Justia Public Benefits Opinion Summaries

Medicare pays teaching hospitals for work by residents when a teaching physician supervises. During the 1990s, HHS concluded that many hospitals were billing for unsupervised services and began to audit invoices. There was also a GAO report and private litigation: qui tam suits under the False Claims Act, allowing relators to collect a bounty. Under 31 U.S.C. 3730(e)(4)(A), suits cannot be based upon public disclosure of allegations or transactions in public agencies’ official reports unless the relator is an original source of information. A prior case concluded that the 1998 GAO report and similar public documents disclosed that billing for unsupervised work was common practice. The district court dismissed a suit filed against a teaching hospital in 2004, claiming to describe conduct, such as inadequate supervision, not previously disclosed. The Seventh Circuit vacated. No one who read the GAO report, or followed the progress of the audits, would suspect that Rush University was misrepresenting "immediate availability" of teaching physicians during concurrently scheduled procedures. The complaint alleged a kind of deceit that the GAO report does not attribute to any teaching hospital. View "Goldberg v. Rush Univ. Med. Ctr." on Justia Law

Duchesneau served on active duty in the Army, July 1996 to January 1999. In 2000, a VA Regional Office granted service connection for her right shoulder bursitis with a 10 percent disability rating. In 2003 she sought an increased disability rating, but the RO denied her claim. The Board affirmed. The veterans' court rejected her claim for two separate disability ratings under a single diagnostic code, set aside the Board's decision as to a single appropriate disability rating under DC 5201 and remanded to the Board to clarify the precise extent of her right shoulder limitation. The Federal Circuit rejected an appeal for lack of jurisdiction, stating that the veterans' court decision was not a final judgment. View "Duchesneau v. Shinseki" on Justia Law

Morris served on active duty for two months in 1964. His entrance examination and examination upon separation revealed no psychiatric abnormality. In 1966 Morris sought disability compensation for a psychiatric disorder, claiming that in basic training, he had suffered abuse from his sergeant, which caused him to experience nervous breakdown. The VA Regional Office denied the claim. In 1986, the RO concluded that additional evidence did not constitute new and material evidence. Following another denial, Morris presented evidence that he had been diagnosed with schizophrenia and a VA physician's opinion that it had its onset during service. The Board denied the claim. On remand in 1992, the Board concluded that evidence supported the claim but that its 1988 decision was final. In 1993, the RO awarded service connection for schizophrenia effective from 1987. In 1996, the Board denied a claim that the award should be retroactive to 1966. The Veterans Court rejected an argument that the 1988 Board failed to apply correctly 38 U.S.C. 105(a), 1110, and 1111, noting no evidence that the Board incorrectly considered his condition a personality disorder. The Federal Circuit affirmed. Under 38 C.F.R. 3.303(c), personality disorders are not diseases or injuries within the meaning of 1110 and are not compensable. View "Morris v. Shinseki" on Justia Law

Plaintiff brought this qui tam suit alleging that the District of Columbia and its schools violated the False Claims Act (FCA), 31 U.S.C. 3729-3733, by submitting a Medicaid reimbursement claim without maintaining adequate supporting documents. The district court dismissed the case, relying on the court's precedent in United States ex rel. Findley v. FPC-Boron Employees' Club. Because the court concluded that the Supreme Court had implicitly overruled Findley in Rockwell International Corp. v. United States, the court reversed. View "Davis v. DC" on Justia Law

States both appealed the district court's grants of summary judgment in favor of HHS, which upheld HHS's disallowance of certain Medicaid claims for Federal Financial Participation (FFP) as ineligible for "medical assistance" under the "Institution for Mental Diseases" (IMD) exclusion set forth in section 1905(a) of 42 U.S.C. 1396 et seq. (Medicaid Statute). Because HHS correctly concluded that the disputed claims were not eligible for FFP under the plain language of the IMD exclusion and the under-21 exception, the court affirmed the judgment of the district court. View "Virginia Dept. of Medical Assist. Svcs. v. HHS, et al." on Justia Law

Plaintiff appealed the district court's grant of summary judgment to the Commissioner in its review of the Commissioner's denial of Social Security Disability Insurance (SSDI) and Social Security Income (SSI) benefits. Based on the rarity of the surveillance system monitor jobs, and considering plaintiff's physical and mental limitations, the court was compelled to find that the ALJ's decision was not supported by substantial evidence. Accordingly, the court reversed the district court's grant of summary judgment and remanded for further proceedings. View "Beltran v. Astrue" on Justia Law

T.B.'s parents, on behalf of their autistic child, appealed the district court's finding that the school district did not violate the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400 et seq., by failing to provide a free appropriate public education (FAPE) to T.B., making the parents ineligible for reimbursement for the costs of T.B.'s home-based program. Given the parents' decision to ultimately settle the issue of the adequacy of the proposed individualized education program (IEP), the court questioned whether they could claim, much less successfully show, that the school district failed to provide a FAPE to T.B. Nonetheless, based on the record, the court could not say that T.B.'s home-based program was "reasonably calculated to enable [him] to receive educational benefits." The program was therefore not "proper" within the meaning of the IDEA and the parents were not entitled to reimbursement for the costs associated with it. Accordingly, the court affirmed the judgment. View "T.B., et al. v. St. Joseph School District" on Justia Law

Plaintiff, the Chapter 7 trustee for the bankruptcy estate of BioniCare Medical Technologies, contested determinations of the Medicare Appeals Council (MAC) refusing to provide coverage for the BIO-1000, a device to treat osteoarthritis of the knee. Plaintiff alleged that the Secretary improperly used the adjudicative process to create a policy of denying coverage for the BIO-1000, that the MAC's decisions were not supported by substantial evidence, and that the MAC's decisions were arbitrary and capricious on account of a variety of procedural errors. The court rejected those contentions and affirmed the judgment of the district court. View "Almy v. Sebelius" on Justia Law

Plaintiffs sought compensation under the National Vaccine Injury Compensation Program, 42 U.S.C. 300aa, for injuries to their children allegedly caused by the Diptheria-Tetanus-acellular Pertussis vaccine. The children suffer a seizure disorder, known as Severe Myoclonic Epilepsy of Infancy. The same special master presided over both cases and determined that plaintiffs failed to show entitlement to compensation because evidence showed that a gene mutation present in both children was the sole cause of their injuries. The Court of Federal Claims affirmed. The Federal Circuit affirmed, noting considerable evidentiary support for the conclusion. View "Stone v. Sec'y of Health & Human Servs." on Justia Law

Petitioner served in the Army for about 30 months, 1981-1983 and suffered injury to her knees and wrist. The VA regional office assigned a 10 percent rating to her left wrist with an effective date of 1986. In 1987, her right arm was injured as a result of medical care she received from the VA. In 1990, her injury to right knee and shoulder were each rated at 20 percent and her left knee at 30 percent. In 1996, she was unable to continue working as a bookkeeper and brought a claim for total disability based on individual unemployability. The regional office rated her service-connected disabilities at 70 percent, but denied a total rating based on unemployability under 38 C.F.R. 4.16(a). The regional office and Board of Veterans’ Appeals rejected her 2004 application for review. The Secretary conceded that the regional office committed error by incorrectly computing petitioner’s rating. The Veterans Court found no “clear and unmistakeable error” and that the error was harmless because the RO had made an unemployability determination that satisfied the requirements for a 4.16(a) analysis. The Federal Circuit dismissed for lack of jurisdiction because there was no issue of the interpretation of 4.16(a)View "Githens-Bellas v. Shinseki" on Justia Law