Justia Public Benefits Opinion Summaries

This appeal involved a putative class action filed by three Pennsylvania Medicaid beneficiaries subject to the Pennsylvania Department of Public Welfare's (DPW) liens against future settlements or judgments. At issue was whether state agencies responsible for administering the Medicaid program have the authority to assert such liens and, if so, whether Pennsylvania's statutory framework was consistent with the Supreme Court's decision in Arkansas Department of Health and Human Services v. Ahlborn. The court examined the text, structure, history, and purpose of the Social Security Act, 42 U.S.C. 301 et seq., and held that liens limited to medical costs were not prohibited by the anti-lien and anti-recovery provisions of the Act, 42 U.S.C. 1396p(a)-(b). Accordingly, the court upheld Pennsylvania's longstanding practice of imposing such liens. The court also held that Pennsylvania's current statutory framework, which afforded Medicaid recipients a right of appeal from the default allocation, was a permissible default apportionment scheme.

This case stemmed from the discovery in an unrelated case that the Center for Medicare & Medicaid Services ("CMS") had paid hospitals less than they were due because it had miscalculated the disproportionate share hospital ("DSH") payment. Appellants, a group of hospitals that received DSH payments, filed claims with the Provider Reimbursement Review Board ("PRRB") seeking full payments for the fiscal years 1987-1994. At issue was whether the district court lacked jurisdiction in the matter and whether the Medicare statute, 42 U.S.C. 1395oo(a), allowed for equitable tolling. The court held that a decision by the PRRB denying jurisdiction was a final decision subject to judicial review by the district court. The court also held that, given the factors emphasized in United States v. Brockamp did not apply to the facts presented, and without any other reasons for rebutting the presumption of equitable tolling, the court found that equitable tolling was available under 1395oo(a). The court noted that whether tolling was appropriate in this particular case, however, was a different question for the district court to answer on remand. The court also rejected appellants' alternative arguments and therefore, reversed and remanded for further proceedings.

This case involved cost-saving tools that Congress had devised for Medicare payments to cancer hospitals and specifically concerned Medicare reimbursements paid to one cancer hospital, appellant, in 2000 and 2001. The first issue on appeal related to the cancer hospitals' inpatient costs where appellant requested an increase to its target amount in 2000 and 2001 due to the high cost of certain new cancer drugs and where the Department of Health and Human Services ("HHS") denied that request. Appellant argued that it did not receive proper notice of the new net financial impact requirement and thus did not have a fair opportunity to satisfy the requirement at the administrative hearing. The court agreed and held that appellant did not receive timely notice of the requirement and, on remand to HHS, must be given an opportunity to satisfy it. The second issued on appeal concerned cancer hospitals' outpatient costs where appellant contended that HHS misapplied the statutory formula that provided hospitals a fraction of their reasonable costs and undercompensated appellant. The court rejected appellant's arguments and affirmed summary judgment in favor of HHS.

Appellant, a medicare provider, appealed its notice of program reimbursement for the fiscal year ending in 2001 to the Provider Reimbursement Review Board ("Board"), which dismissed the appeal because appellant missed its deadline to file a preliminary position paper. After the Board denied appellant's motion for reinstatement of its appeal, appellant filed the current action and subsequently appealed from the district court's order granting summary judgment for appellee. The court affirmed summary judgment and held that the Board's Instructions requiring dismissal of claims due to failure to timely submit preliminary position papers did not violate the Medicare Act, 42 U.S.C. 1395, and the Board's dismissal of appellant's claim was neither arbitrary or capricious.

Under Medicaid, the federal government reimburses between 50% and 83% of state costs for patient care for eligible low-income individuals, including developmentally-disabled individuals receiving care in home- and community-based settings.42 U.S.C.1396n(c). In 2001 Pennsylvania obtained a waiver that authorized reimbursement of state expenses for "habilitation services" for developmentally-disabled individuals. Until 2006, Pennsylvania did not seek reimbursement for occupancy costs for Medicaid recipients living in nonprofit and county facilities, but paid for room and board using state funds and the residents' Supplemental Security Income. The Center for Medicare and Medicaid Services rejected the state's 2006 claim that more than 54 percent of the occupancy costs were for reimbursable habilitation services. The appeals board and district court upheld the denial. The Third Circuit affirmed, based on the plain meaining of the statutory exclusion of costs for "room and board," and noting consistent interpretation of the statute

The employee developed bilateral cubital tunnel syndrome while working at a supermarket, then worked as a greeter until she was laid off in 2003 because she was unable to perform the job. She subsequently started and left a dental hygiene, radiology technology, and electroencephalography training programs because of problems related to her hands and vision. At age 45 she had an extensive medical history, including fibromyalgia, degenerative disc disease, bilateral mild ulnar neuropathy, and multiple eye surgeries with dry eye syndrome. In 2008 an ALJ rejected her claim for social security disability benefits. The appeals council denied review and the district court affirmed. The Seventh Circuit affirmed, noting that the ALJ failed to acknowledge a physician report contrary to her conclusion and to explain the weight she gave that opinion, but stating that remand would serve no purpose in light of the overwhelming evidence supporting the denial.

Plaintiff brought action under the False Claims Act, 31 U.S.C. 3729, claiming that the company used a kickback scheme and knowingly caused submission of false Medicare, Medicaid, and TRICARE claims by hospitals and doctors. The district court held that hospital claims at issue were not false or fraudulent, and that doctor claims were false or fraudulent, but not materially so. The First Circuit reversed. If kickbacks affected the transactions underlying the claims, the claims failed to meet a condition of payment and were false, regardless of the hospital's participation in or knowledge of the kickbacks. It cannot be said, as a matter of law, that the alleged misrepresentations were not capable of influencing Medicare's decision to pay the claims.

Plaintiff applied at age 51 for supplemental security income based on disability. At issue was whether the administrative law judge ("ALJ") erred by failing to develop the record adequately and should have requested more explanation from two of plaintiff's treating physicians at the Department of Veterans Affairs ("VA"). The court held that the ALJ's failure to assist plaintiff in developing the record by getting his disability determination into the record was probably likely to have been prejudicial because the court gave VA disability determinations great weight. Therefore, the court remanded under sentence four of 42 U.S.C. 405(g), concluding that "the agency erred in some respect in reaching a decision to deny benefits."

Plaintiff appealed the administrative law judge's ("ALJ") denial of his application for supplemental security income alleging that he became disabled beginning in March 20, 2005 due to depression, post-traumatic stress disorder, and schizoaffective disorder. At issue was whether the factual findings were supported by substantial evidence and whether the correct legal standards were applied. The court held that the ALJ did not follow the law in evaluating all the medical evidence from a licensed clinical psychologist, a licensed professional counselor, and a physician who diagnosed plaintiff with schizoaffective disorder. The court also held that the ALJ failed to apply the correct legal standards in assessing plaintiff's credibility, and alternatively, the ALJ's adverse credibility determination was not supported by substantial evidence.

Forsyth Memorial Hospital, Inc. and other providers (collectively "appellants") appealed the district court's grant of summary judgment in favor of the Secretary of Health and Human Services ("HHS") upholding the denial of their reimbursement claims arising from the merger of Presbyterian Health Services Corporation ("Presbyterian") and Carolina Medicorp, Inc. ("Carolina"). At issue was whether the denial of the reimbursement claims was arbitrary and capricious, an abuse of discretion, contrary to law, or unsupported by substantial evidence. The court affirmed the denial of the reimbursement claims and held that the district court properly concluded that it was neither arbitrary and capricious nor contrary to law for the Administrator of the Centers for Medicare & Medicaid Services ("Administrator") to find that appellants were not entitled to reimbursement where, in the merger between Carolina and Presbyterian, no bona fide sale took place and the parties were related.