Justia Public Benefits Opinion Summaries

The hospital, located in Philadelphia, received a reclassification into the New York City area, which would sizably increase the hospital’s Medicare reimbursements due to that area’s higher wage index, 42 U.S.C. 1395ww(d). Although a statute makes such reclassifications effective for three fiscal years, the agency updated the geographical boundaries for the New York City area before the close of that period and reassigned the hospital to an area in New Jersey with an appreciably lower wage index. The hospital successfully sued three agency officials in the Eastern District of Pennsylvania.The Third Circuit vacated and remanded for dismissal. The Medicare Act, 42 U.S.C. 1395oo(f)(1), channels reimbursement disputes through administrative adjudication as a near-absolute prerequisite to judicial review. The hospital did not pursue its claim through administrative adjudication before suing in federal court. By not following the statutory channeling requirement, the hospital has no valid basis for subject-matter jurisdiction. View "Temple University Hospital, Inc. v. Secretary United States Department of Health & Human Services" on Justia Law

The plaintiffs retired from the Louisville Metropolitan police department and received free health insurance, administered by Kentucky Retirement Systems. Kentucky initially paid all of their healthcare costs. After the officers turned 65, Medicare became the primary payer, leaving Kentucky to cover secondary expenses. Each officer came out of retirement, joining county agencies different from the ones they served before retiring. They became eligible for healthcare benefits in their new positions. Kentucky notified them that federal law “mandate[d]” that it “cannot offer coverage secondary to Medicare” for retirees “eligible to be on [their] employer’s group health plan” as “active employees.” Some of the officers then paid for insurance through their new employers; others kept their retirement insurance by quitting or going part-time. The officers sued.The district court granted summary judgment to the officers, ordered Kentucky to reinstate their retirement health insurance, and awarded the officers some of the monetary damages requested. The Sixth Circuit affirmed. The officers have a cognizable breach-of-contract claim. Under Kentucky law, the Kentucky Retirement Systems formed an “inviolable contract” with the officers to provide free retirement health insurance and to refrain from reducing their benefits, then breached that contract. The Medicare Secondary Payer Act of 1980 did not bar Kentucky from providing Medicare-eligible police officers with state retirement insurance after they reentered the workforce and became eligible again for employer-based insurance coverage, 42 U.S.C. 1395y. View "River City Fraternal Order of Police v. Kentucky Retirement Systems" on Justia Law

Kirby received a flu shot in her arm on October 8, 2013. One week later, she complained of persistent arm pain, numbness, and tingling that began immediately after the injection. On October 16, Dr. Henry diagnosed Kirby with radial neuritis and complications due to vaccination. Two weeks later, Kirby reported that her wrist and hand had become “very weak.” On November 12, Kirby began working with a physical therapist. Her physical therapy discharge summary reported that Kirby’s pain was a “0/10,” she had regained full muscle strength except in right thumb extension, and her numbness had decreased by 80%. On December 12, Kirby reported mild right arm pain in the morning, almost normal strength, and occasional tingling, but no numbness in her thumb. Dr. Henry determined she had achieved maximum medical improvement.Kirby visited a nurse practitioner five times in January 2014-July 2015, for reasons unrelated to her vaccine injury and generally reported “feeling fine.” On October 13, 2015, she complained of mild, intermittent pain in her right arm. She had no imitations due to the pain, and no muscle weakness.The Federal Circuit reinstated Kirby’s compensation award under the Vaccine Act, 42 U.S.C. 300aa–1. A finding that Kirby’s vaccine injury lasted more than six months was not arbitrary. A reasonable fact-finder could conclude that Kirby’s testimony is not inconsistent with her medical records from January 2014 through July 2015. The court also rejected an argument concerning causation. View "Kirby v. Secretary of Health & Human Services" on Justia Law

Arnold applied for Social Security disability benefits based on ailments related to her back, heart, and joints, and chronic pain syndrome. Following the initial denial of her claim, Arnold requested a hearing before an ALJ. Arnold testified at the hearing, as did a vocational expert. The ALJ concluded that Arnold was not disabled, finding Arnold had several severe impairments, but that she retained the ability, with certain movement restrictions, to perform her past relevant work as a daycare center director. The district court and Seventh Circuit affirmed the ALJ’s decision, rejecting an argument that the ALJ failed to analyze whether the side effects of her medications impacted Arnold’s ability to work. While there is some evidence of side effects in the record, there is no evidence that the side effects impacted Arnold’s ability to work. On this record, the ALJ was not required to make findings about Arnold’s side effects. View "Arnold v. Saul" on Justia Law

When Medicare overpays hospitals, it offsets that mistake by reducing future payments. By 2013, Medicare was out $11 billion because of new diagnostic codes and bookkeeping that did not keep up. Congress required that the Secretary of Health and Human Services recoup that amount by the end of fiscal year 2017 by reducing the base rate (standardized amount) paid for inpatient care and directed the Secretary to adjust the base rate by 0.5% each year through 2023, 129 Stat. 87, 163 (2015). Subsequently, while reviewing the 2017 budget, the Secretary realized that a -3.2% adjustment would leave the agency short of its $11 billion goal and announced a -3.9% adjustment. Congress then told the Secretary to increase the base rate by 0.4588% (not 0.5%) in 2018, 130 Stat. 1033, 1320 (2016). In 2017, the Secretary adjusted the base rate -3.9%. The agency met its goal. In 2018, the Secretary adjusted the base rate -3.4412%.Medicare providers sued, arguing that the Secretary should have reversed that expedient at the end of 2017 rather than carry it over into 2018, costing the hospitals $840 million in lost payments. The D.C. Circuit affirmed the dismissal of the suit. While the hospitals felt a “significant financial impact” from the -0.7% adjustment, Section 7(b)(5) bars judicial review of adjustments made under the Act. View "Fresno Community Hospital and Medical Center v. Cochran" on Justia Law

Dr. Korban and his medical practice Delta, practice diagnostic and interventional cardiology. In 2007, Dr. Deming filed a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729(a)(1)(A)–(C), (G) against Korban, Jackson Regional Hospital, and other Tennessee hospitals, alleging “blatant overutilization of cardiac medical services.” The United States intervened and settled the case for cardiac procedures performed in 2004-2012. Korban entered into an Integrity Agreement with the Office of Inspector General, effective 2013-2016 that was publicly available and required an Independent Review Organization. The U.S. Department of Justice issued a press release that detailed the exposed fraudulent scheme and outlined the terms of Korban’s settlement. In 2015, Jackson Regional agreed to a $510,000 settlement. The Justice Department and Jackson both issued press releases.In 2017, Dr. Maur, a cardiologist who began working for Delta in 2016, alleged that Korban was again performing “unnecessary angioplasty and stenting” and “unnecessary cardiology testing,” paid for in part by Medicare. In addition to Korban and Jackson, Maur sued Jackson’s corporate parent, Tennova, Dyersburg Medical Center, and Tennova’s corporate parent, Community Health Systems. The United States declined to intervene. The district court dismissed, citing the FCA’s public-disclosure bar, 31 U.S.C. 3730(e)(4). The Sixth Circuit affirmed. Maur’s allegations are “substantially the same” as those exposed in a prior qui tam action and Maur is not an “original source” as defined in the FCA. View "Maur v. Hage-Korban" on Justia Law

Alleging debilitating pain in her back, legs, and hands, Zoch sought disability insurance benefits, 42 U.S.C. 413, 423. An ALJ denied the application, finding that, based on the opinions of three of her four treating physicians, a consulting physician, and the objective medical evidence, she could perform sedentary work.The district court and Seventh Circuit affirmed, rejecting Zoch’s arguments that the ALJ improperly discounted her assertions and an opinion by a physician who relied on those assertions. Substantial evidence supports the ALJ’s decision. Zoch’s testimony of incapacitating pain conflicted with the objective medical evidence, including normal test results: lumbar MRI, wrist x-rays, range of motion, straight-leg raising, strength in extremities, and pressure on her nerves. Zoch’s testimony that she usually walked with a cane conflicted with the doctors’ reports that at all but one appointment she walked normally. Zoch’s testimony that she could not raise her arms or bend over to dress conflicted with a doctor’s observation that Zoch could comfortably bend over to touch her fingertips to her knees. Zoch’s hearing testimony that she could not perform the usual activities of daily living was inconsistent with her assertions in her application. View "Zoch v. Saul" on Justia Law

The Supreme Court affirmed the judgment of the circuit court entering judgment in favor of Yankton County on Sacred Heart Health Service Inc.'s (Hospital) declaratory judgment against the County, holding that circuit court did not err in holding S.D. Codified Laws chapter 28-13 is the proper mechanism for the Hospital to obtain reimbursement from the County for medical costs associated with the twenty-three patients in the involuntary commitment process.The Hospital brought a declaratory judgment action against the County seeking a declaration as to the County's liability and reimbursement for charges for the medical care and treatment of patients subject to an emergency hold under S.D. Codified Laws chapter 27A-10. The circuit court first entered a memorandum decision in favor of the Hospital, but after granting the County's motion to reconsider issued a second memorandum decision and corresponding judgment in favor of the County. The Supreme Court affirmed, holding (1) the circuit court did not err in granting the County's motion for summary judgment; (2) the Hospital did not have a claim in quantum merit for reimbursement from the County; and (3) the circuit court did not err in granting the County's motion to reconsider. View "Sacred Heart Health Services v. Yankton County" on Justia Law

Community Mental Health modified the methodology through which it allocated funding to individuals with disabilities receiving community living support services under a Medicaid waiver received by Michigan. Individuals receiving those services, together Advocacy, challenged that methodology as violating the Medicaid Act, 42 U.S.C. 1396a(a)(8), (a)(10)(A), (a)(10)(B), 1396n(c)(2)(A) and (C); Title II of the Americans with Disabilities Act (ADA), 42 U.S.C. 12132; section 504 of the Rehabilitation Act, 29 U.S.C. 794; the Michigan Mental Health Code; and the terms of Michigan’s Medicaid Habilitation Supports Waiver and the contracts implementing it. The district court dismissed the claims in full.The Sixth Circuit reversed, first holding that the plaintiffs have standing, that the defendants are not entitled to Eleventh Amendment immunity, that the plaintiffs were not required to exhaust their administrative remedies provided by the state under the Medicaid Act, and that the plaintiffs have a private right of action under sections 1396a(a)(8) and (a)(10). The plaintiffs’ allegations suffice to state plausible claims that they are being denied sufficient necessary medical services; that feasible alternatives that provide them a meaningful choice between institutionalized and at-home or community-based care exist and are not being ensured; and that they face a serious risk of institutionalization. View "Waskul v. Washtenaw County Community Mental Health" on Justia Law

Most people eligible for Medicaid benefits are “categorically needy” because their income falls below a threshold of eligibility. People with higher income but steep medical expenses are “medically needy” once they spend enough of their own assets to qualify, 42 U.S.C. 1396a(a)(10). Plaintiffs contend that medical expenses they incurred before being classified as “medically needy” should be treated as money spent on medical care, whether or not those bills have been paid, which would increase Illinois's payments for their ongoing care.The Seventh Circuit affirmed the dismissal of their suit. Medicaid is a cooperative program through which the federal government reimburses certain expenses of states that abide by the program’s rules. Medicaid does not establish anyone’s entitlement to receive particular payments. The federal-state agreement is not enforceable by potential beneficiaries. Plaintiffs bypassed their administrative remedies and do not have a judicial remedy under 1396a(r)(1)(A). Section 1396a(a)(8) provides that a state’s plan must provide that all individuals wishing to apply for medical assistance under Medicaid shall have the opportunity to do so and that assistance shall be furnished with reasonable promptness to all eligible individuals; some courts have held that this requirement can be enforced in private suits. If such a claim were available, it would fail. Plaintiffs are receiving benefits. The court also rejected claims under the Americans with Disabilities Act, 42 U.S.C. 12131–34, and the Rehabilitation Act, 29 U.S.C. 794. Plaintiffs receive more governmental aid than nondisabled persons. View "Nasello v. Eagleson" on Justia Law