Justia Public Benefits Opinion Summaries

Stephens was born in 1957 and has a ninth-grade education. He worked as a taxi dispatcher and a security guard in the 15 years preceding his alleged disability. Stephens contends that he is disabled by diabetes, kidney disease, knee and back pain, heart disease, high blood pressure, asthma, arthritis, and obesity. He was denied Supplemental Security Income (SSI) benefits. On remand, a different ALJ determined that Stephens’ impairments, although severe, were not disabling and that he could perform relevant past work. The district court and Seventh Circuit upheld the denial, rejecting arguments that the ALJ erred by improperly evaluating Stephens’s obesity (no longer a stand-alone disability) when determining the aggregate impact of his impairments; that the ALJ’s finding that the record lacked medical opinion evidence as to Stephens’ hypersomnolence or excessive sleepiness; and that the ALJ failed to incorporate all of his impairments and consider their combined impact to evaluate his residual functional capacity. View "Stephens v. Berryhill" on Justia Law

Stephens was born in 1957 and has a ninth-grade education. He worked as a taxi dispatcher and a security guard in the 15 years preceding his alleged disability. Stephens contends that he is disabled by diabetes, kidney disease, knee and back pain, heart disease, high blood pressure, asthma, arthritis, and obesity. He was denied Supplemental Security Income (SSI) benefits. On remand, a different ALJ determined that Stephens’ impairments, although severe, were not disabling and that he could perform relevant past work. The district court and Seventh Circuit upheld the denial, rejecting arguments that the ALJ erred by improperly evaluating Stephens’s obesity (no longer a stand-alone disability) when determining the aggregate impact of his impairments; that the ALJ’s finding that the record lacked medical opinion evidence as to Stephens’ hypersomnolence or excessive sleepiness; and that the ALJ failed to incorporate all of his impairments and consider their combined impact to evaluate his residual functional capacity. View "Stephens v. Berryhill" on Justia Law

Twelve Medicaid-participating hospitals (“Hospitals”) challenged the Department of Medicaid’s (“DOM’s”) recalculation of their Medicaid outpatient rates for fiscal year 2001. The chancery court affirmed the opinion of the DOM, finding that “DOM interpreted its own regulation – the State Plan, which is its contract with the federal government and which it is required to follow to receive federal funds to require Medicaid to calculate the cost to charge ratio by using Medicare Methodology, which at that time was using a blended rate.” The Mississippi Supreme Court found the plain language of Attachment 4.19-B of the State Plan provided a cost-to-charge-ratio formula for calculating outpatient rates. Laboratory and radiology charges were to be excluded from this formula, because they were reimbursed on a fee-for-service basis. DOM’s inclusion of radiology and laboratory services in the charges and substitution of costs with Medicare blended payment amounts was a clear violation of the State Plan. Therefore, the Court reversed the judgments of DOM and the chancery court. Consistent with its opinion, the Court remanded and ordered the Executive Director of DOM to recalculate the Hospitals’ cost-to-charge ratio using the Hospital’s submitted costs in their cost reports, excluding laboratory and radiology services, and reimbursing the Hospitals the appropriate amounts determined by using the State Plan. View "Crossgates River Oaks Hospital v. Mississippi Division of Medicaid" on Justia Law

The Ninth Circuit reversed the district court's partial grant of summary judgment for the Department and held that the Department did not violate the dormant Commerce Clause in adopting Medi-Cal policies related to reimbursement to out-of-state hospitals. The panel held that when a state was acting as a market participant, rather than a market regulator, its decisions were exempted from the dormant Commerce Clause. In this case, the Department sets rates of reimbursement to hospitals for those who were essentially insured as beneficiaries under Medi-Cal in a manner much like that of a private insurer participating in the market. Therefore, the Department was acting as a market participant, rather than a regulator and was exempt from dormant Commerce Clause requirements. View "Asante v. California Department of Healthcare Services" on Justia Law

The Ninth Circuit affirmed the district court's grant of summary judgment for the Department in an action brought by private ambulance companies challenging the reimbursement rate for their transportation of patients covered by Medi-Cal. The panel held that plaintiffs failed to carry their burden of producing evidence upon which a reasonable jury could return a verdict in their favor and thus the district court did not err in entering judgment in the Department's favor on the Takings Clause claim. The panel reasoned that the ambulance companies lacked a constitutionally protected property interest in a particular reimbursement rate, but the mandatory-care provision of Cal. Health & Safety Code 1317(d) implicated a constitutionally protected property right. The panel held that section 1317(d) did not effect a regulatory taking under the Penn Central test. The panel also held that the ambulance companies did not establish a due process claim regarding DHCS's failure to ensure that Medi-Cal reimbursement rates kept pace with their costs because they lacked a constitutionally protected interest in any particular reimbursement rate. View "Sierra Medical Services Alliance v. Kent" on Justia Law

The trial court did not err in dismissing Plaintiffs’ action for lack of subject matter jurisdiction due to Plaintiffs’ failure to exhaust administrative remedies in seeking damages for denied Medicaid reimbursement claims.The court of appeals reversed the trial court’s order, ruling that the trial court erred in dismissing Plaintiffs’ complaint without resolving certain factual issues and that Plaintiffs sufficiently demonstrated that it would be futile to pursue administrative remedies. The Supreme Court reversed, holding that the court of appeals erred in reversing the dismissal of Plaintiffs’ claims where Plaintiffs failed to exhaust their administrative remedies prior to filing suit and failed to demonstrate futility of the available remedies at this time. View "Abrons Family Practice & Urgent Care, PA v. North Carolina Department of Human Services" on Justia Law

The issue presented for the Oregon Supreme Court’s review was whether an adult foster care provider claiming unjust enrichment may recover the reasonable value of its services from a defendant who, through fraud, obtained a lower rate from the provider for the services. Plaintiff owned two adult foster homes for the elderly. Plaintiff had contracted with the Oregon Department of Human Services to provide services in a home-like setting to patients who qualified for Medicaid. For those patients, the rates charged would be those set by the department. Isabel Pritchard resided and received care in one of plaintiff’s adult foster homes until her death in November 2008. Because Prichard had been approved to receive Medicaid benefits, plaintiff charged Prichard the rate for Medicaid-qualified patients: approximately $2,000 per month, with approximately $1,200 of that being paid by the department. Plaintiff’s Medicaid rates were substantially below the rates paid by plaintiff’s “private pay” patients. Prichard’s application for Medicaid benefits, as with her other affairs, was handled by her son, Richard Gardner. Gardner had for years been transferring Prichard’s assets, mostly to himself (or using those funds for his personal benefit). Gardner’s misconduct was discovered by another of Prichard’s children: defendant Karen Nichols-Shields, who was appointed the personal representative for Prichard’s estate. In 2009, defendant contacted the police and reported her brother for theft. Ultimately, Gardner pleaded guilty to three counts of criminal mistreatment in the first degree. Gardner’s sentence included an obligation to pay a compensatory fine to Prichard’s estate, to which he complied. After defendant, in her capacity as personal representative, denied plaintiff Larisa’s Home Care, LLC’s claim against Prichard’s estate, plaintiff filed this action, essentially asserting Prichard had been qualified for Medicaid through fraud and that Prichard should have been charged as a private pay patient. The Oregon Supreme Court concluded that, generally, a defendant who obtains discounted services as a result of fraud is unjustly enriched to the extent of the reasonable value of the services. The Court therefore reversed the contrary holding by the Court of Appeals. Because the fraud here occurred in the context of a person being certified as eligible for Medicaid benefits, however, the Court remanded for the Court of Appeals to consider whether certain provisions of Medicaid law may specifically prohibit plaintiff from recovering in this action. View "Larisa's Home Care, LLC v. Nichols-Shields" on Justia Law

Goodman served in the U.S. Army, 1972-1992, with service in Southwest Asia during the Persian Gulf War. During his service and at his discharge, Goodman underwent medical examinations that returned negative for rheumatoid arthritis; he denied having pain in his joints or arthritis. In 2007, Goodman sought treatment at a VA medical center for hand stiffness and knee pain, which he said had begun during service. He sought VA benefits for rheumatoid arthritis. The Board sought an independent medical advisory opinion from the Veterans Health Administration, which was conducted by a VA medical center Director of Rheumatology in 2014 and concluded that “it is less likely than not” that Goodman’s rheumatoid arthritis can be characterized as a medically unexplained chronic multi-symptom illness (MUCMI) under 38 C.F.R. 3.317, and that it “is less likely than not that his rheumatoid arthritis is related to a specific exposure event experienced … during service. The Board concluded that Goodman was not entitled to a presumptive service connection for a MUCMI; the Federal Circuit affirmed. The VA adjudicator may consider evidence of medical expert opinions and all other facts of record to make the final determination of whether a claimant has proven, based on the claimant’s unique symptoms, the existence of a MUCMI. View "Goodman v. Shulkin" on Justia Law

Rosewood is a skilled nursing facility, 42 U.S.C. 1395i-3(a), participating in Medicare and Medicaid as a provider. The Secretary of Health and Human Services, which enforces the statutory and regulatory provisions governing nursing homes operating in the Medicare/Medicaid network, assessed a civil monetary penalty against Rosewood on the grounds that it had failed to protect a resident from abuse, failed to timely report or to investigate thoroughly allegations of abuse, and failed to implement its internal policies on abuse, neglect, and misappropriation of property. The Centers for Medicare and Medicaid Services (CMS) determined that these deficiencies placed residents in “immediate jeopardy.” An Administrative Law Judge and the Department Appeals Board affirmed the $6,050 per day penalty imposed by CMS. The Seventh Circuit affirmed. Substantial evidence supports the Agency’s findings. The court noted three specific examples of noncompliance and concluded that there was a systemic failure to implement Rosewood’s policies aimed at conforming to federal regulations View "Rosewood Care Center of Swansea v. Price" on Justia Law

Prime Hospitals provide inpatient services under the Medicare program, submitting payment claims to private contractors, who make initial reimbursement determinations. Prime alleged that many short-stay claims were subject to post-payment review and denied. Prime appealed through the Medicare appeal process. Prime alleged short-stay claims audits were part of a larger initiative that substantially increased claim denials and that the Center for Medicare & Medicaid Services (CMS) was overwhelmed by the number of appeals. CMS began offering partial payment (68 percent) in exchange for dismissal of appeals. Prime alleged that it executed CMS's administrative settlement agreement so that CMS was contractually required to pay their 5,079 Medicare appeals ($23,205,245). CMS ultimately refused to allow the Prime to participate because it was aware of ongoing False Claims Act cases or investigations involving the facilities. Prime alleged that the settlement agreement did not authorize that exclusion. The district court denied a motion to dismiss Prime’s suit but transferred it to the Court of Federal Claims. The Federal Circuit affirmed in part. The breach of contract claim is fundamentally a suit to enforce a contract and does not arise under the Medicare Act, so the Claims Court has exclusive jurisdiction under the Tucker Act, 28 U.S.C. 1491. That court does not have jurisdiction, however, over Prime’s alternative claims seeking declaratory, injunctive, and mandamus relief from an alleged secret and illegal policy to prevent and delay Prime from exhausting administrative remedies. View "Alvarado Hospital, LLC v. Cochran" on Justia Law