Justia Public Benefits Opinion Summaries

In 1995, two non-profit hospitals consolidated to form Pinnacle. Pinnacle subsequently submitted a Medicare reimbursement claim for the losses the hospitals had incurred through the sale of their depreciable assets in the consolidation. The Administrator denied Pinnacle's claim, and that order became the final decision of the Secretary. On Pinnacle's Administrative Procedure Act (APA), 42 U.S.C. 12101 et seq., challenge, the district court upheld the Secretary's decision in full. Because the Secretary's interpretation of the relevant Medicare regulations was not plainly erroneous or inconsistent with the regulation, the court concluded that the Secretary reasonably applied the bona fide sale requirement to a reimbursement request from a participant in a "statutory merger." The court also held that the Secretary's finding that the bona fide sale requirement applied to consolidations involving non-profit Medicare providers, like Pinnacle, was not plainly erroneous or inconsistent with the regulation. Finally, substantial evidence supported the Secretary's finding that Pinnacle did not satisfy the bona fide sale requirement. Accordingly, the court affirmed the district court's judgment. View "Pinnacle Health Hospitals v. Sebelius" on Justia Law

This case stemmed from the denial of plaintiff's claim of social security disability benefits. At issue was whether the ALJ's handling of an ex parte contact was error, and if so, whether it was harmless. Because the ALJ erred by considering the ex parte evidence without allowing a supplementary hearing, the court was required to evaluate whether there was prejudice. The court concluded that there was no prejudice from the error where, considering the record as a whole, and the ALJ's explanation of his decision, the court was convinced that plaintiff had not demonstrated that the decision would have been any different without the ex parte communication. Accordingly, the court affirmed the judgment. View "Ludwig v. Astrue" on Justia Law

Suppliers appealed the district court's dismissal of their action against the Secretary of the Department of Health and Human Services and the Administrator of the Centers for Medicare and Medicaid Services (CMS). Suppliers challenged a regulation addressing the "applicable financial standards" that a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) supplier must meet to be eligible for a Medicare contract under the competitive process established in 42 U.S.C. 1395w-3 (DMEPOS Statute). The court affirmed the district court's dismissal on the ground that section 1395w-3(11) precluded judicial review of the Secretary's financial standards regulation and that the district court therefore lacked subject matter jurisdiction. View "Texas Alliance For Home Care, et al. v. Sebelius, et al." 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

Respondent gave birth to twins conceived through in vitro fertilization using her deceased husband's frozen sperm. Respondent applied for Social Security survivors benefits for the twins, relying on 42 U.S.C. 416(e) of the Social Security Act, which defined child to mean, inter alia, "the child or legally adopted child of an [insured] individual." The Social Security Administration (SSA), however, identified subsequent provisions of the Act, sections 416(h)(2) and (h)(3)(C), as critical, and read them to entitle biological children to benefits only if they qualified for inheritance from the decedent under state intestacy law, or satisfied one of the statutory alternatives to that requirement. The Court concluded that the SSA's reading was better attuned to the statute's text and its design to benefit primarily those supported by the deceased wage earner in his or her lifetime. And even if the SSA's longstanding interpretation was not the only reasonable one, it was at least a permissible construction that garnered the Court's respect under Chevron U.S.A. Inc. v. Natural Resources Defense Council, Inc. View "Astrue v. Capato" on Justia Law

Medicare pays teaching hospitals for work by residents when a teaching physician supervises. During the 1990s, HHS concluded that many hospitals were billing for unsupervised services and began to audit invoices. There was also a GAO report and private litigation: qui tam suits under the False Claims Act, allowing relators to collect a bounty. Under 31 U.S.C. 3730(e)(4)(A), suits cannot be based upon public disclosure of allegations or transactions in public agencies’ official reports unless the relator is an original source of information. A prior case concluded that the 1998 GAO report and similar public documents disclosed that billing for unsupervised work was common practice. The district court dismissed a suit filed against a teaching hospital in 2004, claiming to describe conduct, such as inadequate supervision, not previously disclosed. The Seventh Circuit vacated. No one who read the GAO report, or followed the progress of the audits, would suspect that Rush University was misrepresenting "immediate availability" of teaching physicians during concurrently scheduled procedures. The complaint alleged a kind of deceit that the GAO report does not attribute to any teaching hospital. View "Goldberg v. Rush Univ. Med. Ctr." on Justia Law

Duchesneau served on active duty in the Army, July 1996 to January 1999. In 2000, a VA Regional Office granted service connection for her right shoulder bursitis with a 10 percent disability rating. In 2003 she sought an increased disability rating, but the RO denied her claim. The Board affirmed. The veterans' court rejected her claim for two separate disability ratings under a single diagnostic code, set aside the Board's decision as to a single appropriate disability rating under DC 5201 and remanded to the Board to clarify the precise extent of her right shoulder limitation. The Federal Circuit rejected an appeal for lack of jurisdiction, stating that the veterans' court decision was not a final judgment. View "Duchesneau v. Shinseki" on Justia Law

Morris served on active duty for two months in 1964. His entrance examination and examination upon separation revealed no psychiatric abnormality. In 1966 Morris sought disability compensation for a psychiatric disorder, claiming that in basic training, he had suffered abuse from his sergeant, which caused him to experience nervous breakdown. The VA Regional Office denied the claim. In 1986, the RO concluded that additional evidence did not constitute new and material evidence. Following another denial, Morris presented evidence that he had been diagnosed with schizophrenia and a VA physician's opinion that it had its onset during service. The Board denied the claim. On remand in 1992, the Board concluded that evidence supported the claim but that its 1988 decision was final. In 1993, the RO awarded service connection for schizophrenia effective from 1987. In 1996, the Board denied a claim that the award should be retroactive to 1966. The Veterans Court rejected an argument that the 1988 Board failed to apply correctly 38 U.S.C. 105(a), 1110, and 1111, noting no evidence that the Board incorrectly considered his condition a personality disorder. The Federal Circuit affirmed. Under 38 C.F.R. 3.303(c), personality disorders are not diseases or injuries within the meaning of 1110 and are not compensable. View "Morris v. Shinseki" on Justia Law

Plaintiff brought this qui tam suit alleging that the District of Columbia and its schools violated the False Claims Act (FCA), 31 U.S.C. 3729-3733, by submitting a Medicaid reimbursement claim without maintaining adequate supporting documents. The district court dismissed the case, relying on the court's precedent in United States ex rel. Findley v. FPC-Boron Employees' Club. Because the court concluded that the Supreme Court had implicitly overruled Findley in Rockwell International Corp. v. United States, the court reversed. View "Davis v. DC" on Justia Law

States both appealed the district court's grants of summary judgment in favor of HHS, which upheld HHS's disallowance of certain Medicaid claims for Federal Financial Participation (FFP) as ineligible for "medical assistance" under the "Institution for Mental Diseases" (IMD) exclusion set forth in section 1905(a) of 42 U.S.C. 1396 et seq. (Medicaid Statute). Because HHS correctly concluded that the disputed claims were not eligible for FFP under the plain language of the IMD exclusion and the under-21 exception, the court affirmed the judgment of the district court. View "Virginia Dept. of Medical Assist. Svcs. v. HHS, et al." on Justia Law