Justia Public Benefits Opinion Summaries

Prinkey served in the Army, 1969 to 1970, including time in Vietnam. He was diagnosed with diabetes in 1996. Diabetes mellitus type II is presumed to be service connected if the veteran was exposed to Agent Orange, 38 U.S.C. 1116(a)(2)(H) (2002). In 2003, the VA received Prinkey’s claim for benefits on account of his diabetes, asserting exposure to Agent Orange. The VA Regional Office grantedservice connection for diabetes, evaluated at 20%, and lesser rated service connection for other disabilities secondary to diabetes. Prinkey sought to reopen his claim. During reexamination, the VA concluded that his diabetes more likely than not resulted from the surgery that removed most of his pancreas following years of alcohol abuse, not from his exposure to Agent Orange. Ultimately the Board of Veterans’ Appeals sustained severance of service connection for diabetes and related disabilities and denied entitlement to a total disability rating based on individual unemployability. The Veterans Court affirmed. The Federal Circuit affirmed. Under 38 C.F.R. 3.105(d) “service connection will be severed only where evidence establishes that it is clearly and unmistakably erroneous; the VA may consider medical evidence and diagnoses that postdate the original award of service connection. View "Prinkey v. Shinseki" on Justia Law

At age four months, Elias received a Diptheria-Tetanus-acellular-Pertussis (DTaP) vaccine. Elias developed a seizure disorder shortly afterwards. While a petition for compensation under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. 300aa-1, was pending, Elias died as a result of his seizure disorder at the age of seven. A special master determined that the DTaP vaccine caused Elias’ epilepsy and resulting death. The Secretary of Health and Human Services and the estate agreed to a $250,000 death benefit plus $175,000 for actual pain and suffering and past unreimbursable expenses. The estate also sought future lost earnings under section 300aa-15(a)(3)(B). The special master determined that the estate was entitled to future lost earnings. Subject to the right to seek review, the Secretary proffered, and the estate accepted the sum of $659,955.61 as a measure of the lost earnings. The Claims Court affirmed the special master’s future lost earnings award. The Federal Circuit reversed, holding that an estate cannot recover lost future earnings under section 300aa-15(a)(3)(B) when the person injured by a vaccine dies before entry of a compensation judgment. View "Tembenis v. Sec'y of Health & Humans Servs." on Justia Law

Orillo, her husband (a doctor), and another owned Chalice, a home health care provider. Chalice was an enrolled provider with Medicare and could seek reimbursement of home health care through that program. Orillo falsified forms by altering the codes and information that had been completed by the Chalice nurses to make the patient’s condition appear worse and the health care needs greater than the actuality. Those alterations caused Medicare software to generate different reimbursement rates Orillo also aided her husband in paying kickbacks to a Chicago doctor in return for referrals of Medicare patients. Orillo pled guilty to healthcare fraud, 18 U.S.C. 1347 and paying kickbacks to physicians for patient referrals under a federal health care program, 42 U.S.C. 1320a-7b and 18 U.S.C. 2, and was sentenced to 20 months’ imprisonment. Orillo conceded that her scheme caused a loss, to Medicare, in excess of $400,000, and agreed to entry of a $500,000 forfeiture judgment.The district court determined that the loss amount for the healthcare fraud count was $744,481 and ordered her to pay that amount in restitution. The Seventh Circuit affirmed, rejecting Orillo’s argument that the loss and restitution amount should be limited to only those stemming from visible alterations. View "United States v. Orillo" on Justia Law

Southern Rehabilitation Group and its medical director sued the Secretary of Health and Human Services and past and present Medicare contractors, seeking review of the Secretary’s final decision on 6,200 claims for Medicare reimbursement. The district court remanded so that the Secretary could pay the disputed amount. After payment, the case returned to the district court, which concluded that the claims for payment were moot and dismissed remaining constitutional and statutory claims as barred by jurisdictional provisions of the Medicare Act. The court also held that plaintiffs did not show that they were eligible to collect interest on their claims and that it did not have jurisdiction over 8,900 other claims that plaintiffs alleged were still in the administrative process. The Sixth Circuit affirmed summary judgment to defendants on plaintiffs’ federal and state law claims and on the 8,900 claims still in the administrative process, but reversed summary judgment on plaintiffs’ claims for interest. The Secretary could not rely on her unreasonable interpretation of the “clean-claims” statute as a basis for summary judgment concerning interest. View "S. Rehab. Grp. v. Sec'y of Health & Human Servs." on Justia Law

Burris worked in coal mines for 23 years. He twice sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901, abandoning his first claim in 2001, and pursuing a second claim in 2006. After a hearing on the second claim, an Administrative Law Judge determined that Burris was totally disabled by pneumoconiosis arising from his coal mining employment and that he qualified for benefits. The Benefits Review Board affirmed. The Seventh Circuit denied a petition for review, rejecting arguments that the ALJ erred in finding that Burris established a material change in condition following his first, abandoned claim; in concluding that Burris proved 15 years of surface mine employment in conditions substantially similar to those that exist in underground mines; and in rejecting evidence rebutting a presumption of pneumoconiosis. View "Consolidation Coal Co. v. Dir., Office of Workers' Comp. Programs" on Justia Law

Schomas, 54 years old, suffers from scoliosis and degenerative disc disease. Following a hearing, the Social Security Administration denied his application for Disability Insurance Benefits. The district court and the Seventh Circuit upheld the denial, rejecting a challenge to the ALJ’s credibility finding and assessment of his residual functional capacity. The court acknowledged that the ALJ’s decision was “problematic,” but concluded that Schomas waived most of his arguments, and that the rest were unfocused or undeveloped. View "Schomas v. Astrue" on Justia Law

Plaintiffs filed suit against defendant, in her official capacity as Interim Secretary for the Florida Agency for Health Care Administration (AHCA), alleging that defendant violated the Medicaid Act, 42 U.S.C. 1396 et seq., by denying Medicaid coverage of applied behavioral analysis (ABA) to treat plaintiffs' autism spectrum disorders. The court concluded that the district court did not abuse its discretion in issuing a permanent injunction that overruled AHCA's determination that ABA was experimental and required Medicaid coverage of this treatment. However, because the language in the injunction's final sections was out of step with the district court's analysis and what was actually decided, the court vacated the injunction in part and remanded to the district court to modify Paragraphs 2 and 6. View "Garrido, et al. v. Interim Secretary, FL Agency for Health Care Admin." on Justia Law

The U.S. Department of Health and Human Services approved a 2008 amendment to Pennsylvania’s state plan for administering its Medicaid program. Private nursing facilities that provide services to Medicaid recipients challenged the amendment as violating Title XIX of the Social Security Act, 42 U.S.C. 1396, by adjusting Pennsylvania’s method for determining Medicaid reimbursement rates to private nursing facilities for the 2008-09 fiscal year without considering quality of care, which they claim violates 42 U.S.C. 1396a(a)(30)(A) and without satisfying the public process requirements of 42 U.S.C. 1396a(a)(13)(A). The district court rejected the claims on summary judgment. The Third Circuit affirmed in part, finding the state immune from the requested relief under the Eleventh Amendment. The district court erred in granting summary judgment to the federal defendants. By approving the amendment without any assurance that the amended plan would produce payments that are consistent with quality of care, HHS acted arbitrarily. View "Christ the King Manor, Inc. v. Sec'y, U.S. Dep't of Health & Human Servs." on Justia Law

Relators brought a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729(a)(1)(A) and (B), alleging that the Mayo Foundation and others billed Medicare for surgical pathology services it did not provide. The government intervened and the parties settled. Relators then filed a Second Amended Complaint asserting additional claims. On appeal, relators challenged the district court's dismissal of their additional claim that Mayo fraudulently billed for services it did not provide whenever it prepared and read a permanent tissue slide but did not prepare a separate written report of that service. As a preliminary issue, the court concluded that relators satisfied their burden of showing that the public disclosure bar did not deprive the court of jurisdiction over relators' claim. On the merits, the court concluded that nowhere in the Medicare regulations or in the American Medical Association Codebook has the court found a requirement that physicians using the CPT codes for surgical pathology services must prepare the additional written reports that relators claimed Mayo fraudulently failed to provide. Accordingly, the court affirmed the judgment of the district court. View "Ketroser, et al. v. Mayo Foundation, et al." on Justia Law

After researching qui tam actions and meeting with an attorney, Dr. Watson placed an ad in a Sheboygan newspaper soliciting minor Medicaid patients who had been prescribed certain psychotropic medications. The ad referred to participation in a possible Medicaid fraud suit and sharing in any recovery. Meyer responded and entered into an agreement with Watson, who never met Meyer’s child, but obtained the child’s records by using an authorization stating that Meyer was requesting the records “[f]or the purpose of providing psychological services and for no other purpose whatsoever….” Watson searched the records for “off‐label” prescriptions written for a purpose that has not been approved by the FDA. Off‐label use is common, but generally not paid for by Medicaid. In the child’s records, Watson identified 49 prescriptions that he alleged constituted false claims to the U.S. government. The district court rejected Watson’s suit under the qui tam provision of the False Claims Act, 31 U.S.C.3729(a)(1)(A), reasoning that expert testimony was necessary to prove essential elements of the case and Watson had not named experts. While characterizing Watson’s tactics as “borderline fraudulent,” the Seventh Circuit reversed, citing the district court’s “overly rigid” view of the causation and knowledge elements of the claim. View "Watson v. King-Vassel" on Justia Law