Justia Public Benefits Opinion Summaries

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

Kit Carson was born in May 1996, and received numerous vaccinations during his first year of life. At his 18-month and 24-month check-ups, Kit’s pediatricians noted that his speech was delayed. Following his three-year check-up, Kit was referred for evaluation and diagnosed with autism spectrum disorder in 2001. His parents sought compensation under the National Childhood Vaccine Injury Act, 42 U.S.C. 300aa, in 2002. A Special Master concluded that the first symptoms of Kit’s disorder were recorded in May 1999 and that the claim was not filed within the 36-month limitations period. The Federal Circuit affirmed, rejecting an argument that speech delay cannot be a “first symptom” because it is an insufficient basis for a diagnosis of autism. View "Carson v. Sec'y, Health & Human Servs." on Justia Law

Zizic is the former CEO of BioniCare, which sold the BIO-1000, a medical device designed to treat osteoarthritis of the knee. BioniCare attempted to bill Medicare for the BIO-1000, but many claims were denied as not medically necessary. Q2A contracted with the government to review such claim denials across the nation. Q2A’s denials were reached without physician review, which is required by the Medicare Act, 42 U.S.C. 1395, HHS regulations, and its contract. A former Q2A employee testified that it implemented an internal policy to deny all BIO-1000 claims, which were reviewed by a single nurse rather than a panel of physicians; later allowed non-physician subcontractors to prepare BIO-1000 appeals for review by a single physician; and finally developed a mail merge letter that automatically denied BIO-1000 claims without any review. BioniCare’s trustee in bankruptcy became aware of and disclosed these practices. Zizic filed a qui tam suit under the False Claims Act, 31 U.S.C. 3729-33. The district court dismissed, concluding that it lacked jurisdiction because the allegations against Q2A and RTS were based on prior public disclosures and because Zizic was not an original source of that information. The Third Circuit affirmed. View "Zizic v. Q2Adm'rs LLC" on Justia Law

Middleton served on active duty from 1964 until 1990. He first sought compensation for type II diabetes mellitus in 2001. In 2002, a VA Regional Office granted service connection, assigning a disability rating of 20 percent under 38 C.F.R. 4.119. In 2009 Middleton was denied an increased rating after a VA physical examination. During his appeal, Middleton was treated with three oral hypoglycemic agents and daily injections of the drug Byetta®. In 2010, the Board of Veterans’ Appeals again denied a rating increase despite Middleton’s assertions that his diet was restricted, his activities were regulated, and he used an oral hypoglycemic agent, based on the fact that he did n not use insulin to regulate his diabetes. The Board stated that use of insulin is a necessary element for the 40-percent rating. The Veterans Court affirmed the denial. The Federal Circuit affirmed, stating it lacked jurisdiction to review the Veterans Court’s application of the regulations to the facts and that the Veterans Court did not err in interpreting the governing regulations View "Middleton v. Shinseki" on Justia Law

After leaving coal mining, Eckman sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901, in 1985. An ALJ awarded benefits in 1993; the Benefits Review Board affirmed the decision. Marmon paid benefits to Eckman until his 2002 death; his widow, Ethel, sought benefits as a dependent survivor. An ALJ denied the claim in 2005, finding that although Eckman had pneumoconiosis, Ethel failed to prove that his death was due to the disease. The Board affirmed. After Congress enacted the 2010 Patient Protection and Affordable Care Act, 124 Stat. 119, and amended the BLBA, Ethel filed a new claim. A Department of Labor district director awarded benefits. An ALJ upheld the award, finding that Ethel satisfied the familial relationship and dependency criteria for survivors under the BLBA and that, based on Eckman’s lifetime disability award and the filing date of Ethel’s claim, Ethel was entitled to benefits under section 932(l), as amended by the ACA. The Board affirmed. The Third Circuit denied the coal company’s petition for review, noting that in Ethel’s second claim, the cause of death was not at issue, her entitlement to benefits turned primarily on an administrative fact: whether her husband had been awarded benefits. View "Marmon Coal Co. v. Dir. Office of Workers Comp. Programs, U.S. Dep't of Labor" on Justia Law