Justia Public Benefits Opinion Summaries

The U.S. Department of Health and Human Services approved a 2008 amendment to Pennsylvania’s state plan for administering its Medicaid program. Private nursing facilities that provide services to Medicaid recipients challenged the amendment as violating Title XIX of the Social Security Act, 42 U.S.C. 1396, by adjusting Pennsylvania’s method for determining Medicaid reimbursement rates to private nursing facilities for the 2008-09 fiscal year without considering quality of care, which they claim violates 42 U.S.C. 1396a(a)(30)(A) and without satisfying the public process requirements of 42 U.S.C. 1396a(a)(13)(A). The district court rejected the claims on summary judgment. The Third Circuit affirmed in part, finding the state immune from the requested relief under the Eleventh Amendment. The district court erred in granting summary judgment to the federal defendants. By approving the amendment without any assurance that the amended plan would produce payments that are consistent with quality of care, HHS acted arbitrarily. View "Christ the King Manor, Inc. v. Sec'y, U.S. Dep't of Health & Human Servs." on Justia Law

Former U.S. Forest Service employee King had long-term relationships with two women, both of whom claimed federal survivor benefits upon his death. Kathryn believed she had married King in a civil ceremony in 2002. Diana, who had been legally married to and divorced from King twice, but had continued to live with him until 2002, maintained that she was the common law wife of King at the time he married Kathryn. Before his death, Diana had initiated proceedings in Montana to dissolve their common law marriage. The women subsequently entered settlement agreements and engaged in state court litigation. Kathryn received benefits from May 27, 2004 until February 2007. Diana subsequently received the survivor benefits. Kathryn transferred to Diana the funds that she received ($41,939.13), as she believed was required by a Montana court decree. Kathryn challenged the OPM’s effort to recover the improper payments, having transferred the money to Diana, but the government affirmed its decision and determined that collection of the $41,939.13 would not cause Kathryn financial hardship. The Merit Systems Protection Board affirmed, holding that Kathryn did not meet the definition of “widow” under the Civil Service Retirement Act, 5 U.S.C. 8341(A)(1), and had not proved that she was entitled to waiver for the overpayment. The Federal Circuit reversed. The Board failed to credit substantial evidence demonstrating that Kathryn detrimentally relied on the overpayment of survivor annuity funds. View "King v. Office of Pers. Mgmt." on Justia Law

Plaintiff and his wife appealed the denial of his application for Medicaid benefits, arguing that the Department wrongfully denied the application because it had improperly counted against the wife's eligibility an annuity owned by the wife. The district court ruled in favor of plaintiffs and the Department appealed. The court concluded that, because the wife had no right, authority, or power to liquidate the annuity, the annuity benefits were not a resource, but rather was income indicated by the federal statute defining "unearned income." Therefore, the Department applied a more restrictive methodology under state law by classifying the annuity benefits as a resource that counted against plaintiff's eligibility for Medicaid benefits. The court rejected the Department's counter-arguments and the remaining arguments, and affirmed the judgment of the district court. View "Geston, et al. v. Anderson" on Justia Law

Plaintiff appealed the denial of disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. 401 et seq. The court concluded that the failure explicitly to engage in a function-by-function assessment of plaintiff's limitations and restrictions as a part of her residual function capacity (RFC) did not constitute a per se error requiring remand. The court concluded that remand was not required where the ALJ's Step Four analysis of plaintiff's limitations and restrictions provided an adequate basis for meaningful judicial review, the ALJ's determination applied the correct legal standards, and the determination was supported by substantial evidence. Accordingly, the court affirmed the judgment of the district court. View "Cichocki v. Astrue" on Justia Law

The Secretary appealed the district court's order certifying a nationwide class of Medicare beneficiaries and granting summary judgment in the beneficiaries' favor. The beneficiaries raised two claims: (1) the Secretary's practice of demand "up front" reimbursement for secondary payments from beneficiaries who have appealed a reimbursement determination or sought waiver of the reimbursement obligation was inconsistent with the secondary payer provisions of the Medicare statutory scheme; and (2) the Secretary's practice violated their due process rights. The court concluded that Patricia Haro had Article III standing on behalf of the class; John Balentine, as counsel for Haro, had Article III standing on his individual claim; and the beneficiaries' claims for injunctive relief were not moot and Article III's justiciability requirements were satisfied. The court concluded, however, that the beneficiaries' claim was not adequately presented to the agency at the administrative level and therefore the district court lacked subject matter jurisdiction under 42 U.S.C. 405(g). On the merits of Balentine's claim, the court concluded that the Secretary's interpretation of the secondary payer provisions was reasonable. Therefore, the court vacated the district court's injunctions, reversed the district court's summary judgment order, and remanded for consideration of the beneficiaries' due process claim. View "Haro v. Sebelius" on Justia Law

Relators brought a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729(a)(1)(A) and (B), alleging that the Mayo Foundation and others billed Medicare for surgical pathology services it did not provide. The government intervened and the parties settled. Relators then filed a Second Amended Complaint asserting additional claims. On appeal, relators challenged the district court's dismissal of their additional claim that Mayo fraudulently billed for services it did not provide whenever it prepared and read a permanent tissue slide but did not prepare a separate written report of that service. As a preliminary issue, the court concluded that relators satisfied their burden of showing that the public disclosure bar did not deprive the court of jurisdiction over relators' claim. On the merits, the court concluded that nowhere in the Medicare regulations or in the American Medical Association Codebook has the court found a requirement that physicians using the CPT codes for surgical pathology services must prepare the additional written reports that relators claimed Mayo fraudulently failed to provide. Accordingly, the court affirmed the judgment of the district court. View "Ketroser, et al. v. Mayo Foundation, et al." 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

Kit Carson was born in May 1996, and received numerous vaccinations during his first year of life. At his 18-month and 24-month check-ups, Kit’s pediatricians noted that his speech was delayed. Following his three-year check-up, Kit was referred for evaluation and diagnosed with autism spectrum disorder in 2001. His parents sought compensation under the National Childhood Vaccine Injury Act, 42 U.S.C. 300aa, in 2002. A Special Master concluded that the first symptoms of Kit’s disorder were recorded in May 1999 and that the claim was not filed within the 36-month limitations period. The Federal Circuit affirmed, rejecting an argument that speech delay cannot be a “first symptom” because it is an insufficient basis for a diagnosis of autism. View "Carson v. Sec'y, Health & Human Servs." on Justia Law

Zizic is the former CEO of BioniCare, which sold the BIO-1000, a medical device designed to treat osteoarthritis of the knee. BioniCare attempted to bill Medicare for the BIO-1000, but many claims were denied as not medically necessary. Q2A contracted with the government to review such claim denials across the nation. Q2A’s denials were reached without physician review, which is required by the Medicare Act, 42 U.S.C. 1395, HHS regulations, and its contract. A former Q2A employee testified that it implemented an internal policy to deny all BIO-1000 claims, which were reviewed by a single nurse rather than a panel of physicians; later allowed non-physician subcontractors to prepare BIO-1000 appeals for review by a single physician; and finally developed a mail merge letter that automatically denied BIO-1000 claims without any review. BioniCare’s trustee in bankruptcy became aware of and disclosed these practices. Zizic filed a qui tam suit under the False Claims Act, 31 U.S.C. 3729-33. The district court dismissed, concluding that it lacked jurisdiction because the allegations against Q2A and RTS were based on prior public disclosures and because Zizic was not an original source of that information. The Third Circuit affirmed. View "Zizic v. Q2Adm'rs LLC" on Justia Law

Plaintiff appealed the denial of his application for Social Security disability benefits and supplemental security income. The court concluded that the ALJ erred in determining plaintiff's residual functional capacity as "frequent to occasional" handling and fingering, because "frequent" and "occasional" were separate terms of art with distinct meanings. Accordingly, the court reversed and remanded to the district court with directions to remand the case to the Commissioner for clarification of plaintiff's residual functioning capacity and for further proceedings. View "Owens v. Astrue" on Justia Law