Justia Public Benefits Opinion Summaries

Bontrager filed a putative class action complaint challenging Indiana’s $1,000 annual limit for dental services covered by Medicaid, 42 U.S.C. 1396. The district court granted a preliminary injunction, holding that Indiana is required to cover all medically necessary dental services, irrespective of the monetary cap. The Seventh Circuit affirmed. Bontrager has an enforceable federal right capable of redress through Section 1983. The monetary cap, which excludes medically necessary treatment, is not a utilization control procedure, but allows a state to shirk its primary obligation to cover medically necessary treatments. The court acknowledged that Bontrager’s victory may be short-lived if the state decides to end coverage for all dental services. View "Bontrager v. IN Family & Soc. Servs." on Justia Law

Until 2003, Hagans worked as a security guard and as a sanitation worker. At 44 years old, Hagans required open-heart surgery. Hagans claims additional medical problems relating to his cerebrovascular and respiratory systems, hypertension and dysphagia, insomnia, and back pain. He has been diagnosed with depression. Hagans began receiving disability benefits as of January 30, 2003. In September, 2004, pursuant to an updated Residual Function Capacity assessment showing his condition had improved, SSA determined that Hagans was no longer eligible for benefits. The ALJ considered several evaluations of Hagans’s condition, most of which were completed in mid-2004, and found that he was capable of engaging in substantial gainful activity, although he could not perform his past relevant work. The Appeals Council denied review; the district court affirmed. The Third Circuit affirmed, after determining that “relatively high” deference should be afforded to SSA’s Acquiescence Ruling interpreting the cessation provision of 42 U.S.C. 423(f) as referring to the time of the SSA’s initial disability determination. SSA correctly evaluated Hagans’s condition as of the date on which the agency first found that Hagans’s eligibility for disability benefits ceased. Substantial evidence supported the conclusion that Hagans was not fully disabled as of that date. View "Hagans v. Comm'r of Soc. Sec." on Justia Law

TriCenturion audited Nichole Medical as a Program Safeguard Contractor under the Medicare Integrity Program, 42 U.S.C. 395ddd(a), and concluded that Nichole “might” be improperly billing for medical equipment; that Nichole had received overpayments; and that it had not maintained sufficient medical records to establish reasonableness or medical necessity. TriCenturion directed Nichole’s carrier, HealthNow, to withhold payments. TriCenturion calculated the actual overpayment of several specific claims, used those as a representative sampling, and extrapolated an overpayment amount for all relevant claims. The Attorney General found no evidence of fraud and refused to prosecute; HealthNow stopped withholding payments. TriCenturion instructed HealthNow’s successor to re-institute the offset. Nichole went out of business, but pursued an appeal. An ALJ determined that Nichole was entitled to reimbursement on some, but not all, appealed claims and found that the process for arriving at the extrapolated overpayment was flawed. The Medicare Appeals Council found that all 39 claims had been reopened and reviewed improperly. The district court dismissed Nichole’s suit against TriCenturion, which alleged torts and breach of the statutory duty of care under 42 U.S.C. 1320c-6(b). The Third Circuit affirmed. Defendants are immune from suit as officers or employees of the Secretary of the Department of Health and Human Services. View "Nichole Medical Equip & Supply, Inc. v. Tricenturion, Inc." on Justia Law

Adams worked in coal mines for 17 years, leaving A & E Coal in 1988, after 12 years, because he was having difficulty breathing. He has not worked since. Adams also smoked cigarettes for about 25 years, averaging a pack a day before quitting in 1998 or 1999. Adams filed his first claim for benefits under the Black Lung Benefits Act 30 U.S.C. 901 in 1988. His claim was denied: He did not prove that his pneumoconiosis was caused in part by his coal-mine work, or that his pneumoconiosis totally disabled him. In 2007, Adams filed a second claim. Two pulmonologists agreed that he was completely disabled, but disagreed on what lung diseases Adams had, and on what caused them. An Administrative Law Judge awarded benefits, finding that Adams had pneumoconiosis, that the disease was caused by Adams’s exposure to coal dust during his coal-mine employment, and that he was totally disabled because of the disease. The Benefits Review Board and the Third Circuit affirmed. Although the ALJ was not required to look at the preamble to the regulations to assess the doctors’ credibility, he was entitled to do so. View "A & E Coal Co. v. Adams" on Justia Law

Ulman filed her claim for benefits in 2006, alleging that her disability began in 2002. As found by the ALJ, her insured status expired on December 31, 2003. To be eligible for benefits, her disability must have begun on or before that date and continued until she filed her application for benefits. 42 U.S.C. 423(a)(1). Claimant was 47 at the time her insured status expired. She had worked as a waitress, park ranger, and home health aide. In rejecting her claim, the ALJ confused the dates of December 3, 2001 when she fell backwards off a ladder, with the 2006 date of the application, and made an adverse credibility determination. The ALJ recognized that she suffered from physical limitations that prevented her from performing her past work, but found that she could perform other jobs (cashier, parking lot attendant, ticket taker) that existed in the national economy. The Appeals Council and district court affirmed. The Sixth Circuit affirmed, applying harmless error analysis to the credibility determination. With the exception of confusion about the date, the ALJ’s decision carefully parsed the medical records and accorded them fair weight; those records support a finding of no disability.View "Ulman v. Comm'r of Soc. Sec." on Justia Law

Semrau, a Ph.D. in clinical psychology, owned companies that provided psychiatric care to nursing home patients in Tennessee and Mississippi, using contracting psychiatrists who submitted records describing their work. The companies then billed the services to Medicare or Medicaid through private insurance carriers. Services are categorized into five-digit Current Procedural Terminology Codes, published by the American Medical Association. The Centers for Medicare and Medicaid Services sets reimbursement levels for each code as well as “relative value units” corresponding to the amount of work typically required for each service. After audits indicated that the companies had been billing at a higher rate than could be justified by the services actually performed, “upcoding,” Semrau was convicted of healthcare fraud, 18 U.S.C. 1347, and was sentenced to 18 months of imprisonment and ordered to pay $245,435 in restitution. The Sixth Circuit affirmed, rejecting Semrau’s claim that results from a functional magnetic resonance imaging lie detection test should have been admitted to prove the veracity of his denials of wrongdoing. There was ample evidence that Semrau was aware of accepted definitions of the CPT codes; he expressly agreed not to “submit claims with deliberate ignorance or reckless disregard of their truth or falsity.” View "United States v. Semrau" on Justia Law

Filus, a 50-year-old former truck driver, has twice applied for disability benefits under the Social Security Act, claiming that back problems have left him incapable of gainful employment. An administrative law judge concluded that Filus could perform some light work and denied his most recent application. The Seventh Circuit affirmed, holding that substantial evidence supports the denial. The ALJ adequately considered Filus’s testimony about the limiting effects of his pain along with his testimony that he regularly completed his daily household activities without any pain medication, not even over-the-counter products.View "Filus v. Astrue" on Justia Law

Claiming anxiety, depression, suicidal tendencies, insomnia, vertigo, migraine headaches, fibromyalgia, carpal tunnel syndrome, and plantar fasciitis, Farrell, then 33 year old, applied for disability insurance benefits. Her initial application was denied, but the Social Security Administration Appeals Council remanded. The Administrative Law Judge again ruled against her, in part because of her failure to establish definitively that she suffered from fibromyalgia. The Appeals Council summarily affirmed this decision, despite new evidence before it that confirmed the fibromyalgia. The district court affirmed. The Seventh Circuit reversed. The Social Security Administration’s regulations require the Appeals Council to consider “new and material evidence.” The ALJ did not adequately deal with competing expert opinions. View "Farrell v. Astrue" on Justia Law

This appeal concerned the implementation of a federally-assisted Medicaid program by the Commonwealth of Puerto Rico, represented by its Secretary of Health. This was the sixth time the First Circuit Court of Appeals considered issues related to a dispute between the Commonwealth and several federally qualified health centers (FQHCs). The FQHCs here took to federal courts their claims for reimbursement payments owed to them under the Medicaid program. The district court, among other things, set a formula in place by way of a preliminary injunction that calculated payments the Commonwealth owed the FQHCs for providing Medicaid services. The First Circuit (1) concluded the formula that the district court endorsed in its preliminary injunction was not sufficiently supported by the factual record, and therefore, the Court remanded for further reformulation; (2) affirmed the district court's denial of the FQHCs' request for indemnification from debts owed to third party managed care organizations; and (3) affirmed the district court's determination that the Eleventh Amendment precludes a federal court from imposing a judgment for money damages upon the Commonwealth to make payments for periods predating the date of the district court's preliminary injunction. View "Consejo de Salud De La Communidad de Playa de Ponce, Inc. v. Gonzalez-Feliciano" on Justia Law

Cage, born in 1960, has an extensive medical history. She offered evidence of: bipolar disorder, depression, suicidal ideation, dizziness, blackouts, memory loss and chest pain. She has not worked since November 2003. Before then, she had worked as a retail cashier, hotel maid and home healthcare aide. Cage also has a long history of drug and alcohol abuse. Her ongoing medical care has included treatment for drug addiction and alcoholism and her other conditions. An Administrative Law Judge of the Social Security Administration denied Cage’s application for Supplemental Security Income benefits, finding that although Cage met certain requirements for being “disabled” under the Social Security Act, 42 U.S.C. 301, she was ineligible for SSI because drug addiction or alcoholism was a contributing factor material to that determination. The district court affirmed. The Second Circuit affirmed. The ALJ properly imposed upon Cage the burden of proving that she would be disabled in the absence of drug addiction and alcoholism and the record supported the ALJ’s finding that she would not be disabled absent drug addiction and alcoholism. View "Cage v. Comm'r of Soc. Sec." on Justia Law