Justia Public Benefits Opinion Summaries

Tasis and his brother ran a sham medical clinic, recruited homeless Medicare recipients who had tested positive for HIV, hepatitis or asthma, paid the “patients” small sums in exchange for their insurance identification, then billed Medicare for infusion therapies that were never provided. During four months in 2006, the Center billed Medicare $2,855,785 and received $827,000 in return. The scheme lasted 15 months, during which Tasis and his collaborators submitted $9,122,159.35 in Medicare claims. An auditor notified the FBI. After an investigation, prosecutors indicted Tasis on fraud and conspiracy claims. Over Tasis’s objection, co-conspirator Martinez testified that she and Tasis had orchestrated a a similar scam in Florida. The court instructed the jury to consider Martinez’s testimony about the Florida conspiracy only as it related to Tasis’s “intent, plan and knowledge.” The jury found Tasis guilty, and the trial judge sentenced him to 78 months in prison and required him to pay $6,079,445.93 in restitution. The Sixth Circuit affirmed, rejecting various challenges to evidentiary rulings. View "United States v. Tasis" on Justia Law

Plaintiff, through his wife and attorney-in-fact, filed an application for Medicaid benefits with the Connecticut Department of Social Services to cover the cost of his nursing home care. At issue was whether a non-assignable annuity contract that provided the spouse of an institutionalized person with monthly payments counted as an excess resource that must be spent down before the institutionalized person could receive Medicaid benefits under the Medicare Catastrophic Coverage Act of 1988 (MCCA), 42 U.S.C. 1396r-5. The court held that the payment stream for non-assignable annuity was not a resource for purposes of determining Medicaid eligibility. Accordingly, the court affirmed the judgment of the district court granting plaintiff's motion for summary judgment. View "Lopes v. Dept. of Social Services" on Justia Law

Bontrager filed a putative class action complaint challenging Indiana’s $1,000 annual limit for dental services covered by Medicaid, 42 U.S.C. 1396. The district court granted a preliminary injunction, holding that Indiana is required to cover all medically necessary dental services, irrespective of the monetary cap. The Seventh Circuit affirmed. Bontrager has an enforceable federal right capable of redress through Section 1983. The monetary cap, which excludes medically necessary treatment, is not a utilization control procedure, but allows a state to shirk its primary obligation to cover medically necessary treatments. The court acknowledged that Bontrager’s victory may be short-lived if the state decides to end coverage for all dental services. View "Bontrager v. IN Family & Soc. Servs." on Justia Law

Plaintiff-Appellant Pennie Keyes-Zachary appealed a district court order that affirmed the Commissioner's decision denying her applications for Social Security disability and Supplemental Security Income benefits. Plaintiff alleged disability based on, among other things, neck, back, shoulder, elbow, wrist, hand, and knee problems, accompanied by pain; hearing loss; urinary frequency; anger-management problems; depression; and anxiety. The ALJ upheld the denial of her application for benefits. The Appeals Council denied her request for review of the ALJ's decision, and she then appealed to the district court. The district court remanded the case to the ALJ for further consideration. After the second hearing, the ALJ determined that Plaintiff retained residual functional capacity to perform light work with certain restrictions, but that she was not disabled within the meaning of the Social Security Act. The Appeals Council declined jurisdiction, and the ALJ's decision was then deemed the Commissioner's final decision. On appeal Plaintiff raised two issues: (1) that the ALJ "failed to properly consider, evaluate and discuss the medical source evidence;" and (2) the ALJ "failed to perform a proper credibility determination." Upon review, the Tenth Circuit found no error in the ALJ's decision and affirmed the Commission's final determination in Plaintiff's case. View "Keyes-Zachary v. Astrue" on Justia Law

Until 2003, Hagans worked as a security guard and as a sanitation worker. At 44 years old, Hagans required open-heart surgery. Hagans claims additional medical problems relating to his cerebrovascular and respiratory systems, hypertension and dysphagia, insomnia, and back pain. He has been diagnosed with depression. Hagans began receiving disability benefits as of January 30, 2003. In September, 2004, pursuant to an updated Residual Function Capacity assessment showing his condition had improved, SSA determined that Hagans was no longer eligible for benefits. The ALJ considered several evaluations of Hagans’s condition, most of which were completed in mid-2004, and found that he was capable of engaging in substantial gainful activity, although he could not perform his past relevant work. The Appeals Council denied review; the district court affirmed. The Third Circuit affirmed, after determining that “relatively high” deference should be afforded to SSA’s Acquiescence Ruling interpreting the cessation provision of 42 U.S.C. 423(f) as referring to the time of the SSA’s initial disability determination. SSA correctly evaluated Hagans’s condition as of the date on which the agency first found that Hagans’s eligibility for disability benefits ceased. Substantial evidence supported the conclusion that Hagans was not fully disabled as of that date. View "Hagans v. Comm'r of Soc. Sec." on Justia Law

TriCenturion audited Nichole Medical as a Program Safeguard Contractor under the Medicare Integrity Program, 42 U.S.C. 395ddd(a), and concluded that Nichole “might” be improperly billing for medical equipment; that Nichole had received overpayments; and that it had not maintained sufficient medical records to establish reasonableness or medical necessity. TriCenturion directed Nichole’s carrier, HealthNow, to withhold payments. TriCenturion calculated the actual overpayment of several specific claims, used those as a representative sampling, and extrapolated an overpayment amount for all relevant claims. The Attorney General found no evidence of fraud and refused to prosecute; HealthNow stopped withholding payments. TriCenturion instructed HealthNow’s successor to re-institute the offset. Nichole went out of business, but pursued an appeal. An ALJ determined that Nichole was entitled to reimbursement on some, but not all, appealed claims and found that the process for arriving at the extrapolated overpayment was flawed. The Medicare Appeals Council found that all 39 claims had been reopened and reviewed improperly. The district court dismissed Nichole’s suit against TriCenturion, which alleged torts and breach of the statutory duty of care under 42 U.S.C. 1320c-6(b). The Third Circuit affirmed. Defendants are immune from suit as officers or employees of the Secretary of the Department of Health and Human Services. View "Nichole Medical Equip & Supply, Inc. v. Tricenturion, Inc." on Justia Law

The Port Authority’s subsidiary, PATH, operates the Grove Street Station in Jersey City. The Station was built in 1910. In 2000 PATH planned to expand the Station to accommodate larger trains and persons with disabilities, a project that would have involved construction of a new entrance and two elevators. After September 11, 2001, and the resulting closure of two stations, ridership increased at the Station. Concerned about congestion and safety, PATH scrapped its renovation plans and undertook a “fast track” project. Construction began in 2002 and concluded in 2005. Plaintiffs alleged that the renovations triggered an obligation under the Americans with Disabilities Act, 42 U.S.C. 12101–12213, to make the Station accessible to handicapped persons. They also alleged violations under New Jersey’s Law Against Discrimination and certain state construction code provisions. The district court dismissed, state-law claims on the basis that allowing such claims to proceed would violate the interstate compact between New York and New Jersey that created the Authority, but ordered the Authority to make the east entrance accessible. The Third Circuit affirmed dismissal of the state law claims, but remanded the ADA issue for trial on the issue of feasibility. View "Hip Heightened Indep. & Progress, Inc. v. Port Auth. of NY & NJ" on Justia Law

Adams worked in coal mines for 17 years, leaving A & E Coal in 1988, after 12 years, because he was having difficulty breathing. He has not worked since. Adams also smoked cigarettes for about 25 years, averaging a pack a day before quitting in 1998 or 1999. Adams filed his first claim for benefits under the Black Lung Benefits Act 30 U.S.C. 901 in 1988. His claim was denied: He did not prove that his pneumoconiosis was caused in part by his coal-mine work, or that his pneumoconiosis totally disabled him. In 2007, Adams filed a second claim. Two pulmonologists agreed that he was completely disabled, but disagreed on what lung diseases Adams had, and on what caused them. An Administrative Law Judge awarded benefits, finding that Adams had pneumoconiosis, that the disease was caused by Adams’s exposure to coal dust during his coal-mine employment, and that he was totally disabled because of the disease. The Benefits Review Board and the Third Circuit affirmed. Although the ALJ was not required to look at the preamble to the regulations to assess the doctors’ credibility, he was entitled to do so. View "A & E Coal Co. v. Adams" on Justia Law

Ulman filed her claim for benefits in 2006, alleging that her disability began in 2002. As found by the ALJ, her insured status expired on December 31, 2003. To be eligible for benefits, her disability must have begun on or before that date and continued until she filed her application for benefits. 42 U.S.C. 423(a)(1). Claimant was 47 at the time her insured status expired. She had worked as a waitress, park ranger, and home health aide. In rejecting her claim, the ALJ confused the dates of December 3, 2001 when she fell backwards off a ladder, with the 2006 date of the application, and made an adverse credibility determination. The ALJ recognized that she suffered from physical limitations that prevented her from performing her past work, but found that she could perform other jobs (cashier, parking lot attendant, ticket taker) that existed in the national economy. The Appeals Council and district court affirmed. The Sixth Circuit affirmed, applying harmless error analysis to the credibility determination. With the exception of confusion about the date, the ALJ’s decision carefully parsed the medical records and accorded them fair weight; those records support a finding of no disability.View "Ulman v. Comm'r of Soc. Sec." on Justia Law

Semrau, a Ph.D. in clinical psychology, owned companies that provided psychiatric care to nursing home patients in Tennessee and Mississippi, using contracting psychiatrists who submitted records describing their work. The companies then billed the services to Medicare or Medicaid through private insurance carriers. Services are categorized into five-digit Current Procedural Terminology Codes, published by the American Medical Association. The Centers for Medicare and Medicaid Services sets reimbursement levels for each code as well as “relative value units” corresponding to the amount of work typically required for each service. After audits indicated that the companies had been billing at a higher rate than could be justified by the services actually performed, “upcoding,” Semrau was convicted of healthcare fraud, 18 U.S.C. 1347, and was sentenced to 18 months of imprisonment and ordered to pay $245,435 in restitution. The Sixth Circuit affirmed, rejecting Semrau’s claim that results from a functional magnetic resonance imaging lie detection test should have been admitted to prove the veracity of his denials of wrongdoing. There was ample evidence that Semrau was aware of accepted definitions of the CPT codes; he expressly agreed not to “submit claims with deliberate ignorance or reckless disregard of their truth or falsity.” View "United States v. Semrau" on Justia Law