Justia Public Benefits Opinion Summaries

Articles Posted in Health Law
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Adams, born in 1960, smoked about a pack a day starting at age 18 and worked in coal mines at times between 1979-1995, mostly underground using a “cutting machine” in the “dustiest” areas. Adams struggled to breathe after his retirement. Adams’s 1998 application under the Black Lung Benefits Act, 30 U.S.C. 901(b), was denied because he failed to prove that he had pneumoconiosis. In 2008, Adams sought benefits from Wilgar. His treating physician, Dr. Alam, identified the causes of his 2013 death as cardiopulmonary arrest, emphysema, coal worker’s pneumoconiosis, throat cancer, and aspiration pneumonia.A 2019 notice in the case stated “the Court may look to the preamble to the revised” regulations in weighing conflicting medical opinions. Wilgar unsuccessfully requested discovery concerning the preamble and the scientific studies that supported its conclusions. The ALJ awarded benefits, finding that Adams had “legal pneumoconiosis” and giving Dr. Alam’s opinion that Adam’s coal mine work had substantially aggravated his disease “controlling weight.” All things being equal, a treating physician’s opinion is “entitled to more weight,” 30 C.F.R. 718.104(d)(1). Wilgar's three experts had opined that Adams’s smoking exclusively caused his disease The ALJ gave “little weight” to these opinions, believing that they conflicted with the preamble to the 2001 regulation.The Benefits Review Board and Sixth Circuit affirmed. The preamble interpreted the then-existing scientific studies to establish that coal mine work can cause obstructive diseases, either alone or in combination with smoking. The ALJ simply found the preamble more persuasive than the experts. View "Wilgar Land Co. v. Director, Office of Workers’ Compensation Programs" on Justia Law

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The Supreme Court reversed the decision of the court of appeals affirming the final order of the Commissioner of the Department of Human Services' (DHS) concluding that Trinity had engaged in the abuse outlined in DHS's notices and spreadsheets, holding that the first report of the administrative law judge (ALJ) was the binding decision in this matter.Trinity Home Health Care, which provided nursing and personal care assistant services, received reimbursement from DHS for services that it provided to Medicaid-eligible people with disabilities. After an investigation, DHS sent Trinity notices of termination from the program and demanding return of overpayments and payment-withholding. Both before and after remand by the Commissioner, the ALJ found that terminating Trinity's participation in the Minnesota Health Care Programs was an inappropriate sanction for Trinity's failure to provide certain records. The Commissioner modified the report, concluding that Trinity had engaged in the abuse alleged by the DHS. The court of appeals affirmed. The Supreme Court reversed, holding (1) the Commissioner did not have the authority to remand the case due to the DHS's general authority to administer and supervise Medicaid; and (2) the Commissioner did not have implied authority to remand the case to the ALJ under case law. View "In re Surveillance & Integrity Review Appeals by Trinity Home Health Care Services" on Justia Law

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Waters was born with homocystinuria and diagnosed with that condition at the age of six. Homocystinuria is a genetic attribute that causes metabolic issues that prevent Waters’s liver from metabolizing methionine, an amino acid, that produces L-cysteine, another amino acid. Her physician prescribed HCU coolers–a medical food containing a methionine-free protein formula. Waters ingests HCU coolers orally; she has a fully functioning gastrointestinal tract. Waters sought reimbursement for HCU coolers purchased during 2018-2019, under the prosthetic-device benefit of Medicare Part B, 42 U.S.C. 1395k(a)(2)(I); 1395x(s)(8). The National Coverage Determinations Manual explains that, as part of the prosthetic-device benefit, enteral nutrition is considered reasonable and necessary when a patient “cannot maintain weight and strength commensurate with his” “general condition” because food does not reach the digestive tract and specifies that “[e]nteral therapy may be given by nasogastric [nose], jejunostomy [small intestine], or gastrostomy [stomach] tubes.” The NCD acknowledges “[s]ome patients require supplementation of their daily protein and caloric intake,” but “[n]utritional supplementation is not covered under Medicare Part B.”The Sixth Circuit affirmed several levels of denial of Waters’s claim, acknowledging the difficult circumstances of Waters and her family. An HCU cooler is not a stand-alone prosthetic device based on the plain meaning of prosthetic “device” and because an HCU cooler is a medical food according to the FDA. View "Waters v. Becerra" on Justia Law

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Former employees of Alternatives, a for-profit hospice provider, sued under the False Claims Act, 31 U.S.C. 3729, alleging that Alternatives submitted claims for Medicare reimbursement despite inadequate documentation in the patients’ medical records supporting hospice eligibility, under 42 C.F.R. 418.22(b)(2). For a patient to be eligible for Medicare hospice benefits, and for a hospice provider to be entitled to reimbursement, a patient must be certified as “terminally ill.” The district court granted Alternatives summary judgment based on lack of materiality, finding “no evidence” that Alternatives’ insufficiently documented certifications "were material to the Government’s decision to pay.” The court reasoned that “[t]he Government could see what was or was not submitted” yet never refused any of Alternatives’ claims, despite the inadequacy or missing supporting documentation or where compliance was otherwise lacking.The Third Circuit vacated. When a government contractor submits a claim for payment but fails to disclose a statutory, regulatory, or contractual violation, that claim does not automatically trigger liability. The Act requires that the alleged violation be “material” to the government’s decision to pay. The Supreme Court has identified factors to assist courts in evaluating materiality. In this case, the court based its decision principally on the government’s continued payments after being made aware of its deficient documentation, overlooking factors that could have weighed in favor of materiality— and despite an open dispute over the government’s “actual knowledge.” View "Druding v. Care Alternatives" on Justia Law

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The Supreme Court reversed the decision of the court of appeal affirming the conclusion of the State Department of Health Care Services that the costs of outreach and education activities aimed at Medicaid-eligible patients were categorically nonreimbursable, holding that the chief administrative law judge's ruling was an abuse of discretion.Health care providers entitled to government reimbursement, including federally qualified health centers (FQHCs), for reasonable costs related to the care of Medicaid beneficiaries are required to offer outreach and education activities to members of underserved communities. The FQHC operator in this case sought reimbursement for the outreach and education costs, but the Department determined that the costs were nonreimbursable. The court of appeal affirmed. The Supreme Court reversed, holding that the Department's determination rested on a misunderstanding of relevant legal principles governing the reimbursement of medical provider costs. View "Family Health Centers of San Diego v. State Dep't of Health Care Services" on Justia Law

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The Supreme Court held that because Plaintiff's state-law claims were based on allegations that his father's health maintenance organization (HMO) plan and healthcare services administrator that managed his father's benefits (collectively, Defendants) breached state-law duties that incorporated and duplicated standards established under Medicare Part C, Part C's preemption provision preempted them.Plaintiff brought this action alleging a state statutory claim under the Elder Abuse Act and common law claims of negligence and wrongful death for the alleged maltreatment of his father, a Medicare Advantage (MA) enrollee who died after being discharged from a skilled nursing facility. Plaintiff alleged that the MA HMO and healthcare services administrator breached a duty to ensure his father received skilled nursing benefits to which he was entitled under his MA plan. Defendants demurred, arguing that the claims were preempted by Part C's preemption provision. The trial court sustained the demurrers, and the court of appeal affirmed. The Supreme Court affirmed, holding that because Plaintiff's state-law claims were based on allegations that Defendants breached state-law duties that incorporate and duplicate standards established under Part C, the claims were expressly preempted. View "Quishenberry v. UnitedHealthcare, Inc." on Justia Law

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The Supreme Court held that a claim for reimbursement of emergency medical services may be maintained against a health care service plan when the plan is operated by a public entity and that the Government Claims Act, Cal. Gov. Code 810 et seq., did not immunize the County of Santa Clara from such a claim in this case.Two hospitals submitted reimbursement claims for the emergency medical services they provided to three individuals enrolled in a County-operated health care service plan. The hospitals sued for the remaining amounts based on the reimbursement provision of the Knox-Keene Act, and the trial court concluded that the hospitals could state a quantum merit claim against the County. The court of appeal reversed, determining that the County was immune from suit under the Government Claims Act. The Supreme Court reversed, holding that the County was not immune from suit under the circumstances of this case and that the hospitals' claims may proceed. View "County of Santa Clara v. Superior Court" on Justia Law

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The Supreme Court dismissed this direct appeal brought by the Iowa Department of Human Services (HDS) from a district court ruling requiring Iowa's Medicaid program to pay for sex reassignment surgery for two transgender adults and affirmed the denial of fees on cross-appeal, holding that the appeal was moot.Petitioners, adult transgender Iowans who were denied preauthorization for sex reassignment surgeries through the Medicaid program, appealed their managed care organization's denial of coverage to DHS. DHS affirmed the denials. The district court reversed, concluding that Iowa Code 216.7(3), an amendment to the Iowa Civil Rights Act (ICRA) violated the guarantee of equal protection under the Iowa Constitution. DHS appealed, but, thereafter, agreed to pay for Petitioners' surgeries. The Supreme Court dismissed the direct appeal as moot and affirmed the district court's order denying any fee award, holding that the court erred in denying Petitioners' request for attorney fees. View "Vasquez v. Iowa Dep't of Human Services" on Justia Law

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Plaintiff, MSP Recovery Claims, Series LLC (“MSP”) appealed from the district court’s judgment dismissing for lack of standing its putative class action against Defendant Hereford Insurance Company (“Hereford”) and denying leave to amend. MSP has brought several lawsuits around the country seeking to recover from insurance companies that allegedly owe payments to Medicare Advantage Organizations (“MAOs”) under the Medicare Secondary Payer Act (the “MSP Act”). In the putative class action brought here, MSP charges Hereford with “deliberate and systematic avoidance” of Hereford’s reimbursement obligations under the MSP Act.   The Second Circuit affirmed. The court concluded that MSP lacked standing because its allegations do not support an inference that it has suffered a cognizable injury or that the injury it claims is traceable to Hereford. The court also concluded that the district court did not abuse its discretion when it denied MSP leave to amend based on MSP’s repeated failures to cure. The court explained that the plain language of Section 111 provides that when a no-fault insurance provider such as Hereford reports a claim pursuant to Section 111, it does not thereby admit that it is liable for the claim. The statutory context of the section’s reporting obligation and the purpose of the reporting obligation confirms the correctness of this interpretation. Because MSP’s argument that the payments made by EmblemHealth are reimbursable by Hereford rests entirely on its proposed interpretation of Section 111, MSP has not adequately alleged a “concrete” or “actual” injury or that the injury it alleges is fairly traceable to Hereford. View "MSP v. Hereford" on Justia Law

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Stephanie Owens appealed a district court’s order affirming the findings of fact and conclusions of law made by the Ada County Board of Commissioners (the “Board”) in which it determined that Owens was an “applicant” under the Medical Indigency Act (the “Act”) and, therefore, required to pay reimbursement for the medical expenses incurred by her two children at public expense. In 2017, Owens’s children were involved in a serious car accident and suffered substantial injuries, which later resulted in the death of one of the children. Because the children’s father, Corey Jacobs, was unable to pay for the children’s medical bills, he filed two applications for medical indigency with the Board. Owens and Jacobs were never married and did not have a formal custody agreement for their children. At the time of the accident, the children resided with their father. The Board determined that Owens and her children met the statutory requirements for medical indigency. Although Jacobs filed the applications for medical indigency, the Board concluded that Owens was also an “applicant” under the Act and liable to repay the Board. As a result, the Board “recorded notices of statutory liens” against Owens’s real and personal property and ordered Owens to sign a promissory note with Ada County to repay the medical bills. Owens refused to sign the note and instead challenged the sufficiency of her involvement with the applications via a petition for reconsideration with the Board and a subsequent petition for judicial review. Both the Board and the district court ultimately concluded that Owens was an “applicant” and liable for repayment of a portion of the children’s medical bills. Owens timely appealed. The Idaho Supreme Court reversed: because she never signed the medical indigency applications for her children and she did not affirmatively participate in the application process, Owens was not an "applicant" as defined by the Act. As a result, the Board acted outside its authority when it ordered Owens to reimburse Ada County for its expenses and when it placed automatic liens on her property. View "Owens v. Ada County Board of Commissioners" on Justia Law