Justia Public Benefits Opinion Summaries

Nita and Kirtish Patel operated two companies that provided mobile diagnostic medical services. To obtain Medicare reimbursement for neurological testing, they falsely represented that a licensed neurologist would supervise the tests. In reality, Kirtish, who lacked a medical license, wrote the reports, and Nita forged a physician’s signature. Their fraudulent scheme generated over $4 million, including substantial Medicare payments.In 2014, a former employee filed a sealed qui tam action in the United States District Court for the District of New Jersey, alleging healthcare fraud and asserting claims under the False Claims Act. The Patels were subsequently arrested and each pleaded guilty to one count of healthcare fraud. Their plea agreements did not address or preclude future civil or administrative actions. After their guilty pleas, the Government intervened in the qui tam action and obtained summary judgment against the Patels, relying on collateral estoppel from their criminal admissions. The District Court trebled the Medicare loss and imposed civil penalties, resulting in a judgment exceeding $7 million. Nita appealed, and the United States Court of Appeals for the Third Circuit affirmed her liability under the False Claims Act.Both Patels later moved to vacate their criminal sentences under 28 U.S.C. § 2255, arguing ineffective assistance of counsel because their attorneys did not advise them that their guilty pleas could have collateral estoppel effects in the civil qui tam action. The District Court denied their motions, finding that counsel’s performance was not objectively unreasonable and that the Patels were aware their plea agreements did not preclude civil actions.On appeal, the United States Court of Appeals for the Third Circuit held that the Sixth Amendment does not require criminal defense counsel to advise clients of collateral consequences such as civil liability under the False Claims Act. The court affirmed the District Court’s judgment, concluding that Padilla v. Kentucky’s holding is limited to deportation consequences and does not extend to civil liability. View "Patel v. USA" on Justia Law

A personal care assistance provider agency in Minnesota was audited by the Department of Human Services (DHS) for recordkeeping deficiencies related to its provision of services under the state’s Medicaid program. The agency, which served both traditional and PCA Choice recipients, was found to have various documentation errors, including missing or incomplete care plans and timesheets, as well as timesheets lacking required elements. DHS did not allege fraud or that services were not provided, but sought to recover over $420,000 in payments, arguing that these deficiencies constituted “abuse” under state law and justified monetary recovery.After an evidentiary hearing, an administrative law judge (ALJ) recommended limited recovery for some missing documentation but rejected most of DHS’s claims, finding that DHS had not shown the deficiencies resulted in improper payments. The DHS Commissioner disagreed, ordering full repayment. The Minnesota Court of Appeals reversed the Commissioner’s decision, holding that DHS must prove not only that the provider engaged in “abuse” but also that the abuse resulted in the provider being paid more than it was entitled to receive. The court also determined that provider agencies must maintain care plans for both traditional and PCA Choice recipients in their files.The Minnesota Supreme Court affirmed in part, reversed in part, and remanded. It held that, to obtain monetary recovery under Minn. Stat. § 256B.064, subd. 1c(a), DHS must prove either: (1) the provider engaged in conduct described in subdivision 1a and, had DHS known of the conduct before payment, it would have been legally prohibited from paying under a statute or regulation independent of subdivision 1a; or (2) the payment resulted from an error such that the provider received more than authorized by law. The Court also held that provider agencies must keep care plans for all PCA services, including PCA Choice, in their files. View "In the Matter of the SIRS Appeal by Best Care, LLC" on Justia Law

Two children, E.R. and G.S., have severe, complex medical conditions that require constant, skilled care. Their mothers, who are their primary caregivers and sole financial supporters, have been trained by medical professionals to provide the necessary care at home. For years, Indiana’s Medicaid program reimbursed these mothers for providing “attendant care services” under a waiver program designed to keep individuals out of institutions. In July 2024, the Indiana Family and Social Services Administration (FSSA) implemented a policy change that would make parents ineligible to be paid providers of attendant care for their children, threatening to force E.R. and G.S. into institutional care due to the lack of available in-home nurses.The Indiana Protection and Advocacy Services Commission, along with E.R. and G.S., sued to block the policy change and require FSSA to secure in-home nursing. The United States District Court for the Southern District of Indiana initially granted a preliminary injunction requiring FSSA to take steps to obtain in-home nurses and to pay the mothers for a different, lower-paid service. After further proceedings, the court modified its order, ultimately requiring FSSA to pay the mothers for attendant care at the previous rate until in-home nursing could be secured.The United States Court of Appeals for the Seventh Circuit affirmed the district court’s October 1 injunction. The court held that the plaintiffs are likely to succeed on their claims under the Americans with Disabilities Act’s integration mandate, which requires states to provide services in the most integrated setting appropriate. The court found that prohibiting the mothers from providing paid attendant care placed the children at serious risk of institutionalization and that FSSA had not shown that allowing such care would fundamentally alter the Medicaid program or violate federal law. The case was remanded for further proceedings. View "Indiana Protection and Advocacy Services Comm'n v Indiana Family and Social Services Administration" on Justia Law

A skilled nursing facility accepted a new resident who was receiving Medicaid benefits. The resident's husband was designated as her authorized representative. Nearly two years later, the Department of Human Services (DHS) terminated the resident's Medicaid benefits due to excess assets. Both the resident and her husband were incapacitated, and the resident's public guardian submitted a new Medicaid application, which was denied. The nursing facility continued to care for the resident without compensation until her death. The facility later sought an administrative hearing to challenge the eligibility decision, but the request was denied because the facility was not an authorized representative and the appeal was late.The circuit court and the Intermediate Court of Appeals (ICA) affirmed the denial, holding that the nursing home lacked standing to challenge the eligibility determination under Hawai'i Revised Statutes (HRS) § 346-12, which limits appeals to the applicant or recipient. The courts concluded that the nursing home did not have a close relationship with the resident for third-party standing purposes.The Supreme Court of the State of Hawai'i reviewed the case and disagreed with the lower courts regarding standing. The court held that skilled nursing facilities have constitutionally protected property interests in compensation for medical services performed for residents based on DHS eligibility determinations. The court ruled that these facilities have due process rights under the Hawai'i Constitution, including notice and the opportunity to appeal Medicaid eligibility determinations when the beneficiary is incapacitated and no authorized representative is available or willing to appeal. The court vacated the ICA's judgment and the circuit court's order, remanding the case for a new administrative hearing on the merits of the resident's Medicaid eligibility. View "In re FT" on Justia Law

Dionne Marie Nadon applied for disability insurance benefits and supplemental security income in April 2015 and May 2016, respectively, citing conditions such as fibromyalgia, spinal abnormalities, depression, and anxiety. The administrative law judge (ALJ) initially denied her applications in January 2017, finding she could return to her past work as a cashier/checker. On appeal, the case was remanded because the ALJ had not adequately addressed Nadon’s post-traumatic stress disorder (PTSD). On remand, the ALJ again determined that Nadon was not disabled, following the five-step sequential analysis for determining disabilities.The ALJ found that Nadon had engaged in substantial gainful activity as a personal care attendant from July 2021 through 2022 but continued the analysis due to a continuous period of at least twelve months during which Nadon did not engage in substantial gainful activity. The ALJ found that Nadon had severe impairments but did not have an impairment or combination of impairments that met or equaled the severity of a listed impairment. The ALJ determined that Nadon’s residual functional capacity allowed her to perform light work with certain limitations and found that she could perform her past relevant work as a personal care attendant and other work as a housekeeper, marker, or small products assembler.The district court affirmed the ALJ’s decision. The United States Court of Appeals for the Ninth Circuit reviewed the case de novo and affirmed the district court’s decision. The court held that the ALJ did not err by considering Nadon’s work as a personal care attendant, as an ALJ is permitted to consider any work done by a claimant when evaluating a disability claim. The court also found that the ALJ provided several reasons for discounting Nadon’s testimony and the opinions of several healthcare professionals, beyond her work as a personal care attendant. The court rejected Nadon’s argument that the ALJ erred by relying on the vocational expert’s testimony, as it relied on the rejected premise that the ALJ erred in discounting the healthcare professionals’ opinions. View "Nadon v. Bisignano" on Justia Law

Ferida H. Moy suffers from severe PTSD due to her experiences during the Yugoslav Wars. She applied for disability insurance benefits and supplemental security income, citing her PTSD and related mental health issues. An administrative law judge (ALJ) denied her application, finding that she had the residual functional capacity to perform simple, routine tasks with minimal contact with supervisors and co-workers. This decision was upheld by the district court, leading Moy to appeal.The ALJ found that Moy had moderate limitations in concentrating, persisting, or maintaining pace but concluded that she could work at a consistent production pace. The ALJ's decision was based on the testimony of a vocational expert who stated that a person with Moy's limitations could work as a dining room attendant, bus person, scrap sorter, industrial cleaner, or dishwasher. However, the vocational expert also testified that regular absences or being off-task for more than 15% of the workday would result in job loss. The ALJ's decision was affirmed by the district court.The United States Court of Appeals for the Seventh Circuit reviewed the case and found that the ALJ failed to build a logical bridge between Moy's limitations and the conclusion that she could work at a consistent production pace. The court noted that the ALJ's determination did not adequately account for Moy's limitations in concentration, persistence, and pace. The court emphasized that the ALJ's reasoning was internally inconsistent and did not reflect Moy's documented symptoms and treatment needs. Consequently, the Seventh Circuit vacated the judgment and remanded the case to the Commissioner of Social Security for further consideration consistent with its opinion. View "Moy v Bisignano" on Justia Law

Alicia Rae Pufahl applied for disability insurance benefits from the Social Security Administration in August 2012, citing limitations due to Wegener’s granulomatosis, depression, pulmonary disease, back injury, bipolar disorder, and excessive fatigue. She needed to establish disability between August 8, 2011, and December 31, 2016. Her application was initially denied in November 2012, followed by several unfavorable decisions from Administrative Law Judges (ALJs), appeals, and remands. The most recent ALJ decision concluded that she was not disabled during the relevant period, and the district court affirmed this decision.The United States District Court for the Eastern District of Wisconsin affirmed the ALJ’s decision, finding that substantial evidence supported the agency’s determination. The Appeals Council denied further review, making the ALJ’s decision the final decision of the Commissioner of Social Security.The United States Court of Appeals for the Seventh Circuit reviewed the case and affirmed the district court’s judgment. The court held that the ALJ properly weighed the medical opinion evidence, including the opinions of Ms. Pufahl’s neurologist, primary care provider, and psychiatrist, and found substantial evidence supporting the ALJ’s decision to not give controlling weight to these opinions. The ALJ’s evaluation of Ms. Pufahl’s subjective complaints was not patently wrong, as it was supported by specific reasons and evidence. Additionally, the hypothetical question posed to the vocational expert (VE) sufficiently accounted for Ms. Pufahl’s mental limitations, including her ability to maintain attention and concentration for two-hour segments. The court concluded that the ALJ’s decision was supported by substantial evidence and affirmed the district court’s judgment. View "Pufahl v Bisignano" on Justia Law

The City of Huntington and the Cabell County Commission filed lawsuits against AmerisourceBergen Drug Corp., Cardinal Health, Inc., and McKesson Corp., alleging that the defendants contributed to the opioid epidemic by distributing excessive quantities of opioids to pharmacies. The plaintiffs claimed that the defendants' actions created a public nuisance that should be abated under West Virginia common law. The cases were consolidated and remanded to the United States District Court for the Southern District of West Virginia, which held a ten-week bench trial.The district court ruled in favor of the defendants, concluding that the plaintiffs failed to prove that the defendants' conduct was unreasonable or that it proximately caused the opioid epidemic. The court found that the defendants substantially complied with their duties under the Controlled Substances Act (CSA) and that the plaintiffs did not provide sufficient evidence to show that the volume of opioids distributed was excessive or that the defendants failed to maintain effective controls against diversion. The district court also determined that the plaintiffs' proposed abatement plan was not appropriate.The plaintiffs appealed to the United States Court of Appeals for the Fourth Circuit, contesting the district court's factual findings and legal conclusions. The Fourth Circuit certified a question to the Supreme Court of Appeals of West Virginia, asking whether conditions caused by the distribution of a controlled substance can constitute a public nuisance under West Virginia common law and, if so, what the elements of such a claim are.The Supreme Court of Appeals of West Virginia declined to answer the certified question, citing the disputed factual findings and related legal conclusions on appeal. The court emphasized that it could not address the legal issue without a sufficiently precise and undisputed factual record, and any answer would be advisory given the unsettled facts. View "City of Huntington and Cabell County Commission v. AmerisourceBergen Drug Corporation" on Justia Law

Paul Cropper applied for disability insurance benefits and supplemental security income in February 2020, citing various impairments such as anxiety, depression, ADHD, insomnia, and COPD. His application was denied initially and upon reconsideration by the Social Security Administration. Cropper then requested a hearing before an administrative law judge (ALJ), where he presented opinions from his medical providers indicating severe limitations. The ALJ conducted a five-step analysis and denied the application, finding that while Cropper had severe impairments, he could still perform certain jobs available in the national economy. The ALJ found the opinions of Cropper’s primary care provider and psychiatrist unpersuasive.Cropper sought judicial review in the United States District Court for the District of Minnesota, arguing that the ALJ improperly evaluated the evidence, leading to an incorrect residual functional capacity determination. The district court granted summary judgment in favor of the Commissioner, concluding that substantial evidence supported the ALJ’s decision to find the medical opinions unpersuasive.The United States Court of Appeals for the Eighth Circuit reviewed the case de novo and affirmed the district court’s decision. The court held that the ALJ adequately considered the supportability and consistency of the medical opinions as required by the revised regulations. The court emphasized that the ALJ’s findings were supported by substantial evidence, including the conservative course of treatment and the lack of significant outpatient therapy. The court also noted that the ALJ’s reasoning was sufficiently clear to allow for appropriate judicial review. View "Cropper v. Dudek" on Justia Law

Two elderly individuals, Ms. Penelope Lamle and Ms. Maxine Houston, applied for Medicaid but faced delays and additional questions from the Oklahoma Department of Human Services, allegedly directed by attorney Susan Eads. They refused to answer these questions and subsequently sued, seeking an expedited decision, payment of Medicaid benefits, and damages. Both applicants died during the litigation, and their estates were substituted as parties in the appeal.The United States District Court for the Western District of Oklahoma dismissed the action with prejudice, citing the plaintiffs' failure to state a valid claim. However, the court was unaware that the applicants had died while the action was pending.The United States Court of Appeals for the Tenth Circuit reviewed the case. The court found that the claims for an injunction became moot when the agency denied benefits and the applicants died. The court noted that the requested relief would no longer benefit the estates, as the Oklahoma Department of Human Services had already denied the applications. The court also held that the Eleventh Amendment barred the requested retrospective relief. Consequently, the court remanded the case to the district court with instructions to vacate the judgment on the claim for a prospective injunction and dismiss it without prejudice.Regarding the claim against Ms. Eads in her individual capacity, the Tenth Circuit held that she was entitled to qualified immunity. The court found that the plaintiffs did not allege facts showing the violation of a clearly established right. As a result, the court affirmed the dismissal with prejudice of the claim for damages against Ms. Eads. View "Lamle v. Eads" on Justia Law