Justia Public Benefits Opinion Summaries

Husband worked as a miner from 1970 to 1987. In 2000, he was found to be totally disabled by coal workers' pneumoconiosis and was awarded benefits under the Black Lung Benefits Act, 30 U.S.C. 901. He died in 2005. His widow sought survivor’s benefits. At the time, she was required to prove that pneumoconiosis caused, contributed to, or hastened husband's death. An ALJ denied the claim. The Board vacated. On remand, the ALJ again denied benefits. While appeal was pending, Congress amended the Act, retroactively applicable to claims filed after January 1, 2005. The Board reversed and remanded for an order awarding survivor's benefits, holding that section 932(l), as amended, entitled the widow to benefits because husband was receiving black lung benefits at the time of his death and her claim was filed after January 1, 2005. The First Circuit denied the company's petition for review. Under the amendment, the widow is entitled to benefits without having to file a new claim or otherwise revalidate husband's claim because she filed her claim after January 1, 2005. The company's claim that she failed to establish the cause of death is irrelevant. Section 932(l) as amended does not violate the Due Process Clause or Takings Clause. View "B&G Constr. Co Inc. v. Dir., Office of Workers Comp. Programs" on Justia Law

In a 2008 administrative appeal, the Secretary of Health and Human Services ruled that a Medicare beneficiary enrolled in Medicare Part C still qualified as a person "entitled to benefits" under Medicare Part A. As a result, Beverly Hospital received a smaller reimbursement from the Secretary for services it provided to low-income Medicare beneficiaries during fiscal years 1999-2002. The district court granted summary judgment for Beverly Hospital on the ground that the Secretary's interpretation violated the plain language of the Medicare statute. The court held that the statute did not unambiguously foreclose the Secretary's intepretation. The court, nonetheless, affirmed the district court on the alternative ground that the Secretary must be held to the interpretation that guided her approach to reimbursement calculations during fiscal years 1999-2002, an interpretation that differed from the view she now advanced. Under her previous approach, the hospital would have prevailed on its claim for a larger reimbursement.

Patient, insured by defendant, diagnosed with end-stage renal disease, and received dialysis at plaintiff's center. Three months after diagnosis, she became entitled to Medicare benefits (42 U.S.C. 426-1). Her plan provided that coverage ceased at that time, because of her entitlement to Medicare, but the insurer continued to pay for two months. Under the 1980 Medicare Secondary Payer Act, a group health plan may not take into account that an individual is entitled to Medicare benefits due to end-stage renal disease during the first 30 months (42 U.S.C. 1395y(b)(1)(C)(i)), but the insurer terminated coverage. Plaintiff continued to treat and bill. The insurer declared that termination was retroactive and attempted to offset "overpayment" against amounts due on other patients' accounts. The outstanding balance after patient's death was $210,000. Medicare paid less than would have been received from the insurer. The center brought an ERISA claim, 29 U.S.C. 1132(a)(1)(B), and a claim for double damages under the 1980 Act. The district court granted plaintiff summary judgment on its ERISA claim but dismissed the other. The Sixth Circuit affirmed on the ERISA claim and reversed dismissal. A healthcare provider need not previously "demonstrate" a private insurer's responsibility to pay before bringing a lawsuit under the 1980 Act's private cause of action.

A 66-year -old arrived at petitioner's center with complex ailments, but oriented, able to feed herself and able to speak. During her 18 days at the center, she was sent to the hospital twice with serious medical complications. Upon investigation, the center was found to have failed to maintain substantial compliance with federal regulations for facilities that participate in Medicare and Medicaid (42 U.S.C. § 1395) in its treatment of the resident and appealed the resulting civil money penalty. An administrative law judge, the Departmental Appeals Board, and the Sixth Circuit affirmed. The ALJ acted properly in requiring submission of written testimony, properly weighed the evidence, and found violation of the federal hydration standard, laboratory services requirement, and mandate of a care plan, resulting in "immediate jeopardy."

Plaintiffs, a class of economically vulnerable Arizonians who receive public health care benefits through the state's Medicaid agency, sued the U.S. Secretary of Health and Human Services (Secretary) and the Director of Arizona's medicaid agency (director)(collectively, defendants), alleging that the heightened mandatory co-payments violated Medicaid Act, 42 U.S.C. 1396a, cost sharing restrictions, that the waiver exceeded the Secretary's authority, and that the notices they received about the change in their health coverage was statutorily and constitutionally inadequate. The court affirmed the district court's conclusion that Medicaid cost sharing restrictions did not apply to plaintiffs and that Arizona's cost sharing did not violate the human participants statute. The court reversed the district court insofar as it determined that the Secretary's approval of Arizona's cost sharing satisfied the requirements of 42 U.S.C. 1315. The court remanded this claim with directions to vacate the Secretary's decision and remanded to the Secretary for further consideration. Finally, the court remanded plaintiffs' notice claims for further consideration in light of intervening events.

Doctors filed suit, alleging violations of the False Claims Act, 31 U.S.C. 3279 and the Michigan Medicaid False Claim Act, as qui tam relators on behalf of the United States/ The claimed that the business defrauded the government by submitting Medicare and Medicaid billings for defective radiology studies, and that the billings were also fraudulent because the business was an invalid corporation. The federal government declined to intervene. The district court dismissed. Sixth Circuit affirmed. The doctors failed to identify any specific fraudulent claim submitted to the government, as is required to plead an FCA violation with the particularity mandated by the FRCP. A relator cannot merely allege that a defendant violated a standard (in this case, with respect to radiology studies), but must allege that compliance with the standard was required to obtain payment. The doctors had no personal knowledge that claims for nondiagnostic tests were presented to the government, nor do they allege facts that strongly support an inference that such billings were submitted.

The Medicare program pays teaching hospitals to cover "direct" and "indirect costs of medical education," 42 U.S.C. 1395ww(d)(5)(B), (h). Direct costs include expenses such as residents' salaries. Indirect costs are incurred due to "general inefficiencies" and "extra demands placed on other staff." Congress created a formula for calculating indirect expenses based on full-time equivalency interns; an HHS regulation referred to time residents spend in the "portion of the hospital subject to the prospective payment system or in the outpatient department of the hospital." In reimbursing plaintiff, HHS excluded from the FTE count time residents spent on pure research, unrelated to treatment of a patient. While appeal of a decision favoring the hospital was pending, Congress enacted the Patient Protection and Affordable Care Act, 124 Stat. 119, 660–61. For the years at issue, HHS must include in FTE: "all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary." HHS promulgated a regulation specifying that eligible non-patient care activities do not include time residents spend conducting pure research. The Sixth Circuit upheld the regulation as within the Secretary's authority and applicable to the years at issue.

Based on her part in billing Indiana Medicaid for ambulance service while running a car service to take patients to medical appointments, defendant was convicted of Medicaid fraud, 18 U.S.C. 1347, and conspiracy to defraud the U.S. government, 18 U.S.C. 371. She was sentenced to 33 months in prison and to pay restitution of $846,115. The Seventh Circuit affirmed. Data relating to time-stamping of bills, which may have established that multiple people submitted bills, was not concealed; the government simply failed to extract (before trial) information to which it and the defense had access. Even if the data was "Brady" material, it would not have changed the outcome. The judge did not err in telling the jury that a scheduled witness was ill without saying that the witness had refused treatment.

Plaintiff (relator) filed a qui tam complaint under the False Claims Act (FCA), 31 U.S.C. 3730, against defendants, alleging that they participated in a fraudulent scheme where the durable medical equipment (DME) supplier allowed the nursing home to keep a portion of the reimbursement from Medicare in return for a guarantee that the nursing home would buy all of its DME from that supplier. The district court subsequently dismissed relator's action on the ground that it violated the public disclosure provisions of the FCA. Relator appealed, arguing that this suit was not based on public disclosures and that he was an original source of the information on which his suit was based. The court held that because relator's action included no allegations specific to defendants, but merely repeated a general description of fraud easily available in several government documents, the court affirmed the judgment of the district court.

In 2006 the claimant sought disability benefits, alleging injury in a construction accident. An ALJ denied the claim and the appeals council denied review. The district court upheld the denial. The Sixth Circuit vacated. The ALJ's decision was incomplete and improperly gave greatest weight to the opinion of a non-treating state agency physician, rather than to the opinion of a treating physician. The ALJ mischaracterized the treating physician's treatment notes.