Justia Public Benefits Opinion Summaries

Plaintiff hospices exceeded their aggregate caps in the 2013 fiscal year, and three Silverado hospices also exceeded their aggregate caps in the 2014 fiscal year. Plaintiffs appealed their cap determinations to the Provider Reimbursement Review Board (“PRRB”), arguing that their MAC had failed to calculate the aggregate cap using the “actual net amount of payment received by the hospice provider.” The Ninth Circuit affirmed the district court’s summary judgment in favor of the government.   The court held that CMS correctly concluded that the Budget Control Act required it to reduce the total annual amounts paid to hospices, not only the periodic reimbursements, and that the agency’s chosen method for implementing sequestration was consistent with the Medicare statute. The court further held that the agency was not required to undertake notice-and-comment rulemaking before implementing the Budget Control Act’s sequestration mandate. The agency’s sequestration method, as reflected in the TDL and the PRRB’s decisions, did not amount to the “establish[ment]” or “change[]” of a substantive legal standard governing payment for services under Medicare, within the meaning of 42 U.S.C. Section 1395hh. Rather, Congress enacted the Budget Control Act’s sequestration requirements, and the President implemented sequestration when the statutory conditions were triggered. View "SILVERADO HOSPICE, INC. V. XAVIER BECERRA" on Justia Law

Grant Bauserman, Karl Williams, and Teddy Broe, on behalf of themselves and all others similarly situated, brought a putative class action in the Michigan Court of Claims against the Unemployment Insurance Agency, alleging that the Agency violated their due-process rights, and that the Agency also engaged in unlawful collection practices. Plaintiffs, who were all recipients of unemployment compensation benefits, specifically alleged defendant had used an automated fraud-detection system, the Michigan Integrated Data Automated System (MiDAS), to determine that plaintiffs had received unemployment benefits for which they were not eligible and then garnished plaintiffs’ wages and tax refunds to recover the amount of the alleged overpayments, interest, and penalties that defendant had assessed without providing meaningful notice or an opportunity to be heard. Among other remedies for this constitutional violation, plaintiffs sought monetary damages. Although the Michigan Supreme Court had never specifically held that monetary damages were available to remedy constitutional torts, the Court now held that they were. “Inherent in the judiciary’s power is the ability to recognize remedies, including monetary damages, to compensate those aggrieved by the state, whether pursuant to an official policy or not, for violating the Michigan Constitution unless the Constitution has specifically delegated enforcement of the constitutional right at issue to the Legislature or the Legislature has enacted an adequate remedy for the constitutional violation. Because enforcement of Const 1963, art 1, § 17 has not been delegated to the Legislature and because no other adequate remedy exists to redress the alleged violations of plaintiffs’ rights, we agree that plaintiffs have alleged a cognizable constitutional-tort claim for which they may recover money damages and we agree with the lower courts that defendant was properly denied summary disposition.” View "Bauserman v. Unemployment Insurance Agency" on Justia Law

After voluntarily leaving his job due to back problems, Plaintiff applied for disability insurance benefits. The Social Security Administration found that he was not disabled and denied his application. Plaintiff sought judicial review and the district court1 affirmed. He appealed, arguing that the agency’s decision was not supported by substantial evidence.   The Eighth Circuit affirmed, explaining that when reviewing the denial of disability insurance benefits, the court decides whether the findings are supported by substantial evidence on the record as a whole. Here, Plaintiff claims that his treating physician’s opinion was entitled to deference. However, the court explained, that under the current regulations, however, treating physicians are not entitled to special deference. And although Plaintiff may disagree with the ALJ’s conclusion, it is supported by substantial evidence on the record as a whole. View "Jason Bowers v. Kilolo Kijakazi" on Justia Law

Morris served in the Army, 1965-1968. In 1970, he unsuccessfully sought disability benefits (38 U.S.C. 1110), alleging a disability based on a nervous condition connected to his service. The VA instead granted his claim for a pension based on a non-service-connected condition. In 2005, Morris sought compensation based on service-connected PTSD; he was eventually assigned a 100% disability rating.Morris has for many years been seeking an earlier effective date for service-connected disability compensation. The VA regional office and the Board of Veterans’ Appeals found no clear and unmistakable error. The Court of Appeals for Veterans Claims rejected a claim that a September 1970 notice from the VA—giving notice of the August 1970 rating decision—was constitutionally inadequate under the Due Process Clause; Morris had not presented this argument to the Board but contended that the Veterans Court was obligated to consider this constitutional question in the first instance under 38 U.S.C. 7261(a)(1). The Veterans Court exercised its discretion, under issue-exhaustion precedents, to decline to entertain the argument presented for the first time on appeal. The Federal Circuit affirmed the dismissal of the appeal. The Veterans Court had the discretion to apply an issue-exhaustion analysis and correctly applied that analysis. View "Morris v. McDonough" on Justia Law

In 2016, the Secretary of Health and Human Services (“HHS”) issued a final rule that implemented The Protecting Access to Medicare Act of 2014 (“PAMA” or “Act”), definition of “applicable laboratory” (“2016 Rule”). The American Clinical Laboratory Association (“ACLA”) filed a lawsuit challenging the 2016 Rule as arbitrary and capricious under the Administrative Procedure Act (“APA”) on the basis that it depresses Medicare reimbursement rates by excluding most hospital laboratories from PAMA’s reporting requirements. ACLA contended that because hospital laboratories tend to charge higher prices than standalone laboratories, their exclusion from reporting obligations results in an artificially low weighted median.   On remand, the parties cross-moved for summary judgment. The district court declined to reach the merits of ACLA’s APA challenge to the 2016 Rule, based on its determination that the Secretary had issued a new rule (“2018 Rule”) that superseded the 2016 Rule and mooted ACLA’s lawsuit.   The DC Circuit concluded that the case is not moot. Accordingly, the court reversed the district court’s dismissal for lack of subject matter jurisdiction and reached the merits of ACLA’s APA claim. The court explained that the 2016 Rule is arbitrary and capricious because the agency “failed to consider an important aspect of the problem.” The court wrote that PAMA provides that an applicable laboratory “means a laboratory that” receives “a majority” of its Medicare revenues from the Physician Fee Schedule or Clinical Laboratory Fee Schedule. Thus, hospital laboratories that provide outreach services may, in some instances, constitute “applicable laboratories” under PAMA. View "American Clinical Laboratory Association v. Xavier Becerra" on Justia Law

Illinois moved its Medicaid program from a fee‐for‐service model, where a state agency pays providers’ medical bills, to one dominated by managed care, where private insurers pay medical bills. Most patients of Saint Anthony Hospital are covered by Medicaid, so Saint Anthony depends on Medicaid payments. Over the last four years, it has lost roughly 98% of its cash reserves, allegedly because managed‐care organizations have repeatedly and systematically delayed and reduced Medicaid payments to it. Saint Anthony sued, arguing that Illinois officials owe it a duty under the Medicaid Act to remedy the late and short payments.The Seventh Circuit reversed the dismissal of the suit, concluding that Saint Anthony has alleged a viable claim for relief under 42 U.S.C. 1396u‐ 2(f) and may seek injunctive relief under 42 U.S.C. 1983 against the state official who administers the Medicaid program in Illinois. Illinois has tools available to remedy systemic slow payment problems—problems alleged to be so serious that they threaten the viability of a major hospital and even of the managed‐care Medicaid program as administered in Illinois. If Saint Anthony can prove its claims, the chief state official could be ordered to use some of those tools to remedy systemic problems that threaten this literally vital health care program. View "Saint Anthony Hospital v. Eagleson" on Justia Law

Genesis Healthcare was a healthcare provider participating in the federal “340B Program,” which was designed to provide drugs to qualified persons at discounted prices. Under the Program, the Secretary of the Department of Health and Human Services (“HHS”) enters into agreements with drug manufacturers to sell drugs at discounted prices to entities such as Genesis Healthcare, which could, in turn, sell the drugs to their patients at discounted prices. After Genesis Healthcare purchased the covered drugs from the manufacturers, it dispensed them to patients through its wholly owned pharmacies or contract pharmacies. After the Health Resources and Services Administration (“HRSA”) conducted an audit of Genesis Healthcare in June 2017 for Program compliance, HRSA removed Genesis Healthcare from the 340B Program. The audit report found, among other things, that Genesis Healthcare dispensed 340B drugs to individuals who were ineligible because they were not “patients” of Genesis Healthcare. HRSA rejected Genesis Healthcare’s challenges; Genesis Healthcare, in turn, filed suit seeking a declaration it did not violate the requirements of the Program, and injunctive relief requiring HRSA to reinstate it into the Program and to retract any notifications that HRSA had provided to manufacturers stating that Genesis Healthcare was ineligible under the Program. In response to the lawsuit, HRSA ultimately: (1) notified Genesis Healthcare by letter that it “ha[d] voided” all audit findings and that Genesis Healthcare “ha[d] no further obligations or responsibilities in regard to the audit” and (2) filed a motion to dismiss Genesis Healthcare’s action as moot based on the letter. The district court granted HRSA’s motion, finding that the action was moot. The Fourth Circuit reversed the district court's finding the case was moot: Genesis Healthcare continued to be governed by a definition of “patient” that, Genesis maintained, was illegal and harmful to it. Therefore, there remained a live controversy between the parties. View "Genesis HealthCare, Inc. v. Becerra" on Justia Law

After Wilkinson County Senior Care changed ownership, it received the maximum per diem rate from the Mississippi Division of Medicaid (DOM) for a period of twenty months. The DOM notified Wilkinson County Senior Care multiple times that the maximum per diem rate it received during this time period was subject to adjustment based on its initial cost report. The DOM did not seek recoupment of the overpayment based on the adjustment until 2011. Wilkinson County Senior Care argued that this delay foreclosed the DOM from recouping the overpayment it received. The DOM and the chancery court both affirmed that the recoupment was allowable. Because no legal or equitable principles provide that the delay in this case forecloses recoupment, the Mississippi Supreme Court affirmed the decisions of the chancery court and the DOM. View "Wilkinson County Senior Care, LLC v. Mississippi Division of Medicaid" on Justia Law

Patricia Allen appealed the Idaho Industrial Commission’s (the “Commission”) decision denying unemployment benefits. Allen was employed by Partners in Healthcare, Inc., doing business as North Canyon Medical Center (“NCMC”), between February 5, 1999, and May 8, 2020. On May 8, 2020, the CEO of NCMC and the HR director met with Allen to discuss her job performance. Allen was presented with a performance improvement plan (“PIP”), which outlined examples of Allen’s poor job performance and identified expectations for improving her performance. It was explained to Allen that if she wanted to forego the PIP, she could sign a severance agreement. Allen was then presented with a proposed severance agreement. Allen asked if she could discuss her options with her husband, but was pressed to make her decision then and there. The CEO told Allen that he thought it was in her best interest to take the severance package. Allen decided to forgo the PIP and took the severance agreement. After separating from NCMC, Allen filed an unemployment claim with the Idaho Department of Labor (“IDOL”). NCMC’s response to the Idaho Department of Labor was prepared by the Idaho Hospital Association (“IHA”), NCMC’s third-party administrator. IHA’s human resources director identified Allen’s reason for separation as “Fired/Discharged” and indicated Allen did not receive any compensation after her separation. IDOL determined Allen was eligible for unemployment benefits. NCMC’s HR director appealed the IDOL decision; IDOL sent NCMC and Allen a hearing notice on whether Allen quit voluntarily and, if so, whether she quit for good cause or was discharged for misconduct in connection with her employment. Following the hearing, the appeals examiner issued a written decision that denied Allen unemployment benefits. The examiner also found that Allen did not follow the grievance procedures to report her issues with her supervisor prior to quitting. In reversing the Commission’s decision, the Idaho Supreme Court concluded the Commission erred in failing to analyze whether the PIP was a viable option that would have allowed Allen to continue working. The matter was remanded for further proceedings. View "Allen v. Partners in Healthcare, Inc." on Justia Law

Long served in the Air Force, 1969-1976 and spent most of that time as an air traffic control radar repairman, working without ear protection near active runways. In 2009, Long filed a disability compensation claim for hearing loss and tinnitus. The Department of Veterans Affairs found his hearing loss and tinnitus were service-connected, assigning a 0% disability rating for his hearing loss and a 10% disability rating for his tinnitus according to the schedular rating criteria, 38 C.F.R. 4.85. The Board of Veterans’ Appeals denied his request for an extra-schedular rating. Long had argued that the schedular rating criteria did not capture the functional effects of his hearing loss, including ear pain caused by his hearing aids. The Veterans Court affirmed, finding no direct causal link between Long’s ear pain and his service-connected hearing loss.The Federal Circuit vacated. A secondary condition is considered service-connected if it is “proximately due to or the result of” a service-connected disability. Direct causation is not required. The court remanded, stating that the Veterans Court engaged in impermissible fact-finding. View "Long v. McDonough" on Justia Law