Justia Public Benefits Opinion Summaries

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

Jewish Home of Eastern Pennsylvania (JHEP) provides nursing care to Medicare beneficiaries and is required to comply with the mandatory health and safety requirements for participation. JHEP must submit to random surveys conducted by state departments of health. In 2005, the Pennsylvania Department of Health conducted a survey that concluded that JHEP had eight regulatory deficiencies, including violations of 42 C.F.R. 483.25(h)(2), which requires a facility to ensure that each resident receives adequate supervision and assistance with devices to prevent accidents. Based on those deficiencies and those found in a 2006 survey, the Center for Medicare and Medicaid Services imposed fines totaling $17,150 and $12,800. JHEP claimed that the allegations of noncompliance were based on the inadmissible disclosure of privileged‖ quality assurance records and that the monetary penalties violated its right to equal protection because they were the product of selective enforcement based on race and religion. An ALJ upheld the fines against JHEP. The Third Circuit denied a petition for review. View "Jewish Home of E. PA v. Centers for Medicare and Medicaid Servs." on Justia Law

Humana sued, alleging that Glaxo was obligated to reimburse Humana for expenses Humana had incurred treating its insureds’ injuries resulting from Glaxo’s drug, Avandia. Humana runs a Medicare Advantage plan. Its complaint asserts that, pursuant to the Medicare Act, Glaxo is in this instance a “primary payer” obligated to reimburse Humana as a “secondary payer.” The district court dismissed, agreeing with Glaxo that the Medicare Act did not provide Medicare Advantage organizations with a private cause of action to seek such reimbursement. The Third Circuit reversed and remanded. The Medicare Secondary Payer Act, in 42 U.S.C. 1395y(b)(3)(A), provides Humana with a private cause of action against Glaxo. Even if the provision is ambiguous, regulations issued by the Centers for Medicare and Medicaid Services make clear that the provision extends the private cause of action to MAOs. View "Humana Med. Plan Inc. v. GlaxoSmithKline LLC" on Justia Law

Plaintiffs brought a putative class action challenging 62 Pa. Stat. 1414, which was enacted to regulate special needs trusts. The comprehensive Medicaid eligibility rules enacted by Congress generally mandate that trusts be counted as assets of those seeking Medicaid, but exempt special needs trusts, which are intended to provide disabled individuals with necessities and comforts not covered by Medicaid. Plaintiffs allege Section 1414 is preempted by 42 U.S.C. 1396p(d)(4). The district court held that all but one of the challenged provisions of Section 1414 was preempted, finding that plaintiffs had a private right of action under both Section 1983 and the Supremacy Clause. The court also held that Section 1414 was severable, certified a class, and appointed class counsel. The Third Circuit affirmed in part, agreeing that the case is justiciable and that plaintiffs have a private right of action. Section 1414's 50% repayment provision, "special needs" provision, expenditure provision, and age restriction are all preempted by federal law. The enforcement provision of Section 1414, however, when used to enforce provisions not otherwise preempted, is a reasonable exercise of the Commonwealth's retained authority to regulate trusts. View "Lewis v. Alexander" on Justia Law

A psychologist challenged the government's claim that he had over-billed Medicare and owed the government more than $600,000 in overpayments. At a hearing on the claim, the doctor presented extensive evidence, but the government neither appeared nor presented argument or advocacy, either written or in person. The ALJ concluded that the overpayment was actually $5,434.48. The doctor moved, under the Equal Access to Justice Act, 5 U.S.C. 504(a)(1), to recoup tens of thousands of dollars in attorneys' fees and expenses incurred in fighting the claim. His request was denied by an administrative appeals council and the district court based on their conclusion that the hearing before the ALJ was not an adversary adjudication, as is required for a fee award under the EAJA. The Third Circuit affirmed denial, finding that the government did not engage in purposeful advocacy.View "Handron v. Sec'y of Health & Human Servs." on Justia Law

In 2007, the HHS Office of Inspector General conducted a nationwide audit to determine whether states were complying with the requirements to reimburse the federal share of recovered AFDC overpayments made before October 1, 1996. The audit found that the Pennsylvania DPW had recovered $10,598,095 in AFDC overpayments from October 1, 1996 through June 30, 2006, but had not reimbursed ACF for the federal share of $5,609,572. DPW appealed a reimbursement request, challenging HHS authority to conduct the audit, but not the audit findings. The appeals board and district court upheld the HHS determination, rejecting an argument that the Personal Responsibility and Work Opportunity Reconciliation Act, 42 U.S.C. 601, designates a procedure established by the Single Audit Act, 31 U.S.C. 7501-7507 as the exclusive audit procedure. Under the SAA, "[e]ach non-Federal entity" that expends at least $300,000 of federal awards in a fiscal year "shall have either a single audit or a program-specific audit made for such fiscal year in accordance with the requirements of this chapter." The Third Circuit affirmed, also rejecting claims under FOIA and that DPW was entitled to retain the federal share of the AFDC overpayment recoveries under substantive law. View "Commonwealth of PA v. Sebelius" on Justia Law

Petitioner, a bookkeeper, part-time receptionist, and house-cleaner, developed reflexive sympathetic dystrophy after she fell. After reducing her hours, she stopped working in April 2008. Her application for disability benefits and SSI was denied in June 2008. In June 2009, she had a hearing before an ALJ, who denied her applications, finding that she was not disabled because she had the residual functional capacity to perform sedentary work with certain limitations and that jobs meeting those criteria were available. Eight months later, the Appeals Council denied review. The district court held that the ALJ's RFC determination was not supported by substantial evidence. The Third Circuit reversed, holding that the ALJ adequately explained the decision and properly relied on a 2008 report by the state agency medical consultant. View "Chandler v. Comm'r of Soc. Sec." on Justia Law

An employee, injured on the job, returned to work and presented a specialist's note, restricting her lifting. After five days her supervisor told her that her restrictions made it impossible for her to work and advised her to seek permanent disability. She submitted copies of additional doctors' notes in an effort to be reinstated, but the company concluded that the notes contained conflicting dates, contradictory answers on whether the medical condition was work related, ambiguities about the employee's ability to lift, and illegible content. The employee did not respond to requests for clarification, but filed a Workers' Compensation lawsuit and contacted the EEOC. She then filed suit, and, during discovery, turned over new copies of the notes. After plaintiff failed to produce originals at trial, there was conflicting testimony about the existence and location of originals. The district court declared a mistrial. Plaintiff sent the original notes to the court five days later. The court dismissed the case with prejudice, based on spoliation of evidence. The Third Circuit reversed and remanded. It is not clear that plaintiff intentionally withheld the documents or that the company suffered severe harm. View "Bull v. United Parcel Serv., Inc." on Justia Law

Husband worked as a miner from 1970 to 1987. In 2000, he was found to be totally disabled by coal workers' pneumoconiosis and was awarded benefits under the Black Lung Benefits Act, 30 U.S.C. 901. He died in 2005. His widow sought survivor’s benefits. At the time, she was required to prove that pneumoconiosis caused, contributed to, or hastened husband's death. An ALJ denied the claim. The Board vacated. On remand, the ALJ again denied benefits. While appeal was pending, Congress amended the Act, retroactively applicable to claims filed after January 1, 2005. The Board reversed and remanded for an order awarding survivor's benefits, holding that section 932(l), as amended, entitled the widow to benefits because husband was receiving black lung benefits at the time of his death and her claim was filed after January 1, 2005. The First Circuit denied the company's petition for review. Under the amendment, the widow is entitled to benefits without having to file a new claim or otherwise revalidate husband's claim because she filed her claim after January 1, 2005. The company's claim that she failed to establish the cause of death is irrelevant. Section 932(l) as amended does not violate the Due Process Clause or Takings Clause. View "B&G Constr. Co Inc. v. Dir., Office of Workers Comp. Programs" on Justia Law