Justia Public Benefits Opinion Summaries

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.

Plaintiff sued defendant seeking a declaratory judgment that defendant was required to comply with the rules laid out in Title XIX of the Social Security Act, section 1396-1396v, where there was a dispute as to what rate plaintiff must pay defendant when defendant provided emergency transportation services to plaintiff's Medicaid enrollees. At issue was whether the definition of emergency services in section 1396(u)-2(b)(2)(B) applied to section 1396(u)-2(b)(2)(D) and whether section 1396(u)-2(b)(2)(D) covered the services provided by defendants to members of plaintiff's Medicaid program. The court held that the definition of emergency services found in 1396(u)-2(b)(2)(B) applied to section 1396(u)-2(b)(2)(D) where applying different definitions to a single term of art within this one statute would be both cumbersome and illogical. The court also held that the district court erred in granting summary judgment to defendant where the plain meaning of the word outpatient and the structure of the statute supported a finding in favor of plaintiff.