Justia Public Benefits Opinion Summaries

Orillo, her husband (a doctor), and another owned Chalice, a home health care provider. Chalice was an enrolled provider with Medicare and could seek reimbursement of home health care through that program. Orillo falsified forms by altering the codes and information that had been completed by the Chalice nurses to make the patient’s condition appear worse and the health care needs greater than the actuality. Those alterations caused Medicare software to generate different reimbursement rates Orillo also aided her husband in paying kickbacks to a Chicago doctor in return for referrals of Medicare patients. Orillo pled guilty to healthcare fraud, 18 U.S.C. 1347 and paying kickbacks to physicians for patient referrals under a federal health care program, 42 U.S.C. 1320a-7b and 18 U.S.C. 2, and was sentenced to 20 months’ imprisonment. Orillo conceded that her scheme caused a loss, to Medicare, in excess of $400,000, and agreed to entry of a $500,000 forfeiture judgment.The district court determined that the loss amount for the healthcare fraud count was $744,481 and ordered her to pay that amount in restitution. The Seventh Circuit affirmed, rejecting Orillo’s argument that the loss and restitution amount should be limited to only those stemming from visible alterations. View "United States v. Orillo" on Justia Law

Philpot, former Clerk of Lake County, Indiana, took $25,000 in incentive payments from a federally funded child‐support fund (42 U.S.C. 658a(a)) without the required approval of the county fiscal body. The Indiana Department of Child Services disburses those federal funds to the counties, Ind. Code 31‐25‐4‐23(a), which have a relatively free hand in directing the money, although “amounts received as incentive payments may not, without the approval of the county fiscal body, be used to increase or supplement the salary of an elected official.” Philpot had used the funds to provide himself and staff members with bonuses. Convicted of mail fraud, 18 U.S.C. 1341, and theft from a federally funded program 18 U.S. 666(a)1A, he was sentenced to 18 months in prison. The Seventh Circuit affirmed, despite claims concerning whether Philpot “knowingly” violated the statute and the fact that Philpot had voluntarily returned the funds. View "United States v. Philpot" on Justia Law

Burris worked in coal mines for 23 years. He twice sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901, abandoning his first claim in 2001, and pursuing a second claim in 2006. After a hearing on the second claim, an Administrative Law Judge determined that Burris was totally disabled by pneumoconiosis arising from his coal mining employment and that he qualified for benefits. The Benefits Review Board affirmed. The Seventh Circuit denied a petition for review, rejecting arguments that the ALJ erred in finding that Burris established a material change in condition following his first, abandoned claim; in concluding that Burris proved 15 years of surface mine employment in conditions substantially similar to those that exist in underground mines; and in rejecting evidence rebutting a presumption of pneumoconiosis. View "Consolidation Coal Co. v. Dir., Office of Workers' Comp. Programs" on Justia Law

Schomas, 54 years old, suffers from scoliosis and degenerative disc disease. Following a hearing, the Social Security Administration denied his application for Disability Insurance Benefits. The district court and the Seventh Circuit upheld the denial, rejecting a challenge to the ALJ’s credibility finding and assessment of his residual functional capacity. The court acknowledged that the ALJ’s decision was “problematic,” but concluded that Schomas waived most of his arguments, and that the rest were unfocused or undeveloped. View "Schomas v. Astrue" on Justia Law

After researching qui tam actions and meeting with an attorney, Dr. Watson placed an ad in a Sheboygan newspaper soliciting minor Medicaid patients who had been prescribed certain psychotropic medications. The ad referred to participation in a possible Medicaid fraud suit and sharing in any recovery. Meyer responded and entered into an agreement with Watson, who never met Meyer’s child, but obtained the child’s records by using an authorization stating that Meyer was requesting the records “[f]or the purpose of providing psychological services and for no other purpose whatsoever….” Watson searched the records for “off‐label” prescriptions written for a purpose that has not been approved by the FDA. Off‐label use is common, but generally not paid for by Medicaid. In the child’s records, Watson identified 49 prescriptions that he alleged constituted false claims to the U.S. government. The district court rejected Watson’s suit under the qui tam provision of the False Claims Act, 31 U.S.C.3729(a)(1)(A), reasoning that expert testimony was necessary to prove essential elements of the case and Watson had not named experts. While characterizing Watson’s tactics as “borderline fraudulent,” the Seventh Circuit reversed, citing the district court’s “overly rigid” view of the causation and knowledge elements of the claim. View "Watson v. King-Vassel" on Justia Law

Health and Hospital Corporation of Marion County, Indiana is a municipal corporation that operates a major hospital and other facilities, including a health center operated in partnership with Citizens Health to serve the medically under-served population in Indianapolis. The health center was funded in part by a Section 330 Grant, awarded by the federal Health Resources and Services Administration, which is part of the Department of Health and Human Services. Section 330 grants fund qualifying health centers that provide primary health care services to medically under-served populations, 42 U.S.C. 254b. A In 2012, Health and Hospital decided to terminate the partnership with Citizens and relinquish the federal grant, which still had several years of funding remaining. Citizens sued Health and Hospital, HRS, and others in an effort to retain the grant funds. The district court granted defendants summary judgment, concluding that Citizens had no contractual, statutory, or constitutionally cognizable interest in the grant. The Seventh Circuit affirmed, finding that Health and Hospital was the grantee; Citizens had no constitutionally-protected entitlement to the grant; and the terms of the contract between Health and Hospital and Citizens clear; there was no obligation to renew. View "Citizens Health Corp. v. Sebelius" on Justia Law

In 2011 Wisconsin reduced subsidies for the Wisconsin Care Program, which funds grants for organizations administering programs for disabled persons who live in group homes. The plaintiffs are developmentally disabled and suffered the largest cuts. Persons who had received smaller payments bore smaller cuts. For some (frail elderly) per capita payments increased. Plaintiffs claim that making larger absolute cuts for persons whose care is most expensive violated the Rehabilitation Act and the Americans with Disabilities Act and that reduction in payments increases the risk that they will be moved from group homes to institutions. The district judge noted that states have waived sovereign immunity with respect to the Rehabilitation Act, as a condition to receiving federal funds. The Supreme Court has held that the portions of the ADA that are not designed to implement disabled persons’ constitutional rights cannot be used to override states’ sovereign immunity. The district court concluded that the relevant provisions of the ADA do not concern the Constitution and that other claims were premature because no plaintiff has been moved to an institution. The Seventh Circuit affirmed, noting that without information about care provided to other disabled persons, there is no useful theory of discrimination. View "Amundson v. WI Dep't of Health Servs." on Justia Law

ITT is a for-profit institution with more than 140 locations and offers post-secondary education. Leveski, who worked at the ITT campus, alleged, under the qui tam provisions of the False Claims Act, 31 U.S.C. 3730(b) that ITT knowingly submitted false claims to the Department of Education to receive funds from federal student financial assistance programs under the Higher Education Act, 20 U.S.C. 1001. The district court dismissed for lack of jurisdiction, finding that the allegations had already been publicly disclosed and that Leveski was not the original source of the allegations. The court granted sanctions of $394,998.33 against Leveski's lawyers. The Seventh Circuit reversed, finding the allegations that ITT paid illegal incentive compensation throughout Leveski’s employment as a recruiter and financial aid assistant, sufficiently distinct from prior public disclosures to give the court jurisdiction. The court noted the lack of temporal overlap with allegations by other ITT employees and Leveski’s more detailed allegations. View "Timothy J. Matusheski v. ITT Educational Services, Inc" on Justia Law

The Black Lung Benefits Act, 30 U.S.C. 901, originally included a “15-year presumption” that total pulmonary or respiratory impairment of a coal worker with 15 years of experience in the mines was due to pneumoconiosis (black lung). Congress removed this presumption in 1981, but in 2010 revived the presumption for claims filed after January 1, 2005, still pending on or after March 23, 2010. Bailey, employed by Consolidation Coal for 26 years, also smoked cigarettes for many years. He was diagnosed with chronic obstructive pulmonary disease and sought benefits. Three claims were considered during the interval when the 15-year presumption was withdrawn. Two were denied, and he withdrew a third. For his current claim, filed in 2007, three doctors agreed that Bailey is totally disabled by COPD. Because of the rejected claims, Bailey was required to show a change in condition. An ALJ, using the 15-year presumption, held that Bailey can now establish pneumoconiosis caused in part by coal dust exposure, two elements deficient in earlier claims, and awarded benefits. The Benefits Review Board affirmed. The Seventh Circuit affirmed. The ALJ correctly applied the 15-year presumption, addressed evidence relating to Bailey’s health and smoking history, and delivered a rational decision, supported by substantial evidence. View "Consolidation Coal Co. v. Dir., Office of Workers Comp. Programs" on Justia Law

Natale,a vascular surgeon, was compensated by Medicare for repairing a patient’s aortic aneurysm. Another doctor reviewed the post-surgical CT scan, which did not match the procedure Natale described in his operative reports. After an investigation, Natale was indicted for health care fraud related to his Medicare billing, mail fraud, and false statements related to health care. A jury acquitted Natale on the fraud counts but convicted him of making false statements, 18 U.S.C. 1035. The trial court used jury instructions that seemingly permitted conviction for false statements completely unrelated to Medicare reimbursement. The Seventh Circuit affirmed, finding the error harmless, but clarified that under the statute, even conviction for false statements made in connection with items or services still must relate to a “matter involving a health care benefit program.” View "United States v. Natale" on Justia Law