Justia Public Benefits Opinion Summaries

Presser, who has 20 years of experience as a Wisconsin nurse and a nurse practitioner, began working with Acacia in 2011, providing psychiatric evaluations, managing patient medication, and providing other medical services. Presser alleges that Acacia and its owner, Freund, engaged in “upcoding,” provided unnecessary medical procedures, and then charged the federal and state governments for those expenses. The district court dismissed Presser’s qui tam action under the False Claims Act, 31 U.S.C. 3729 and the Wisconsin False Claims Act. Citing the need for particularity in pleading, the court noted Presser did not allege that the defendants actually sent any of the alleged claims or made any of the alleged statements to the state or federal governments. The Seventh Circuit affirmed that judgment except with respect to the claims regarding the use of an improper billing code, which were stated with sufficient particularity. Presser otherwise provided no medical, technical, or scientific context which would enable a reader of the complaint to understand why Acacia’s alleged actions amount to unnecessary care forbidden by the statute. View "Presser v. Acacia Mental Health Clinic, LLC" on Justia Law

Alvarado was born in 1967. In 1993 he was granted childhood disability benefits and Supplemental Security Income. The Social Security Act requires the Social Security Administration to periodically review whether a recipient remains disabled. Alvarado’s eligibility was reviewed and affirmed in 1999. In a 2004 review, the Administration determined that his disability had ended, so his benefits were discontinued. After a remand, a hearing officer and ALJ each upheld the decision, finding that Alvarado continued to suffer from a severe learning disorder, which prevented him from performing many jobs, but which did not prevent him from doing simple jobs that did not require interaction with the public and that a significant number of such jobs exist in Illinois,. The Appeals Council denied review. The district judge and Third Circuit affirmed, finding the denial supported by substantial evidence. The court noted evidence evidence that Alvarado: had a driver’s license and drove regularly, including long trips; used public transportation; had obtained an associate’s degree and was only a few credits short of a bachelor’s degree; had lived alone, in a different state from his family; assisted at his mother’s flower shop; performed chores at home; and used the internet. View "Alvarado v. Colvin" on Justia Law

O’Connor-Spinner, age 47, suffers from depression and several physical impairments, including degenerative disk disease, bilateral carpal tunnel syndrome, sleep apnea, “restrictive lung disease,” and obesity. Several times since 2001 she has applied for Disability Insurance Benefits and Supplemental Security Income. In 2010, the Seventh Circuit invalidated the Social Security Administration’s denial of her 2004 request for benefits, noting that the ALJ had not asked a testifying vocational expert to assess how O’Connor-Spinner’s employment prospects would be affected by her moderate limitation on concentration, persistence, and pace, and had ignored a psychologist’s opinion that O’Connor-Spinner also faces a moderate limitation on her ability to accept instructions from, and respond appropriately to, supervisors. On remand, a different ALJ contradicted his colleague and declared that O’Connor-Spinner’s depression is not, and never was a severe impairment. The Seventh Circuit again vacated and remanded, stating that the medical evidence contradicts the ALJ’s assertion. The court noted symptoms including recurring agitation, impulsivity, fatigue, crying spells, and two or three “explosive episodes” weekly involving violent behavior and memory blackouts. View "O'Connor-Spinner v. Colvin" on Justia Law

In 2000, while working as a welder, Cole (then in his 20s) broke his left arm and wrist, requiring insertion of a metal plate and screws in his arm. He experienced pain that has still not gone away. In 2008, employed as a factory foreman, he fell off a 10‐foot ladder, landing on his right elbow. He received physical and occupational therapy, but the pain has persisted. An orthopedic surgeon diagnosed cubital tunnel syndrome and performed an anterior ulnar nerve transposition. Cole’s pain increased. Another orthopedic surgeon diagnosed posterolateral rotatory instability and replaced the ligament in Cole’s elbow with a graft from Cole’s arm. Cole’s pain became constant. Another orthopedic surgeon noted his “chronic pain” but said that Cole could return to work “without restrictions.” Cole settled his worker’s compensation claim and obtained unemployment benefits. When they ran out, Cole unsuccessfully applied for social security disability benefits. The Seventh Circuit reversed, stating that the ALJ “appears to have thought Cole a malingerer,” and “cherry-picked” the medical record. View "Cole v. Colvin" on Justia Law

Taylor has an IQ of 70-75. In her twenties, living with her mother, and never having worked, Taylor needs help to get dressed, wash her hair, and take her medications. She can do simple household chores, very slowly and only if reminded, sometimes repeatedly. She cannot drive and cries when she feels overwhelmed. She has poor depth perception and is clumsy. She has seizures and debilitating headaches that require her to sleep during the day. She has a history of kidney problems. A social security field officer interviewed her regarding her application for Supplemental Security Income benefits and reported that her “capability [of working] is questionable.” A psychologist found her verbal comprehension to be particularly low and deemed her “incapable of managing her funds independently.” Taylor had volunteered an hour a week at the public library folding brochures, cutting slips and notices, and affixing labels. The librarian reported that Taylor “completes her tasks well” but “has problems following procedures unless she has a list to follow, which her mother created.” The librarian said she “would hesitate in giving [Taylor] any more responsibilities” The Seventh Circuit reversed the denial of benefits, stating “there is no evidence to support the administrative law judge’s conjecture” that Taylor could work full-time. View "Taylor v. Colvin" on Justia Law

Baptist began working at Ford’s assembly plant, operating a forklift. Less than three months later, Baptist inadvertently hit a pillar, injuring his left wrist. He visited Ford’s medical department and submitted an injury report. An investigator and Ford’s physician doubted Baptist’s account of his injury; Baptist did not report the incident properly and refused to release medical records from a prior workers’ compensation case against another employer involving an injury to his other wrist. Ford paid for Baptist’s initial visit to an orthopedic surgeon, Dr. Heller. The parties are litigating Baptist’s workers’ compensation claim. After working two months, Baptist again sought medical attention. Dr. Heller diagnosed him with a complete ligament tear, recommended surgery, indicated that Baptist was not able to perform the essential function of his job, and cleared him to return to work if he did not lift or grip over five pounds with his left hand. Disagreeing with Ford's doctor, Baptist believed that this prevented him from operating the forklift and asked for another position. He did not work for several days. Ford suspended him for one month. When Baptist returned, he was told that the only available work was as a forklift driver. Baptist later testified that he was told that he would be fired unless he agreed to state that his injury did not happen at work. The company denied this assertion. Baptist was discharged for having three consecutive absences without justification. In a suit alleging retaliation for exercising his workers’ compensation rights, the court granted Ford summary judgment. The Seventh Circuit vacated. A triable issue exists regarding whether Baptist was put to the impracticable choice between keeping his job or giving up a key argument for workers’ compensation. View "James Baptist v. Ford Motor Company" on Justia Law

Thomas applied for Supplemental Security Income in 2010 when she was 55 years old. An administrative law judge identified her medically determinable impairments as degenerative changes in her back and left shoulder, Graves’ disease, and dysthymic disorder (a form of chronic depression), but concluded that the impairments did not impose more than minimal limitations on Thomas’s ability to work and denied her application. The Seventh Circuit reversed and remanded. The ALJ’s omission of fibromyalgia from Thomas’s medically determinable impairments and his conclusion that she has no severe impairments were not supported by substantial evidence. Thomas’s doctors’ lack of specialization in rheumatology was not an acceptable basis for discounting their assessments. View "Thomas v. Colvin" on Justia Law

In 2005, D.U., then three years old, was severely injured in a car accident. She qualified for Wisconsin Medicaid services on financial grounds and was provided extensive medical care until August 2013. After a change in family circumstances, D.U. no longer qualified on financial grounds. Wisconsin continued to provide the same services under its “Katie Beckett Program,” which funds Medicaid benefits for children who are otherwise ineligible because of the assets or income of their parents, 42 U.S.C. 1396a(e)(3). The state noted that D.U., whose condition had substantially improved over the years, was “borderline” for meeting the criteria to qualify for private duty nursing care and later informed D.U. and her father that D.U. no longer qualified for those services. D.U.filed a new request for 70 hours per week of private duty nursing and submitted additional information, but the request was denied. D.U. did not appeal the denial, but sought a preliminary injunction. The district court concluded that the evidence that D.U. submitted in support of her request for injunctive relief failed to demonstrate a likelihood of success on the merits. The Seventh Circuit affirmed, holding that D.U. failed to demonstrate that she will suffer irreparable harm if the injunction is denied. View "D. U. v. Rhoades" on Justia Law

In 2009 Crespo applied for Supplemental Security Income benefits for his mother, representing that she lived with him in Illinois and that he took care of her. He served as her representative payee. By signing the form, Crespo acknowledged that he could be held liable for any improper overpayments he caused. Crespo’s mother was not entitled to those benefits because she lived in Puerto Rico (20 C.F.R. 416.215), which Crespo hid from the Social Security Administration by falsely representing, in three subsequent reports as representative payee, that she lived with him. Airline records established that she resided in Puerto Rico; his mother was serving as representative payee for her own mother’s retirement benefits, declaring herself a resident of Puerto Rico. An ALJ imposed a $114,956 civil penalty on Crespo for misrepresentation. The Departmental Appeals Board of the Department of Health and Human Services dismissed his appeal as untimely. The Seventh Circuit affirmed. The Board did not abuse its discretion in rejecting Crespo’s untimely appeal and finding good cause lacking. Appeals are due 30 days after the ALJ’s initial decision is deemed served. A copy of the regulation is included when the decision is delivered. Crespo offered no reason why he did not request an extension. View "Crespo v. Colvin" on Justia Law

Garbe, an experienced pharmacist, began working at Kmart pharmacy in Ohio in 2007. When Garbe picked up a personal prescription at a competitor pharmacy, he discovered the competitor pharmacy had charged his Medicare Part D insurer far less than Kmart ordinarily charged it for the same prescription. He inspected Kmart’s pharmacy reimbursement claims and discovered that Kmart routinely charged customers with insurance—whether public or private—higher prices than customers who paid out of pocket, even ignoring “discount programs sales. Garbe shared his discovery with the government and filed a qui tam suit in 2008. The government has not intervened. Garbe asserts that Kmart’s “usual and customary” prices should be based on the prices Kmart charged the majority of its cash customers. The district court granted Garbe partial summary judgment. On interlocutory appeal, the Seventh Circuit, reversed in part, holding that Medicare Part D Pharmacy Benefit Managers and Plan Sponsors are not “officers or employees of the United States” for purposes of the False Claims Act, 31 U.S.C. 3729(a). The court agreed that Garbe has satisfied the materiality requirement under the Act for his Medicare Part D claims; and that Kmart’s “discount” prices were offered to the “general public.” View "Garbe v. Kmart Corp." on Justia Law