Justia Public Benefits Opinion Summaries

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

Jewish Home of Eastern Pennsylvania (JHEP) provides nursing care to Medicare beneficiaries and is required to comply with the mandatory health and safety requirements for participation. JHEP must submit to random surveys conducted by state departments of health. In 2005, the Pennsylvania Department of Health conducted a survey that concluded that JHEP had eight regulatory deficiencies, including violations of 42 C.F.R. 483.25(h)(2), which requires a facility to ensure that each resident receives adequate supervision and assistance with devices to prevent accidents. Based on those deficiencies and those found in a 2006 survey, the Center for Medicare and Medicaid Services imposed fines totaling $17,150 and $12,800. JHEP claimed that the allegations of noncompliance were based on the inadmissible disclosure of privileged‖ quality assurance records and that the monetary penalties violated its right to equal protection because they were the product of selective enforcement based on race and religion. An ALJ upheld the fines against JHEP. The Third Circuit denied a petition for review. View "Jewish Home of E. PA v. Centers for Medicare and Medicaid Servs." on Justia Law

Applicants for and recipients of Medicaid home health Services claimed that the New York State Office of Temporary and Disability Assistance and the New York State Department of Health, violated their statutory right, enforceable under 42 U.S.C.1983, to an opportunity for Medicaid fair hearings. They claimed that this right, as construed by federal regulation, entitles them to “final administrative action” within 90 days of their fair hearing requests. The district court declared that “final administrative action” includes the holding of Medicaid fair hearings, the issuance of fair hearing decisions, and the implementation of any relief ordered in those decisions and permanently enjoined the state agencies to ensure that “final administrative action” implemented within 90 days of fair hearing requests. The Second Circuit affirmed in part, holding that the plaintiffs have a right to a Medicaid hearing and decision ordinarily within 90 days of their fair hearing requests, and that such right is enforceable under section 1983. The permanent injunction was, however, overbroad because “final administrative action” refers not to the implementation of relief ordered in fair hearing decisions, but to the holding of fair hearings and to the issuance of fair hearing decisions. View "Shakhnes v. Eggleston" on Justia Law

Griglock, a 70-year-old retired woman, received an influenza vaccination in 2005. Weeks later, she went to her doctor, complaining of weakness, and was admitted to the hospital. Her treating neurologist determined that she suffered from Guillain-Barré Syndrome. She improved initially, but soon developed respiratory failure and was placed on a ventilator. She died about 18 months later; her death certificate lists “ventilator-dependent respiratory failure due to GBS” as the immediate cause of death. Her estate filed a petition for compensation under the Vaccine Injury Compensation Program, 42 U.S.C. 300aa-1, 300aa-10(a). The government responded that there was insufficient evidence to find that the influenza vaccine caused her GBS and death, but that it would not contest the issue and recommended an award of up to $250,000. The estate then sought unreimbursable medical expenses and compensation for pain and suffering. The Special Master determined that Griglock’s death was caused by an influenza vaccination, that her estate had standing, but that entitlement was limited to death benefits because injury benefits were barred by the statute of limitations. The Court of Federal Claims affirmed. The Federal Circuit affirmed. View "Griglock v. Sec'y of Health & Human Servs." on Justia Law

Watson’s father, Hickle, worked for the Department of Energy, 1954 to 1962. Hickle died of Hodgkin’s disease in 1964. Congress enacted the Energy Employees Occupational Illness Compensation Program Act in 2000 to compensate for illnesses caused by exposure to radiation and other toxic substances while working for the Department of Energy. Covered employees or eligible survivors may receive compensation in a lump sum payment; under specific circumstances, a covered employee’s child is also eligible, 42 U.S.C. 7385s-3(d)(2). When her father died, Watson was 19 years old, not a full-time student; she lived with her parents, worked as a waitress, relied on her parents for support, and was listed as a dependent on their income tax returns. She sought survivor benefits in 2002 and received a lump-sum payment of $150,000. She later claimed further compensation as a “covered child,” under a different section of the Act, arguing that she was “incapable of self-support” at the time of Hickle’s death. The Department of Labor denied her claim. Before the district court, Watson challenged the interpretation of “incapable of self-support,” claiming that the Department impermissibly required a showing of physical or mental incapability. The district court denied her motion for summary judgment. The Sixth Circuit affirmed. View "Watson v. Solis" on Justia Law

Banks worked as a coal miner for 17 years and smoked about one pack of cigarettes per day for 38 years. His employment ended in 1991. After two unsuccessful attempts, in 2003, Banks filed a claim for benefits under the Black Lung Benefits Act, which provides benefits to coal miners who become disabled due to pneumoconiosis, 30 U.S.C. 901. An ALJ found that Banks had shown a change in his condition and that he suffered from legal pneumoconiosis which substantially contributed to his total disability. Banks was awarded benefits and the Benefits Review Board affirmed. The Sixth Circuit affirmed, adopting the regulatory interpretation urged by the Director of the Office of Workers’ Compensation Programs. The ALJ relied on reasoned medical opinions. View "Cumberland River Coal Co. v. Banks" on Justia Law