paid hospitals less than they were due because it had miscalculated the disproportionate share hospital ("DSH") payment. Appellants, a group of hospitals that received DSH payments, filed claims with the Provider Reimbursement Review Board ("PRRB") seeking full payments for the fiscal years 1987-1994. At issue was whether the district court lacked jurisdiction in the matter and whether the Medicare statute, 42 U.S.C. 1395oo(a), allowed for equitable tolling. The court held that a decision by the PRRB denying jurisdiction was a final decision subject to judicial review by the district court. The court also held that, given the factors emphasized in United States v. Brockamp did not apply to the facts presented, and without any other reasons for rebutting the presumption of equitable tolling, the court found that equitable tolling was available under 1395oo(a). The court noted that whether tolling was appropriate in this particular case, however, was a different question for the district court to answer on remand. The court also rejected appellants' alternative arguments and therefore, reversed and remanded for further proceedings.

The Department of Human Services appealed a judgment reversing the Department's calculations of Appellees David and Sarah Kaspari's monthly recipient liabilities for their nursing home costs. In 1996, the Kasparis conveyed approximately 561 acres of farmland to their son and daughter-in-law. The Kasparis retained a life estate in the farmland and leased their interest in the land to a third-party tenant. The Kasparis exercised their water rights and constructed irrigation equipment on the land, which was paid for with a series of loans secured by mortgages on the land. The new loans were combined with an existing mortgage on the land. After the irrigation equipment was placed on the land, the Kasparis received increased rental payments for the irrigated land. In April 2009, the Kasparis entered a nursing home and thereafter applied to Social Services for Medicaid for their nursing home care. After an initial determination by Social Services and a subsequent administrative hearing, the Department decided the Kasparis were eligible for benefits and calculated their respective recipient liabilities without allowing deductions for their payments for interest on the mortgage. The district court reversed and remanded the case for recalculation of the Kasparis' respective monthly recipient liabilities, concluding deductions for their payments of mortgage interest and real estate taxes should be considered. The Department argued to the Supreme Court that the district court erred in construing Medicaid regulations to allow the Kasparis to reduce their monthly recipient liabilities for nursing home care by their payments for mortgage interest and for real estate taxes relating to their life estate interest in the farmland. Upon review, the Supreme Court held that the district court erred in construing the Medicaid regulations. The Court reversed the judgment and remanded the case to reinstate the Department's decision.

Plaintiffs, married couples who worked as house parents to children who were "severely emotionally disturbed" in defendants' homes, sued defendants for overtime pay under the Fair Labor Standards Act ("FLSA"), 29 U.S.C. 203(r)(2)(A). The children attended local public schools and participated in other activities away from the homes. Although, the children participated in group therapy conducted by clinicians in the homes, they received most of their medical and psychological treatment outside the homes. Plaintiffs were not licensed medical or social service professionals. Defendants filed an interlocutory appeal challenging the district court's conclusion that defendants' homes were covered by the FLSA and were subject to its overtime provisions. The court held that defendants' homes were not covered by the FLSA because they were not an "institution primarily engaged in the care of the sick, the aged, mentally ill or defective who resided on the premises of such institution." Accordingly, the court reversed and remanded for further proceedings.

This case involved cost-saving tools that Congress had devised for Medicare payments to cancer hospitals and specifically concerned Medicare reimbursements paid to one cancer hospital, appellant, in 2000 and 2001. The first issue on appeal related to the cancer hospitals' inpatient costs where appellant requested an increase to its target amount in 2000 and 2001 due to the high cost of certain new cancer drugs and where the Department of Health and Human Services ("HHS") denied that request. Appellant argued that it did not receive proper notice of the new net financial impact requirement and thus did not have a fair opportunity to satisfy the requirement at the administrative hearing. The court agreed and held that appellant did not receive timely notice of the requirement and, on remand to HHS, must be given an opportunity to satisfy it. The second issued on appeal concerned cancer hospitals' outpatient costs where appellant contended that HHS misapplied the statutory formula that provided hospitals a fraction of their reasonable costs and undercompensated appellant. The court rejected appellant's arguments and affirmed summary judgment in favor of HHS.