Justia Public Benefits Opinion Summaries

Banks worked as a coal miner for 17 years and smoked about one pack of cigarettes per day for 38 years. His employment ended in 1991. After two unsuccessful attempts, in 2003, Banks filed a claim for benefits under the Black Lung Benefits Act, which provides benefits to coal miners who become disabled due to pneumoconiosis, 30 U.S.C. 901. An ALJ found that Banks had shown a change in his condition and that he suffered from legal pneumoconiosis which substantially contributed to his total disability. Banks was awarded benefits and the Benefits Review Board affirmed. The Sixth Circuit affirmed, adopting the regulatory interpretation urged by the Director of the Office of Workers’ Compensation Programs. The ALJ relied on reasoned medical opinions. View "Cumberland River Coal Co. v. Banks" on Justia Law

Cybriwsky served as Turner's attorney to obtain social security disability benefits. The representation agreement relieved Turner of the obligation to pay if they did not win the case, but assigned to Cybriwsky any fees that the court may award under the Equal Access to Justice Act, 42 U.S.C. 2412. After holding a hearing, the Commissioner denied Turner's benefits request. The district court reversed and remanded and Turner sought attorney’s fees under the EAJA. The district court denied this motion, finding that Turner did not “incur” fees as a result of the remand and that the assignment was void under the Anti-Assignment Act, 31 U.S.C. 3727. The Sixth Circuit reversed. A "sentence-four remand," 42 U.S.C. 405(g), like the remand at issue, makes the plaintiff a "prevailing party" under the EAJA. The award is consistent with the purposes of EAJA. Litigants "incur" fees under the EAJA when they have an express or implied legal obligation to pay over such an award to their legal representatives, regardless of whether the court subsequently voids the assignment provision under the AAA. View "Corns v. Commissioner of Soc. Sec." on Justia Law

Hit by a vehicle in 2004, plaintiff had medical bills of $82,036 that were paid in full by Medicare. The owner of the vehicle settled with plaintiff for $125,000. Medicare sought reimbursement of $62,338 under 42 U.S.C. 13955y(b)(2)(B)(i)., which plaintiff paid under protest. An ALJ rejected plaintiff's argument that an unknown motorist was responsible for 90 percent of the damage so that only 10 percent of the settlement was for medical expenses and the rest was for pain and suffering. The Medicare Appeals Council, district court, and Sixth Circuit affirmed, noting that plaintiff presented no evidence of hardship. View "Hadden v. United States" on Justia Law

Plaintiff suffered a back injury in a work-related vehicle accident in 1994, developed depression, then sought social security disability benefits. The Commissioner of Social Security adjudged him not to be disabled for purposes benefits. The district court affirmed. The Sixth Circuit reversed. The ALJ did not apply the "treating physicians" or "good reasons" rules in rejecting the treating doctor's opinion. That opinion was not patently wrong, so the ALJ's decision was not supported by substantial evidence.

Patient, insured by defendant, diagnosed with end-stage renal disease, and received dialysis at plaintiff's center. Three months after diagnosis, she became entitled to Medicare benefits (42 U.S.C. 426-1). Her plan provided that coverage ceased at that time, because of her entitlement to Medicare, but the insurer continued to pay for two months. Under the 1980 Medicare Secondary Payer Act, a group health plan may not take into account that an individual is entitled to Medicare benefits due to end-stage renal disease during the first 30 months (42 U.S.C. 1395y(b)(1)(C)(i)), but the insurer terminated coverage. Plaintiff continued to treat and bill. The insurer declared that termination was retroactive and attempted to offset "overpayment" against amounts due on other patients' accounts. The outstanding balance after patient's death was $210,000. Medicare paid less than would have been received from the insurer. The center brought an ERISA claim, 29 U.S.C. 1132(a)(1)(B), and a claim for double damages under the 1980 Act. The district court granted plaintiff summary judgment on its ERISA claim but dismissed the other. The Sixth Circuit affirmed on the ERISA claim and reversed dismissal. A healthcare provider need not previously "demonstrate" a private insurer's responsibility to pay before bringing a lawsuit under the 1980 Act's private cause of action.

A 66-year -old arrived at petitioner's center with complex ailments, but oriented, able to feed herself and able to speak. During her 18 days at the center, she was sent to the hospital twice with serious medical complications. Upon investigation, the center was found to have failed to maintain substantial compliance with federal regulations for facilities that participate in Medicare and Medicaid (42 U.S.C. § 1395) in its treatment of the resident and appealed the resulting civil money penalty. An administrative law judge, the Departmental Appeals Board, and the Sixth Circuit affirmed. The ALJ acted properly in requiring submission of written testimony, properly weighed the evidence, and found violation of the federal hydration standard, laboratory services requirement, and mandate of a care plan, resulting in "immediate jeopardy."

Doctors filed suit, alleging violations of the False Claims Act, 31 U.S.C. 3279 and the Michigan Medicaid False Claim Act, as qui tam relators on behalf of the United States/ The claimed that the business defrauded the government by submitting Medicare and Medicaid billings for defective radiology studies, and that the billings were also fraudulent because the business was an invalid corporation. The federal government declined to intervene. The district court dismissed. Sixth Circuit affirmed. The doctors failed to identify any specific fraudulent claim submitted to the government, as is required to plead an FCA violation with the particularity mandated by the FRCP. A relator cannot merely allege that a defendant violated a standard (in this case, with respect to radiology studies), but must allege that compliance with the standard was required to obtain payment. The doctors had no personal knowledge that claims for nondiagnostic tests were presented to the government, nor do they allege facts that strongly support an inference that such billings were submitted.

The Medicare program pays teaching hospitals to cover "direct" and "indirect costs of medical education," 42 U.S.C. 1395ww(d)(5)(B), (h). Direct costs include expenses such as residents' salaries. Indirect costs are incurred due to "general inefficiencies" and "extra demands placed on other staff." Congress created a formula for calculating indirect expenses based on full-time equivalency interns; an HHS regulation referred to time residents spend in the "portion of the hospital subject to the prospective payment system or in the outpatient department of the hospital." In reimbursing plaintiff, HHS excluded from the FTE count time residents spent on pure research, unrelated to treatment of a patient. While appeal of a decision favoring the hospital was pending, Congress enacted the Patient Protection and Affordable Care Act, 124 Stat. 119, 660–61. For the years at issue, HHS must include in FTE: "all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary." HHS promulgated a regulation specifying that eligible non-patient care activities do not include time residents spend conducting pure research. The Sixth Circuit upheld the regulation as within the Secretary's authority and applicable to the years at issue.

Plaintiff was in a work-related vehicle accident that injured his back in 1994. He worked on and off until 2000 when back pain prevented him from continuing as a truck driver. A 2001 claim for social security disability benefits was denied. Plaintiff had some relief following surgery in 2001 and was released to work in 2002. When the pain increased he began mental health treatment. In 2004 an ALJ found that plaintiff was not disabled. In 2007, following remand, an ALJ again denied benefits. The appeals council denied jurisdiction. The district court affirmed. The Sixth Circuit reversed and remanded, finding that the decision was not supported by substantial evidence because the ALJ failed to properly apply the treating physician rule and the good reasons rule in disregarding the conclusion of a treating psychiatrist and testimony of a treating counselor. Agency procedural rules require that the ALJ balance factors to determine what weight to give a treating source and to give good reasons for the weight actually assigned.

Petitioner worked as an underground surveyor for a coal company for more than 22 years. He filed an unsuccessful claim for black lung benefits (30 U.S.C. 901) about a year after being laid off. He filed a second claim 10 years later, accompanied by medical opinions and x-ray interpretations. The DOL provided a pulmonary examination for each claim. The first diagnosed shortness of breath of unknown etiology but opined that petitioner suffered no impairment. The second resulted in diagnosis of restrictive lung disease, right mid lung density, bilateral hilar adenopathy and concluded that there was no impairment. An ALJ rejected the second claim. The Benefits Review Board affirmed. The Sixth Circuit vacated for consideration under an amendment to the Act, under which a miner who worked underground for at least 15 years and who demonstrates that he suffers from a total respiratory disability is presumed to be totally disabled due to pneumoconiosis (30 U.S.C. 921(c)(4)). Rebuttal requires an affirmative showing; it is not enough to show that medical evidence does not include a well documented opinion of pneumoconiosis. The ALJ failed to consider all evidence relevant to the issue of disability.