Justia Public Benefits Opinion Summaries

Vazquez-Claudio is a Vietnam veteran. Following his service, Vazquez-Claudio filed a claim with the VA seeking disability compensation for post-traumatic stress disorder. In 2005, after finding that his PTSD was service- connected, the VA granted his request for benefits with an effective date in June, 1994. The VA rated Mr. Vazquez-Claudio’s PTSD as 50 percent disabling, Vazquez-Claudio appealed, arguing entitlement to a 70 percent rating. He had been unable to work since 1994, when he left his job as a police officer as the result of an emotional breakdown following a prisoner’s suicide. The Board of Veterans’ Appeals found that other than occasional suicidal ideation, social isolation, and some difficulty adapting to stressful situations, none of his symptoms corresponded to impairment greater than 50 percent. The Veterans Court agreed, stating that “[t]he issue before the Board was not how many ‘areas’ Mr. Vazquez-Claudio has demonstrated deficiencies in but, rather, ‘the frequency, severity, and duration of the psychiatric symptoms, the length of remissions, and Mr. Vazquez-Claudio’s capacity for adjustment during periods of remission.’” The Federal Circuit affirmed. View "Vazquez-Claudio v. Shinseki" on Justia Law

This dispute arose from California's implementation of a change to Medicare in 2006. The Centers argued that California mishandled the shift in payment responsibility for dual-eligibles' prescription drug costs from state Medicaid programs to the new, federal Medicare Part D Program. The Centers brought suit for declaratory and injunctive relief. Among other things, the Centers urged the federal courts to declare unlawful California's "seizure" of the Centers' Medicare Part D funds, in excess of what would be owed under the per-visit rate for the Centers' expenses. The court concluded that the Eleventh Amendment barred the Centers' claims for retroactive monetary relief; the court affirmed the district court's dismissal of the Centers' claims to the extent that they sought money damages; however, the court reversed the district court and remanded to allow the district court to assess Ex parte Young's application to the Center's remaining claims. View "North East Medical Services v. CA Dept. of Health" on Justia Law

In 2008, Pepper, then 54 years old, applied for Supplemental Security Disability Insurance Benefits, alleging that she became unable to work in November 1998 as a result of numerous physical and mental impairments. The alleged onset date was later amended to October 2002, when Pepper last worked. Extensive medical records show that Pepper sought treatment for numerous health concerns over the years. At various times, Pepper has been assessed as having ongoing neck pain and limited range of motion in her neck, degenerative disc disease in her spine, left knee problems, migraine headaches, problems with her vision, diabetes, asthma, mitral valve prolapse, sciatica, dyslipidemia, hyperglycemia, hypertension, allergic rhinitis, obesity, plantar fasciitis in her left heel, caregiver stress, and depression. An ALJ denied the claim and the district court affirmed. The Seventh Circuit affirmed, rejecting arguments that the ALJ erred when addressing Pepper’s residual function capacity and that the ALJ’s credibility determination was inadequately supported and patently wrong. Substantial evidence supported denial of benefits. View "Pepper v. Astrue" on Justia Law

MedQuest is a diagnostic testing company that operates more than 90 testing facilities in 13 states. In 2006 a former MedQuest employee, brought a qui tam suit against MedQuest alleging violations of the False Claims Act. The United States intervened and obtained summary judgment ($11,110,662.71) that MedQuest used supervising physicians who had not been approved by the Medicare program and the local Medicare carrier to supervise the range of tests offered at the Nashville-area sites, and after acquiring one facility, MedQuest failed to properly re-register the facility to reflect the change in ownership and enroll the facility in the Medicare program, instead using the former owner’s payee ID number. The Sixth Circuit reversed, stating that the Medicare regulatory scheme (42 U.S.C. 1395x) does not support FCA liability for failure to comply with the supervising-physician regulations. MedQuest’s failure to satisfy enrollment regulations and its use of a billing number belonging to a physician’s practice it controlled do not trigger the hefty fines and penalties created by the FCA. View "United States v. MedQuest Assocs, Inc." on Justia Law

In 2004 the U.S. Department of Health and Human Services promulgated 42 C.F.R. § 412.106(b), concerning the amount that certain hospitals are entitled to receive as enhancements to their regular reimbursement payments from the Medicare program. In connection with the Medicare program, Congress created a statutory formula to identify hospitals that serve a disproportionate number of low-income patients and to calculate the increased payments due such hospitals. Metropolitan Hospital challenged the way that the Secretary of HHS interprets this statutory formula to exclude certain patients who are simultaneously eligible for benefits under both Medicare and Medicaid, claiming that exclusion of dual-eligible patients cost it more than $2.1 million in 2005. The district court ruled that the challenged HHS regulation was invalid as violating the statute that it purported to implement. The Sixth Circuit reversed, upholding HHS’s interpretation of 42 U.S.C. 1395. View "Metro. Hosp. v. U.S. Dept of Health & Human Servs." on Justia Law

The Medicaid statute’s anti-lien provision, 42 U. S. C. 1396p(a)(1), pre-empts state efforts to take any portion of a tort judgment or settlement not “designated as payments for medical care.” A North Carolina statute requires that up to one-third of damages recovered by a beneficiary for a tortious injury be paid to the state to reimburse it for payments made for medical treatment on account of the injury. E. M. A. suffered serious birth injuries that require her to receive 12 to 18 hours of skilled nursing care per day and that will prevent her from working or living independently. North Carolina’s Medicaid program pays part of the cost of her ongoing care. E. M. A. and her parents filed a medical malpractice suit against the physician who delivered her and the hospital where she was born and settled for $2.8 million, due to insurance policy limits. The settlement did not allocate money among medical and nonmedical claims. The state court placed one-third of the recovery into escrow pending a judicial determination of the amount owed by E. M. A. to the state. While that litigation was pending, the North Carolina Supreme Court held in another case that the irrebuttable statutory one-third presumption was a reasonable method for determining the amount due the state for medical expenses. The federal district court, in E.M.A.’s case, agreed. The Fourth Circuit vacated. The Supreme Court affirmed. The federal anti-lien provision pre-empts North Carolina’s irrebuttable statutory presumption that one-third of a tort recovery is attributable to medical expenses. North Carolina’s irrebuttable, one-size-fits-all statutory presumption is incompatible with the Medicaid Act’s clear mandate View "Wos v. E. M. A." on Justia Law

In 1979, Plaintiffs sued under 42 U.S.C. 1983, on behalf of present and future recipients, alleging that Tennessee’s Medicaid program violated federal requirements, 42 U.S.C. 1396, and the Due Process Clause. The decades that followed involved intervenors, consent orders, revisions, and creation of a subclass. In 1994, Tennessee converted to a managed care program, TennCare. In 1995, five class members filed motions alleging that TennCare was being administered inconsistent with a 1992 decree and federal law. In 2009, the district court awarded plaintiffs more than$2.57 million for fees and expenses leading up to a 2005 Revised Consent Decree. Plaintiffs had originally requested a lodestar amount of $3,313,458.00, but the court reduced the award by 20 percent on account of plaintiffs’ “limited” success relative to the breadth of defendants’ requests and the scope of the litigation. The court noted that there was “no dispute that Plaintiffs in this case are the prevailing party, and thus entitled to attorneys’ fees under 42 U.S.C. 1988.” The Sixth Circuit vacated parts of the award, noting that section 1988 “is not for the purpose of aiding lawyers and that the original petition for fees included requests for dry cleaning bills, mini blinds, and health insurance. View "Binta B. v. Gordon" on Justia Law

Tennessee participates in Medicaid through “TennCare,” Tenn. Code 71-5-102. The Medicaid Act requires that TennCare administer an Early and Periodic Screening, Diagnosis, and Treatment program for all enrollees under age 21, 42 U.S.C. 1396a(a)(43), 1396d(r) and must provide outreach to educate its enrollees about these services. In 1998 plaintiffs filed a putative class action under 42 U.S.C. 1983, alleging that TennCare had failed to fulfill these obligations. The district court entered a consent decree that explained in detail the requirements that TennCare had to meet to “achieve and maintain compliance” with the Medicaid Act, based on the assumption that the Act created rights enforceable under section 1983. Eight years later, the Sixth Circuit held that one part of the Medicaid Act was unenforceable under section 1983. Following a remand, the district court vacated paragraphs of the decree that were based on parts of the Act that are not privately enforceable. After a thorough review of TennCare’s efforts, the court then vacated the entire decree, finding that TennCare had fulfilled the terms of the decree’s sunset clause by reaching a screening percentage greater than 80% and by achieving current, substantial compliance with the rest of the decree. The Sixth Circuit affirmed. View "John B. v.Emkes" on Justia Law

Gayheart applied for Social Security disability insurance benefits in 2005 due to manifestations of anxiety, panic disorder, bipolar disorder, and depression. After an initial denial and three separate hearings, an administrative law judge (ALJ) found that the limitations caused by Gayheart’s impairments did not preclude him from performing a significant number of jobs available in the national economy and denied Gayheart’s application. Gayheart’s request for an administrative appeal was denied. The Report and Recommendation issued by the federal court’s assigned magistrate judge concluded that the ALJ’s decision was not supported by substantial evidence and that Gayheart should be awarded benefits. But the district court sustained the Commissioner’s objections and affirmed the ALJ’s decision. The Sixth Circuit reversed and remanded, holding that the ALJ failed to weigh the medical opinions according to 20 C.F.R. 404.1527. View "Gayheart v. Comm'r of Soc. Sec." on Justia Law

Plaintiffs, teaching hospitals, received Medicare payments to offset the costs associated with training "full-time equivalent" residents and intern physicians (FTEs). In 1997, Congress capped those payments in such a way that the number of FTEs the hospitals trained in 1996 would dictate the maximum reimbursement in all future years. Although the parties agreed that the 1996 data was not accurate, the Secretary believed that this predicate fact could not be corrected outside the three-year reopening window. The court held that the reopening regulation allowed for modification of predicate facts in closed years provided the change would only impact the total reimbursement determination in open years. Alternatively, the court agreed with the district court that the Secretary had acted arbitrarily in treating similarly situated parties differently. The court rejected the Secretary's claim that the Medicare Act, 42 U.S.C. 1395 et seq., would not allow the intermediary to change the 1996 GME resident count without changing the corresponding reimbursement amount, which all parties conceded would constitute a reopening of an "Intermediary determination." Accordingly, the court affirmed the judgment. View "Kaiser Foundation Hospitals v. Sebelius" on Justia Law