Justia Public Benefits Opinion Summaries

Providers of “habilitation services” under Idaho’s Medicaid plan are reimbursed by the state Department of Health and Welfare. Section 30(A) of the Medicaid Act requires Idaho’s plan to “assure that payments are consistent with efficiency, economy, and quality of care” while “safeguard[ing] against unnecessary utilization of . . . care and services,” 42 U.S.C. 1396a(a)(30)(A). Providers of habilitation services claimed that Idaho reimbursed them at rates lower than section 30(A) permits. The district court entered summary judgment for the providers. The Ninth Circuit affirmed, concluding that the Supremacy Clause gave the providers an implied right of action, under which they could seek an injunction requiring compliance. The Supreme Court reversed, concluding that there is no private right of action. The Supremacy Clause instructs courts to give federal law priority when state and federal law clash, but it is not the source of any federal rights and does not create a cause of action. The suit cannot proceed in equity. The power of federal courts of equity to enjoin unlawful executive action is subject to express and implied statutory limitations. The express provision of a single remedy for a state’s failure to comply with Medicaid’s requirements, the withholding of Medicaid funds by the Secretary of Health and Human Services, 42 U.S.C. 1396c, and the complexity associated with enforcing section 30(A) combine to establish Congress’s “intent to foreclose” equitable relief. View "Armstrong v. Exceptional Child Ctr., Inc." on Justia Law

Pomianowski was 19 years old when she was in an automobile accident which left her a ventilator-dependent quadriplegic. She required total care in all aspects of daily living. A lawsuit filed against the County of Santa Cruz and Ford Motor Company, resulted in a settlement for $3,175,000.00. The court directed that the funds be deposited in a special needs trust (Probate Code sections 3600-3605). At age 23, Pomianowski died, with $1,294,453.23 left in the trust, which was ordered to reimburse the Department of Health Care Services for medical expenses paid on her behalf before her death. The trustee argued that the assets were exempt from reimbursement rights because the beneficiary was under 55 years of age when the services were provided. The court of appeal affirmed, holding that the Department was entitled to reimbursement under both the Medicaid statute, 42 U.S.C. 1396a, and the statutes and regulations implementing Medicaid through California’s Medi-Cal program. The statutes and regulations do not exempt beneficiaries under age 55, nor is there a public policy reason to shield the trust assets from recovery so that $417, 812.43 spent by the public can pass to the beneficiary’s parents along with the rest of the trust assets. View "Herting v. Cal. Dep;t of Health Care Servs." on Justia Law

Relators’ daughter was being treated by counselors at Arbour Counseling Services in Lawrence, Massachusetts when she was prescribed a medication for her purported bipolar disorder. The daughter experienced an adverse reaction to the drug and eventually suffered a fatal seizure. Relators filed this action against Defendant Universal Health Services, Inc., Arbour’s owner and operator, under both the federal and Massachusetts False Claims Acts, alleging that Arbour, in submitting reimbursement claims to the state Medicaid agency for services rendered by the staff members who treated their daughter, fraudulently misrepresented that those staff members were properly licensed and supervised, as required by law. Specifically, Relators alleged that Arbour’s alleged noncompliance with supervision and licensure requirements rendered its reimbursement claims actionably false. The district four dismissed the complaint for failure to state a claim. The First Circuit reversed the dismissal of the complaint with one limited exception, holding (1) a healthcare provider’s noncompliance with conditions of payment is sufficient to establish the falsity of a claim for reimbursement; and (2) Relators appropriately stated a claim with particularity under the False Claims Act. View "United States, ex rel. Escobar v. Universal Health Servs., Inc." on Justia Law

The Secretary of the United States Department of Health and Human Services imposed a civil money penalty on Plott Nursing Home in California for Plott’s violations of the Medicare Act’s standards of care for nursing home patients. The Department’s Appeals Board largely affirmed. Plott petitioned for review. The Ninth Circuit affirmed in part and reversed in part, holding (1) sufficient evidence supported the Secretary’s determination that Plott violated the quality of care for bed sores; (2) the Secretary’s finding that Plott violated the quality of care for urinary tract infections was not supported by substantial evidence on the record; and (3) Plott was entitled to administrative review of all cited deficiencies. Remanded with directions to review or dismiss the violations that were not reviewed by the agency. View "Plott Nursing Home v. Burwell" on Justia Law

Johnson began working for U.S. Steel in 2004. On May 12 2011, he left work, complaining of a headache, and went to a clinic where a physician’s assistant indicated that he had high blood pressure. The next day he provided a note that was deemed insufficient by his employer. His regular physician later indicated that Johnson's blood pressure was normal. Emails, memoranda, and letters indicate that Johnson was suspended on May 16 and then terminated for altering, falsifying, or forging the work excuse. U.S. Steel never provided him with notice of his FMLA rights and obligations. Nor was such notice included in the employee handbook. Johnson filed suit under the Family and Medical Leave Act (FMLA), 29 U.S.C. 2601-2654, alleging that U.S. Steel retaliated against him for taking protected FMLA leave, failed to reinstate him after a period of protected leave, and otherwise unlawfully interfered with his FMLA rights. The district court entered summary judgment for the employer. The Eighth Circuit affirmed. Johnson did not demonstrate how any alleged technical violations could have prejudiced him if his condition was not a serious health condition and did not qualify him for FMLA leave in the first place. View "Johnson v. Wheeling Mach. Prods." on Justia Law

Plaintiffs filed a putative class action suit against the Secretary on behalf of Medicare beneficiaries who were placed into "observation status" by their hospitals rather than being admitted as "inpatients." Placement into "observation status" allegedly caused these beneficiaries to pay thousands of dollars more for their medical care. The district court granted the Secretary's motion to dismiss and plaintiffs appealed. The court affirmed the dismissal of plaintiffs' Medicare Act, 42 U.S.C. 1395, claims where plaintiffs lack standing to challenge the adequacy of the notices they received and nothing in the statute entitles plaintiffs to the process changes they seek. However, the court vacated the district court's dismissal of plaintiffs' Due Process claims where the district court erred in concluding that plaintiffs lacked a property interest in being treated as "inpatients," because the district court accepted as true the Secretary's assertion that a hospital's decision to formally admit a patient is "a complex medical judgment" left to the doctor's discretion. The district court's conclusion constituted impermissible factfinding, which in any event is inconsistent with the complaint's allegations that the decision to admit is guided by fixed and objective criteria. View "Barrows v. Burwell" on Justia Law

Babaria, a licensed radiologist and medical director and manager of Orange Community MRI, an authorized Medicare and Medicaid provider, pleaded guilty to one count of making illegal payments (kickbacks), 42 U.S.C. 1320a-7b(b)(2)(A). From 2008 through 2011, he paid physicians to refer patients to Orange for diagnostic testing and billed Medicare and Medicaid for testing that was tainted by the corrupt referrals. Orange received $2,014,600.85 in payments that were directly traceable to the kickback scheme. There was no evidence that Babaria falsified patient records, billed Medicare or Medicaid for testing that was not medically necessary, or otherwise compromised patient care. Babaria objected to the PreSentence Investigation Report, which recommended a two-level adjustment for abuse of a position of trust (USSG 3B1.3) and a four-level adjustment for aggravating role (USSG 3B1.1(a)), resulting in a recommended Guidelines range of 70-87 months’ imprisonment. Ultimately, the Guidelines range was 60 months, capped by the statutory maximum for Babaria’s count of conviction. He argued that the correct range was 37 to 46 months. The court applied both adjustments but granted a downward variance and sentenced Babaria to 46 months’ imprisonment, a fine of $25,000, and forfeiture of the $2,014,600.85. The Third Circuit affirmed the sentence. View "United States v. Babaria" on Justia Law

Todd, born in 1963, was a high school graduate, and worked primarily as a laborer, often for temporary services. Todd’s last employment before seeking disability benefits ended in April 2007 because the temporary job was completed. Todd claimed inability to work due to anxiety, cramping in his feet, and difficulty breathing. Until his death in July 2009, Todd was treated for major depressive disorder, alcoholism, alcohol dependence, emphysema, and generalized anxiety disorder. Todd also experienced tremors of unknown etiology. An ALJ decided: Todd had not engaged in substantial gainful activity since April 14, 2007; Todd suffered from emphysema, tremors, an affective disorder, an anxiety disorder, and alcohol dependence; Todd did not have an impairment or combination of impairments so severe as to meet or equal the criteria of a listed impairment; Todd had the residual functional capacity to perform light work and was capable of performing his past relevant work as a laborer; and Todd was “not under a disability.” The district court agreed. Although the ALJ improperly weighed the medical professionals’ opinions, the error was harmless because substantial evidence supported a finding that Todd’s limitations would not be disabling if he stopped using alcohol. The Eighth Circuit affirmed. View "Bernard v. Colvin" on Justia Law

Systemic juvenile idiopathic arthritis (SJIA), an autoinflammatory disease, has symptoms including arthritis, fever, rash, and muscle and joint pain, caused by dysfunctional production of proteins, which cells release almost immediately after contact with an antigen. Gardasil, a vaccine against HPV administered in three doses, contains virus-like particles created from an HPV protein, and an adjuvant to generate a robust immune response. Vanessia, born in 1995, was healthy until 2008. After receiving two doses of Gardasil, she experienced an all-over rash. Days later, she had joint pain and high fever. The hospital discharged her with a presumptive diagnosis of SJIA. Vanessia’s family history included SJIA. Her rheumatologist communicated these findings to the doctor who administered Vanessia’s third dose of Gardasil on August 19. Vanessia experienced a SJIA flare on August 25. Vanessia’s Vaccine Act injury claim was rejected. Injuries that do not appear on the Vaccine Injury Table, 42 C.F.R. 100.3, require proof of a medical theory causally connecting the vaccination to the injury; a logical sequence of cause and effect; and proximate temporal relationship between the vaccine and injury. The Claims Court and Federal Circuit affirmed, finding that the claim did not meet the burden of demonstrating proximate temporal relationship. View "Koehn v. Sec'y of Health & Human Servs." on Justia Law

Keathley retired from working at strip mines. His health deteriorated. He sought Black Lung Benefits Act benefits, 30 U.S.C. 901. Keathley established eligibility under the 15 -year presumption; he had worked in mines for more than 16 years and was able to show a totally disabling impairment by medical opinion testimony and tests showing poor pulmonary function. His employer rebutted this presumption by offering testimony by Dr. Broudy, who diagnosed Keathley with “a combination of chronic obstructive asthma and pulmonary emphysema and chronic bronchitis” caused by smoking. Conceding that “coal dust may have contributed,” Broudy concluded that “it’s far more likely that the impairment was due to obstructive airways disease from cigarette smoking and some predisposition to asthma or bronchospasm.” On remand, the ALJ awarded benefits; the Benefits Review Board affirmed, rejecting Broudy’s opinion that “bronchitis associated with coal dust exposure usually ceases with cessation of exposure,” as contrary to federal regulations, which state that “pneumoconiosis” may be “latent and progressive” and arise after exposure ceases. The Sixth Circuit denied the employer’s petition for review. The employer did not challenge the evaluation of individual tests, identify any factor the ALJ overlooked, or offer any basis for distinguishing among the tests. View "Sunny Ridge Mining Co., Inc. v. Keathley" on Justia Law