Justia Public Benefits Opinion Summaries

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

Health and Hospital Corporation of Marion County, Indiana is a municipal corporation that operates a major hospital and other facilities, including a health center operated in partnership with Citizens Health to serve the medically under-served population in Indianapolis. The health center was funded in part by a Section 330 Grant, awarded by the federal Health Resources and Services Administration, which is part of the Department of Health and Human Services. Section 330 grants fund qualifying health centers that provide primary health care services to medically under-served populations, 42 U.S.C. 254b. A In 2012, Health and Hospital decided to terminate the partnership with Citizens and relinquish the federal grant, which still had several years of funding remaining. Citizens sued Health and Hospital, HRS, and others in an effort to retain the grant funds. The district court granted defendants summary judgment, concluding that Citizens had no contractual, statutory, or constitutionally cognizable interest in the grant. The Seventh Circuit affirmed, finding that Health and Hospital was the grantee; Citizens had no constitutionally-protected entitlement to the grant; and the terms of the contract between Health and Hospital and Citizens clear; there was no obligation to renew. View "Citizens Health Corp. v. Sebelius" on Justia Law

Massie served on active duty in the Army, 1968-1970 and was awarded VA benefits for varicose veins and related surgery, initially at 10% and increased to 50%, disability effective in 1990. In, 2001, Massie sought an increased disability rating. He submitted a letter from a VA physician who had treated Massie for “multiple medical problems” including “chronic venous insufficiency” that had “persisted in spite of prior surgical treatment with vein stripping” and that left Massie with significant pain when he was on his feet for any period of time. The regional office increased Massie’s rating to 100%, as of the 2001 date of his filing. The Veterans Court determined that the physician’s letter, dated 1999, did not qualify as an informal claim that would entitle Massie to an earlier effective date for the 100% rating. The Federal Circuit affirmed that the letter was not a “report of examination” because it did not describe the results of a “specific, particular examination” and did not suggest that Massie’s condition had worsened. View "Massie v. Shinseki" on Justia Law

In 2011 Wisconsin reduced subsidies for the Wisconsin Care Program, which funds grants for organizations administering programs for disabled persons who live in group homes. The plaintiffs are developmentally disabled and suffered the largest cuts. Persons who had received smaller payments bore smaller cuts. For some (frail elderly) per capita payments increased. Plaintiffs claim that making larger absolute cuts for persons whose care is most expensive violated the Rehabilitation Act and the Americans with Disabilities Act and that reduction in payments increases the risk that they will be moved from group homes to institutions. The district judge noted that states have waived sovereign immunity with respect to the Rehabilitation Act, as a condition to receiving federal funds. The Supreme Court has held that the portions of the ADA that are not designed to implement disabled persons’ constitutional rights cannot be used to override states’ sovereign immunity. The district court concluded that the relevant provisions of the ADA do not concern the Constitution and that other claims were premature because no plaintiff has been moved to an institution. The Seventh Circuit affirmed, noting that without information about care provided to other disabled persons, there is no useful theory of discrimination. View "Amundson v. WI Dep't of Health Servs." on Justia Law

States participating in Medicaid in a managed care environment are required to make, at least every fourth month, supplemental “wraparound” payments to federally-qualified health centers (FQHCs) equal to the difference between a rate set by statute multiplied by the number of Medicaid patient encounters, and the amount paid to FQHCs by managed care organizations (MCOs) for all Medicaid-covered patient encounters, 42 U.S.C.1396. Concerned that gaps in FQHC claim verification led to overpayments, the New Jersey Department of Human Services changed its calculation: instead of basing wraparound payments solely on the number of Medicaid encounters and total MCO receipts as self-reported by FQHCs, the state would rely on data reported by MCOs absent receipt of certain additional data from the FQHCs. Because MCOs report only encounters that they have approved and paid, prior MCO payment would be a prerequisite to wraparound reimbursement under the new system. An association of FQHCs sued, claiming that the change violated their due process rights as well as state and federal law, resulting in budget shortfalls. The district court granted the association summary judgment and a preliminary injunction. The Third Circuit affirmed the holding that the requirement that wraparound payments be contingent on prior MCO payment violated the Medicaid statute’s requirement that FQHCs receive timely full wraparound payment for all Medicaid-eligible claims. View "NJ Primary Care Assoc. v. NJ Dep't of Human Servs." on Justia Law

The Clinics filed suit challenging California Welfare and Institutions Code 14131.10, which eliminated certain Medi-Cal benefits that the state deemed optional, including adult dental, podiatry, optometry, and chiropractic services. The court reversed the district court's holding that the Clinics have a private right of action to challenge the Department's implementation of the state plan amendments (SPA) prior to obtaining approval; affirmed that the Clinics have a private right of action to bring a claim pursuant to 42 U.S.C. 1983 challenging the validity of section 14131.10; and reversed the district court's interpretation of the Medicaid Act, 42 U.S.C. 1396 et seq., holding that section 14131.10 impermissibly eliminated mandatory services from coverage. View "California Ass'n of Rural Health Clinics v. Douglas" on Justia Law