Justia Public Benefits Opinion Summaries

In 1988, an ALJ awarded Smith supplemental security income (SSI). Smith received benefits until 2004 when he was found to be over the resource limit. Smith filed another SSI application in 2012, alleging additional medical conditions. The application was denied on March 26, 2014. Smith claims that he mailed a request for review on April 24, 2014. On September 21, Smith faxed a correspondence to the Social Security Administration, inquiring about the status of his appeal, with a copy of his request, dated April 24, 2014. A representative informed Smith that his request was not in the “electronic folder,” that if the Council had received the request, it would have mailed a receipt, and that his appeals request was filed as of October 1, 2014. The Council dismissed the request as untimely, finding no good cause to extend the deadline because Smith could not provide evidence that it was sent within the appropriate time. The district court determined that there was no judicial review available because the dismissal did not constitute a final decision and Smith made no colorable constitutional claims. The Sixth Circuit affirmed, rejecting arguments that Smith suffered due process violations because his request was timely submitted, different ALJs presided over his hearing and signed his decision, and the ALJ referenced the 1988 decision but failed to attach a copy as an exhibit. View "Smith v. Commissioner of Social Security" on Justia Law

Under California’s workers’ compensation law, effective in 2013, an injured worker may challenge a decision denying medical treatment by requesting a determination of medical necessity from an independent medical review (IMR) organization. (Labor Code 139.5, 4610.5.1) The IMR organization, which is regulated by the Division of Workers’ Compensation and operates under contract with the Division, designates one or more medical professionals to review pertinent medical records, determine whether the disputed treatment is medically necessary, and prepare a written report including statutorily-required findings. The IMR organization is required to describe the qualifications of the medical professionals who prepare the determination of medical necessity and to keep the names of the reviewers confidential in all communications outside the IMR organization. The determination of the IMR organization is deemed to be the determination of the administrative director and is binding on all parties, subject to appeal on narrow statutory grounds. Zuniga availed himself of the IMR process and then petitioned the Workers’ Compensation Appeals Board to disclose the names of the reviewers. The Board declined to do so. The court of appeal upheld that decision. IMR determinations are not testimonial in character; IMR reviewers are not workers’ adversaries and are not subject to cross-examination. View "Zuniga v. Workers' Compensation Appeals Board" on Justia Law

Under California’s workers’ compensation law, effective in 2013, an injured worker may challenge a decision denying medical treatment by requesting a determination of medical necessity from an independent medical review (IMR) organization. (Labor Code 139.5, 4610.5.1) The IMR organization, which is regulated by the Division of Workers’ Compensation and operates under contract with the Division, designates one or more medical professionals to review pertinent medical records, determine whether the disputed treatment is medically necessary, and prepare a written report including statutorily-required findings. The IMR organization is required to describe the qualifications of the medical professionals who prepare the determination of medical necessity and to keep the names of the reviewers confidential in all communications outside the IMR organization. The determination of the IMR organization is deemed to be the determination of the administrative director and is binding on all parties, subject to appeal on narrow statutory grounds. Zuniga availed himself of the IMR process and then petitioned the Workers’ Compensation Appeals Board to disclose the names of the reviewers. The Board declined to do so. The court of appeal upheld that decision. IMR determinations are not testimonial in character; IMR reviewers are not workers’ adversaries and are not subject to cross-examination. View "Zuniga v. Workers' Compensation Appeals Board" on Justia Law

The Supreme Judicial Court vacated the judgment entered by the superior court upholding the final agency decision of the Department of Health and Human Services denying Appellant’s application for food supplement benefits.The Department denied Appellant’s application for food benefits based on language in the public law not present within the statutory text. The language at issue contained a fiscal limitation of $261,384 and a temporal limitation - June 30, 2015 - on the availability of funding for benefits for persons otherwise eligible under Me. Rev. Stat. 22, 3104-A(1)(D) (Paragraph D). The Supreme Judicial Court concluded that the Legislature intended for Paragraph D to be a permanent exception to the general ineligibility of noncitizen for food assistance under section 3104-(A)(1) and that the temporal and fiscal limitations contained in P.L 2013, ch. 368, section 00-14 applied only to the fiscal years ending June 30, 2013, June 30-2015, and June 30, 2015 and not beyond June 30, 2015. View "Manirakiza v. Department of Health & Human Services" on Justia Law

The Supreme Judicial Court vacated the judgment entered by the superior court upholding the final agency decision of the Department of Health and Human Services denying Appellant’s application for food supplement benefits.The Department denied Appellant’s application for food benefits based on language in the public law not present within the statutory text. The language at issue contained a fiscal limitation of $261,384 and a temporal limitation - June 30, 2015 - on the availability of funding for benefits for persons otherwise eligible under Me. Rev. Stat. 22, 3104-A(1)(D) (Paragraph D). The Supreme Judicial Court concluded that the Legislature intended for Paragraph D to be a permanent exception to the general ineligibility of noncitizen for food assistance under section 3104-(A)(1) and that the temporal and fiscal limitations contained in P.L 2013, ch. 368, section 00-14 applied only to the fiscal years ending June 30, 2013, June 30-2015, and June 30, 2015 and not beyond June 30, 2015. View "Manirakiza v. Department of Health & Human Services" on Justia Law

Brown, the manager of a company that provided home physician visits, and Talaga, who handled the company’s billing, were convicted of conspiracy to commit health-care fraud, 18 U.S.C. 1349; six counts of health-care fraud, 18 U.S.C. 1347; and three counts of falsifying a matter or providing false statements, 18 U.S.C. 1035(a). The district court sentenced Mr. Brown to 87 months’ imprisonment, 34 months below the Guidelines’ range, stating that a significant sentence was warranted because of the duration of the scheme, the amount of the fraud, the need for general deterrence, and Brown’s failure to accept responsibility. Ms. Talaga was sentenced to 45 months. The Seventh Circuit affirmed, rejecting Brown’s argument that the court’s assumptions about the need for general deterrence were unfounded and constituted procedural error and Talaga’s arguments that the court calculated the amount of loss for which she was responsible by impermissibly including losses that occurred before she joined the conspiracy. The district court was under no obligation to accept or to comment further on Brown’s deterrence argument. Talaga, as a trained Medicare biller, knew that that the high-volume billings were fraudulent. View "United States v. Talaga" on Justia Law

Accredo delivers clotting medication and provides nursing assistance for hemophilia patients. Accredo makes donations to charities concerned with hemophilia, including HSI and HANJ, which allegedly recommended Accredo as an approved provider for hemophilia patients. Greenfield, a former Accredo area vice president, sued, alleging violations of the Anti-Kickback Statute, 42 U.S.C. 1320a-7b(b), and the False Claims Act, 31 U.S.C. 3729(a)(1)(A)-(B). If Greenfield prevailed, he would get at least 25% of any civil penalty or damages award. The government did not intervene. The district court, following discovery, granted Accredo summary judgment, finding that Greenfield failed to provide evidence of even a single federal claim for reimbursement that was linked to the alleged kickback scheme. The Third Circuit affirmed. The Anti-Kickback Statute prohibits kickbacks regardless of their effect on patients’ medical decisions. Because any kickback violation is not eligible for reimbursement, to certify otherwise violates the False Claims Act but there must be some connection between a kickback and the reimbursement claim. It is not enough to show temporal proximity. Greenfield was required to show that at least one of the 24 federally-insured patients for whom Accredo provided services and submitted reimbursement claims was exposed to a referral or recommendation by HSI/HANJ in violation of the Anti-Kickback Statute. View "Greenfield v. Medco Health Solutions Inc" on Justia Law

Gumila, the head of clinical operations for a company that provided home medical care to the elderly, was convicted of 21 counts of health-care fraud, 18 U.S.C. 1347 and three counts of making a false statement in a health-care matter, 18 U.S.C. 1035. There was testimony from more than 20 witnesses and documentary evidence establishing that Gumila regularly overruled physicians who wanted to discharge patients and instructed employees to bill services at unjustifiably high rates, to claim that patients were homebound even when they weren’t, and to order skilled-nursing services even if no doctor had ever examined the patient. The government estimated Medicare’s financial loss: approximately $2.375 million for unnecessary and upcoded home visits; $9.45 million for unnecessary skilled-nursing services that did not meet Medicare’s requirements; and $3.779 million for oversight services that did not qualify for payment or were never performed. The guidelines range was 151-188 months in prison. Gumila argued that the loss should be limited to payments for the eight patients specifically mentioned in the indictment ($14,449). The judge concluded that the government was not required to present specific evidence to prove the fraudulent nature of each individual transaction contributing to the total loss, determined that the loss estimate was reasonable, imposed a sentence of 72 months, and ordered Gumila to pay $15.6 million in restitution. The Seventh Circuit affirmed, upholding the loss calculation and the prison term as substantively unreasonable. View "United States v. Gumila" on Justia Law

In 2005, the State of Mississippi filed suit against more than eighty prescription drug manufacturers alleging, among other things, that each committed common-law fraud and violations of the Mississippi Consumer Protection Act. The allegations primarily focused on whether the prescription-drug manufacturers inflated reported prices, which caused the Mississippi Division of Medicaid to reimburse pharmacies at inflated rates. The cases were eventually severed; this appeal involved only Watson Laboratories, Inc., Watson Pharma Inc., and Watson Pharmaceuticals, Inc. (collectively “Watson”). Following a bench trial, the Chancery Court concluded that Watson had committed common-law fraud and had violated the Mississippi Consumer Protection Act. As a result, the chancery court awarded the State a total of $30,262,052 in civil penalties, compensatory damages, and punitive damages. The chancery court also awarded post-judgment interest of three percent on the compensatory and punitive damages. Watson appealed, challenging the chancery court’s decision; the State also filed a cross-appeals relating to damages. After review, the Mississippi Supreme Court affirmed the chancery court’s judgment in favor of Mississippi Medicaid. Further, the Court affirmed the ruling on the State’s cross-appeal. View "Watson Laboratories, Inc. v. Mississippi" on Justia Law

Gerstner, age 27, applied for disability insurance benefits and supplemental security income was denied. An administrative law judge found that she was severely impaired by anxiety, bipolar disorder, panic disorder, depression, and fibromyalgia but that these impairments were not disabling, and denied benefits. The Seventh Circuit vacated the denial as not supported by substantial evidence. The ALJ fixated on select portions of the treating psychiatrist’s treatment notes, inadequately analyzed his opinions, and overlooked the extent to which those opinions were consistent with the diagnoses and opinions of other medical sources who treated Gerstner. ALJs must consider psychologists’ and nurse practitioners’ opinions on the severity of a patient’s impairments. In discrediting Gerstner’s testimony, the ALJ overstated findings from three diagnostic tests and misunderstood the nature of her fibromyalgia pain. Fibromyalgia pain cannot be measured with objective tests aside from a trigger-point assessment. View "Gerstner v. Berryhill" on Justia Law