Justia Public Benefits Opinion Summaries

Jewish Home of Eastern Pennsylvania (JHEP) provides nursing care to Medicare beneficiaries and is required to comply with the mandatory health and safety requirements for participation. JHEP must submit to random surveys conducted by state departments of health. In 2005, the Pennsylvania Department of Health conducted a survey that concluded that JHEP had eight regulatory deficiencies, including violations of 42 C.F.R. 483.25(h)(2), which requires a facility to ensure that each resident receives adequate supervision and assistance with devices to prevent accidents. Based on those deficiencies and those found in a 2006 survey, the Center for Medicare and Medicaid Services imposed fines totaling $17,150 and $12,800. JHEP claimed that the allegations of noncompliance were based on the inadmissible disclosure of privileged‖ quality assurance records and that the monetary penalties violated its right to equal protection because they were the product of selective enforcement based on race and religion. An ALJ upheld the fines against JHEP. The Third Circuit denied a petition for review. View "Jewish Home of E. PA v. Centers for Medicare and Medicaid Servs." on Justia Law

Suppliers appealed the district court's dismissal of their action against the Secretary of the Department of Health and Human Services and the Administrator of the Centers for Medicare and Medicaid Services (CMS). Suppliers challenged a regulation addressing the "applicable financial standards" that a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) supplier must meet to be eligible for a Medicare contract under the competitive process established in 42 U.S.C. 1395w-3 (DMEPOS Statute). The court affirmed the district court's dismissal on the ground that section 1395w-3(11) precluded judicial review of the Secretary's financial standards regulation and that the district court therefore lacked subject matter jurisdiction. View "Texas Alliance For Home Care, et al. v. Sebelius, et al." on Justia Law

Medicare pays teaching hospitals for work by residents when a teaching physician supervises. During the 1990s, HHS concluded that many hospitals were billing for unsupervised services and began to audit invoices. There was also a GAO report and private litigation: qui tam suits under the False Claims Act, allowing relators to collect a bounty. Under 31 U.S.C. 3730(e)(4)(A), suits cannot be based upon public disclosure of allegations or transactions in public agencies’ official reports unless the relator is an original source of information. A prior case concluded that the 1998 GAO report and similar public documents disclosed that billing for unsupervised work was common practice. The district court dismissed a suit filed against a teaching hospital in 2004, claiming to describe conduct, such as inadequate supervision, not previously disclosed. The Seventh Circuit vacated. No one who read the GAO report, or followed the progress of the audits, would suspect that Rush University was misrepresenting "immediate availability" of teaching physicians during concurrently scheduled procedures. The complaint alleged a kind of deceit that the GAO report does not attribute to any teaching hospital. View "Goldberg v. Rush Univ. Med. Ctr." on Justia Law

In 2009, plaintiff applied for an IT specialist position with the Miami VA Healthcare System. He did not get the job and, after exhausting rights before the Department of Labor, filed an appeal, asserting that the VA violated his rights relating to veteran's preference. The AJ concluded that the Merit Systems Protection Board had no authority to review the merits of the VA’s non-selection of plaintiff. The Board agreed. The Federal Circuit vacated. There is no way to determine whether the Veterans' Preference Act (58 Stat. 390) has been violated without examining the grounds for non-selection. The Board has jurisdiction to determine whether the VA properly afforded plaintiff the right to compete for the job and properly determined, in accordance with 5 C.F.R. § 302.302(d), that he was not qualified for the position View "Lazaro v. Dep't of Veterans Affairs" on Justia Law

A 66-year -old arrived at petitioner's center with complex ailments, but oriented, able to feed herself and able to speak. During her 18 days at the center, she was sent to the hospital twice with serious medical complications. Upon investigation, the center was found to have failed to maintain substantial compliance with federal regulations for facilities that participate in Medicare and Medicaid (42 U.S.C. § 1395) in its treatment of the resident and appealed the resulting civil money penalty. An administrative law judge, the Departmental Appeals Board, and the Sixth Circuit affirmed. The ALJ acted properly in requiring submission of written testimony, properly weighed the evidence, and found violation of the federal hydration standard, laboratory services requirement, and mandate of a care plan, resulting in "immediate jeopardy."

Doctors filed suit, alleging violations of the False Claims Act, 31 U.S.C. 3279 and the Michigan Medicaid False Claim Act, as qui tam relators on behalf of the United States/ The claimed that the business defrauded the government by submitting Medicare and Medicaid billings for defective radiology studies, and that the billings were also fraudulent because the business was an invalid corporation. The federal government declined to intervene. The district court dismissed. Sixth Circuit affirmed. The doctors failed to identify any specific fraudulent claim submitted to the government, as is required to plead an FCA violation with the particularity mandated by the FRCP. A relator cannot merely allege that a defendant violated a standard (in this case, with respect to radiology studies), but must allege that compliance with the standard was required to obtain payment. The doctors had no personal knowledge that claims for nondiagnostic tests were presented to the government, nor do they allege facts that strongly support an inference that such billings were submitted.

The Medicare program pays teaching hospitals to cover "direct" and "indirect costs of medical education," 42 U.S.C. 1395ww(d)(5)(B), (h). Direct costs include expenses such as residents' salaries. Indirect costs are incurred due to "general inefficiencies" and "extra demands placed on other staff." Congress created a formula for calculating indirect expenses based on full-time equivalency interns; an HHS regulation referred to time residents spend in the "portion of the hospital subject to the prospective payment system or in the outpatient department of the hospital." In reimbursing plaintiff, HHS excluded from the FTE count time residents spent on pure research, unrelated to treatment of a patient. While appeal of a decision favoring the hospital was pending, Congress enacted the Patient Protection and Affordable Care Act, 124 Stat. 119, 660–61. For the years at issue, HHS must include in FTE: "all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary." HHS promulgated a regulation specifying that eligible non-patient care activities do not include time residents spend conducting pure research. The Sixth Circuit upheld the regulation as within the Secretary's authority and applicable to the years at issue.

Based on her part in billing Indiana Medicaid for ambulance service while running a car service to take patients to medical appointments, defendant was convicted of Medicaid fraud, 18 U.S.C. 1347, and conspiracy to defraud the U.S. government, 18 U.S.C. 371. She was sentenced to 33 months in prison and to pay restitution of $846,115. The Seventh Circuit affirmed. Data relating to time-stamping of bills, which may have established that multiple people submitted bills, was not concealed; the government simply failed to extract (before trial) information to which it and the defense had access. Even if the data was "Brady" material, it would not have changed the outcome. The judge did not err in telling the jury that a scheduled witness was ill without saying that the witness had refused treatment.

The former governor and former financial director of the Tribe were convicted for conspiracy to defraud the United States (18 U.S.C. 371), and of violations of 18 U.S.C. 287, 666 and 669, involving misuse of federal grant and tribal monies at the Passamaquoddy Tribe Indian Township Reservation in Maine. The First Circuit vacated the conviction of the financial director for making material misstatements about how grant money intended for HIV and substance abuse prevention was spent, but otherwise affirmed. The evidence that the director knew that his statements were false was insufficient. The district court had jurisdiction; several counts involved mismanagement of federal grants and contracts, which are subject to regulations that the Tribe is not free to ignore, and do not constitute internal tribal matters.

Plaintiff brought action under the False Claims Act, 31 U.S.C. 3729, claiming that the company used a kickback scheme and knowingly caused submission of false Medicare, Medicaid, and TRICARE claims by hospitals and doctors. The district court held that hospital claims at issue were not false or fraudulent, and that doctor claims were false or fraudulent, but not materially so. The First Circuit reversed. If kickbacks affected the transactions underlying the claims, the claims failed to meet a condition of payment and were false, regardless of the hospital's participation in or knowledge of the kickbacks. It cannot be said, as a matter of law, that the alleged misrepresentations were not capable of influencing Medicare's decision to pay the claims.