Justia Public Benefits Opinion Summaries

In 1995, two non-profit hospitals consolidated to form Pinnacle. Pinnacle subsequently submitted a Medicare reimbursement claim for the losses the hospitals had incurred through the sale of their depreciable assets in the consolidation. The Administrator denied Pinnacle's claim, and that order became the final decision of the Secretary. On Pinnacle's Administrative Procedure Act (APA), 42 U.S.C. 12101 et seq., challenge, the district court upheld the Secretary's decision in full. Because the Secretary's interpretation of the relevant Medicare regulations was not plainly erroneous or inconsistent with the regulation, the court concluded that the Secretary reasonably applied the bona fide sale requirement to a reimbursement request from a participant in a "statutory merger." The court also held that the Secretary's finding that the bona fide sale requirement applied to consolidations involving non-profit Medicare providers, like Pinnacle, was not plainly erroneous or inconsistent with the regulation. Finally, substantial evidence supported the Secretary's finding that Pinnacle did not satisfy the bona fide sale requirement. Accordingly, the court affirmed the district court's judgment. View "Pinnacle Health Hospitals v. Sebelius" on Justia Law

Suppliers appealed the district court's dismissal of their action against the Secretary of the Department of Health and Human Services and the Administrator of the Centers for Medicare and Medicaid Services (CMS). Suppliers challenged a regulation addressing the "applicable financial standards" that a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) supplier must meet to be eligible for a Medicare contract under the competitive process established in 42 U.S.C. 1395w-3 (DMEPOS Statute). The court affirmed the district court's dismissal on the ground that section 1395w-3(11) precluded judicial review of the Secretary's financial standards regulation and that the district court therefore lacked subject matter jurisdiction. View "Texas Alliance For Home Care, et al. v. Sebelius, et al." on Justia Law

Medicare pays teaching hospitals for work by residents when a teaching physician supervises. During the 1990s, HHS concluded that many hospitals were billing for unsupervised services and began to audit invoices. There was also a GAO report and private litigation: qui tam suits under the False Claims Act, allowing relators to collect a bounty. Under 31 U.S.C. 3730(e)(4)(A), suits cannot be based upon public disclosure of allegations or transactions in public agencies’ official reports unless the relator is an original source of information. A prior case concluded that the 1998 GAO report and similar public documents disclosed that billing for unsupervised work was common practice. The district court dismissed a suit filed against a teaching hospital in 2004, claiming to describe conduct, such as inadequate supervision, not previously disclosed. The Seventh Circuit vacated. No one who read the GAO report, or followed the progress of the audits, would suspect that Rush University was misrepresenting "immediate availability" of teaching physicians during concurrently scheduled procedures. The complaint alleged a kind of deceit that the GAO report does not attribute to any teaching hospital. View "Goldberg v. Rush Univ. Med. Ctr." on Justia Law

Plaintiff brought this qui tam suit alleging that the District of Columbia and its schools violated the False Claims Act (FCA), 31 U.S.C. 3729-3733, by submitting a Medicaid reimbursement claim without maintaining adequate supporting documents. The district court dismissed the case, relying on the court's precedent in United States ex rel. Findley v. FPC-Boron Employees' Club. Because the court concluded that the Supreme Court had implicitly overruled Findley in Rockwell International Corp. v. United States, the court reversed. View "Davis v. DC" on Justia Law

States both appealed the district court's grants of summary judgment in favor of HHS, which upheld HHS's disallowance of certain Medicaid claims for Federal Financial Participation (FFP) as ineligible for "medical assistance" under the "Institution for Mental Diseases" (IMD) exclusion set forth in section 1905(a) of 42 U.S.C. 1396 et seq. (Medicaid Statute). Because HHS correctly concluded that the disputed claims were not eligible for FFP under the plain language of the IMD exclusion and the under-21 exception, the court affirmed the judgment of the district court. View "Virginia Dept. of Medical Assist. Svcs. v. HHS, et al." on Justia Law

Plaintiff, the Chapter 7 trustee for the bankruptcy estate of BioniCare Medical Technologies, contested determinations of the Medicare Appeals Council (MAC) refusing to provide coverage for the BIO-1000, a device to treat osteoarthritis of the knee. Plaintiff alleged that the Secretary improperly used the adjudicative process to create a policy of denying coverage for the BIO-1000, that the MAC's decisions were not supported by substantial evidence, and that the MAC's decisions were arbitrary and capricious on account of a variety of procedural errors. The court rejected those contentions and affirmed the judgment of the district court. View "Almy v. Sebelius" on Justia Law

Plaintiffs sought compensation under the National Vaccine Injury Compensation Program, 42 U.S.C. 300aa, for injuries to their children allegedly caused by the Diptheria-Tetanus-acellular Pertussis vaccine. The children suffer a seizure disorder, known as Severe Myoclonic Epilepsy of Infancy. The same special master presided over both cases and determined that plaintiffs failed to show entitlement to compensation because evidence showed that a gene mutation present in both children was the sole cause of their injuries. The Court of Federal Claims affirmed. The Federal Circuit affirmed, noting considerable evidentiary support for the conclusion. View "Stone v. Sec'y of Health & Human Servs." on Justia Law

Petitioner, then 45 years old and having previously worked in a factory and as a health aid, applied for disability benefits in 2004, claiming an onset date in 2004. Her conditions include peripheral vascular disease, chronic obstructive pulmonary disease, osteoarthritis, obesity, vascular dementia, depression, panic disorder, and anxiety. The Social Security Appeals Council denied review of the ALJ's adverse decision. The Seventh Circuit reversed and remanded. The ALJ failed to adequately consider petitioner's mental impairments, her obesity, and several of her physical problems. View "Arnett v. Astrue" on Justia Law

This appeal arose from the district court's order granting final judgment to the United States upon equitable claims of payment by mistake of fact and unjust enrichment against Tuomey arising out of alleged violations of the Social Security Act, 42 U.S.C. 1395nn, (the Stark Law), and awarding damages plus pre- and post-judgment interest. Because the court concluded that the district court's judgment violated Tuomey's Seventh Amendment right to a jury trial, the court vacated the judgment and remanded for further proceedings. Because the court was remanding the case, the court also addressed other issues raised on appeal that were likely to recur upon retrial. View "Drakeford v. Tuomey Healthcare System" on Justia Law

Plaintiff first sought treatment in 1988, at age 27, experiencing double vision, eye strain, and facial numbness, and was diagnosed with abducens nerve palsy of the left eye. He continued to work as a welder until 2004, when symptoms forced him to sell his business. In 2007, he applied for disability insurance benefits, alleging onset in 2004. In 2010 an ALJ rejected the claim, concluding that plaintiff; she noted plaintiff’s complaints of headaches, but concluded that they must be non-severe. The district court upheld the denial. The Seventh Circuit remanded to the Social Security Administration, holding that the ALJ’s credibility determination was not supported by substantial evidence. View "Shauger v. Astrue" on Justia Law