Justia Public Benefits Opinion Summaries

MSPA Claims 1 LLC—the assignee of a now-defunct Medicare Advantage Organization—sued Tower Hill Prime Insurance Company to recover a reimbursable payment. The district court granted Tower Hill’s motion for summary judgment because it determined that MSPA Claims 1’s suit was untimely.The Eleventh Circuit affirmed. The court explained that because it is at least “plausible” that the term “accrues” in Section 1658(a) incorporates an occurrence rule—in fact, and setting presumptions aside, the court wrote that it thinks that’s the best interpretation—that is how the court interprets it. Therefore, MSPA Claims 1’s cause of action accrued in 2012 when MSPA Claims 1’s assignor, Florida Healthcare, paid D.L.’s medical bills and became entitled to reimbursement through the Medicare Secondary Payer Act. Because that was more than four years before MSPA Claims 1 filed suit in 2018, its suit is not timely under 28 U.S.C. Section 1658(a). View "MSPA Claims 1, LLC. v. Tower Hill Prime Insurance Co." on Justia Law

An Administrative Law Judge (“ALJ”) denied Plaintiff benefits based on the testimony of a vocational expert (“VE”) that there were an estimated 72,000 “Table worker,” 65,000 “Assembler,” and 32,000 “Film touch up inspector” jobs in the national economy that claimant could perform. After the ALJ issued her decision, claimant’s attorney submitted to the Social Security Administration (“SSA”) Appeals Council different estimates for those same jobs, allegedly using the same software program used by the VE. The Appeals Council considered the new evidence but denied claimant’s request for review.The Ninth Circuit reversed the district court’s decision granting summary judgment to the Commissioner of Social Security and affirming the denial of Plaintiff’s claim for Supplemental Security Income (“SSI”) benefits, and remanded to the district court with directions that the case be remanded to the agency for further proceedings. The court held that under Buck v. Berryhill, 869 F.3d 1040 (9th Cir. 2017), remand was required to allow the ALJ to address claimant’s evidence of widely discrepant job number estimates.The claimant estimated—using SkillTRAN Job Browser Pro and the same DOT codes the VE had used—that there were 2,957 table worker, 0 assembler, and 1,333 film tough-up inspector jobs in the national economy. The discrepancy between the VE and the claimant’s estimates was comparable to the discrepancy in Buck. View "TYRONE WHITE V. KILOLO KIJAKAZI" on Justia Law

The Seventh Circuit affirmed the judgment of the district court denying Heart of CarDon, LLC's motion for judgment on the pleadings in this interlocutory appeal concerning section 1557 of the Patient Protection and Affordable Care Act, holding that T.S. was a proper plaintiff against CarDon under section 1557, and his suit may continue on that basis.CarDon was a healthcare provider that was reimbursed by Medicare and Medicaid for its serves. CarDon provided health insurance to its employees and their depends through a self-funded employee benefits plan. T.S., a dependent who had autism, brought this action alleging that the plan's exclusion of coverage for autism treatment violated section 1557. CarDon moved for judgment on the pleadings, arguing that only a recipient of CarDon's healthcare services was a permissible plaintiff under section 1557. The district court denied the motion. The Seventh Circuit affirmed, holding that T.S. plausibly alleged an interest that comes within the zone of interests section 1557 seeks to protect. View "T.S. v. Heart of CarDon, LLC" on Justia Law

Robert Procive appealed when a district court dismissed his appeal of an Administrative Law Judge’s order that denied his claim for Workforce Safety and Insurance (“WSI”) benefits. Procive submitted his first claim in 2020, alleging he suffered carpal tunnel syndrome due to injuries to both wrists, elbows, and shoulders resulting from repetitive digging, hammering and driving stakes, steel posts, and iron rods into the ground. He claimed his original injury occurred in western North Dakota, and he notified his employer of his injury in November 2004 and October 2016. WSI accepted liability for Procive’s right carpal tunnel injury, but denied for the left. Later WSI issued its order reversing its acceptance of liability for the right carpal tunnel, finding Procive willfully made false statements about whether he had prior injuries or received treatment. WSI ordered Procive to repay past benefits he received. After a hearing the ALJ affirmed WSI’s decisions denying coverage. Procive appealed to the district court in Stutsman County. WSI moved to dismiss the appeal, arguing the district court lacked subject matter jurisdiction because Procive was required to file his appeal in the county where the injury occurred or the county where he resided. To this, the North Dakota Supreme Court affirmed, finding the district court did not have jurisdiction. View "Procive v. WSI" on Justia Law

Plaintiff hospices exceeded their aggregate caps in the 2013 fiscal year, and three Silverado hospices also exceeded their aggregate caps in the 2014 fiscal year. Plaintiffs appealed their cap determinations to the Provider Reimbursement Review Board (“PRRB”), arguing that their MAC had failed to calculate the aggregate cap using the “actual net amount of payment received by the hospice provider.” The Ninth Circuit affirmed the district court’s summary judgment in favor of the government.   The court held that CMS correctly concluded that the Budget Control Act required it to reduce the total annual amounts paid to hospices, not only the periodic reimbursements, and that the agency’s chosen method for implementing sequestration was consistent with the Medicare statute. The court further held that the agency was not required to undertake notice-and-comment rulemaking before implementing the Budget Control Act’s sequestration mandate. The agency’s sequestration method, as reflected in the TDL and the PRRB’s decisions, did not amount to the “establish[ment]” or “change[]” of a substantive legal standard governing payment for services under Medicare, within the meaning of 42 U.S.C. Section 1395hh. Rather, Congress enacted the Budget Control Act’s sequestration requirements, and the President implemented sequestration when the statutory conditions were triggered. View "SILVERADO HOSPICE, INC. V. XAVIER BECERRA" on Justia Law

Grant Bauserman, Karl Williams, and Teddy Broe, on behalf of themselves and all others similarly situated, brought a putative class action in the Michigan Court of Claims against the Unemployment Insurance Agency, alleging that the Agency violated their due-process rights, and that the Agency also engaged in unlawful collection practices. Plaintiffs, who were all recipients of unemployment compensation benefits, specifically alleged defendant had used an automated fraud-detection system, the Michigan Integrated Data Automated System (MiDAS), to determine that plaintiffs had received unemployment benefits for which they were not eligible and then garnished plaintiffs’ wages and tax refunds to recover the amount of the alleged overpayments, interest, and penalties that defendant had assessed without providing meaningful notice or an opportunity to be heard. Among other remedies for this constitutional violation, plaintiffs sought monetary damages. Although the Michigan Supreme Court had never specifically held that monetary damages were available to remedy constitutional torts, the Court now held that they were. “Inherent in the judiciary’s power is the ability to recognize remedies, including monetary damages, to compensate those aggrieved by the state, whether pursuant to an official policy or not, for violating the Michigan Constitution unless the Constitution has specifically delegated enforcement of the constitutional right at issue to the Legislature or the Legislature has enacted an adequate remedy for the constitutional violation. Because enforcement of Const 1963, art 1, § 17 has not been delegated to the Legislature and because no other adequate remedy exists to redress the alleged violations of plaintiffs’ rights, we agree that plaintiffs have alleged a cognizable constitutional-tort claim for which they may recover money damages and we agree with the lower courts that defendant was properly denied summary disposition.” View "Bauserman v. Unemployment Insurance Agency" on Justia Law

After voluntarily leaving his job due to back problems, Plaintiff applied for disability insurance benefits. The Social Security Administration found that he was not disabled and denied his application. Plaintiff sought judicial review and the district court1 affirmed. He appealed, arguing that the agency’s decision was not supported by substantial evidence.   The Eighth Circuit affirmed, explaining that when reviewing the denial of disability insurance benefits, the court decides whether the findings are supported by substantial evidence on the record as a whole. Here, Plaintiff claims that his treating physician’s opinion was entitled to deference. However, the court explained, that under the current regulations, however, treating physicians are not entitled to special deference. And although Plaintiff may disagree with the ALJ’s conclusion, it is supported by substantial evidence on the record as a whole. View "Jason Bowers v. Kilolo Kijakazi" on Justia Law

Morris served in the Army, 1965-1968. In 1970, he unsuccessfully sought disability benefits (38 U.S.C. 1110), alleging a disability based on a nervous condition connected to his service. The VA instead granted his claim for a pension based on a non-service-connected condition. In 2005, Morris sought compensation based on service-connected PTSD; he was eventually assigned a 100% disability rating.Morris has for many years been seeking an earlier effective date for service-connected disability compensation. The VA regional office and the Board of Veterans’ Appeals found no clear and unmistakable error. The Court of Appeals for Veterans Claims rejected a claim that a September 1970 notice from the VA—giving notice of the August 1970 rating decision—was constitutionally inadequate under the Due Process Clause; Morris had not presented this argument to the Board but contended that the Veterans Court was obligated to consider this constitutional question in the first instance under 38 U.S.C. 7261(a)(1). The Veterans Court exercised its discretion, under issue-exhaustion precedents, to decline to entertain the argument presented for the first time on appeal. The Federal Circuit affirmed the dismissal of the appeal. The Veterans Court had the discretion to apply an issue-exhaustion analysis and correctly applied that analysis. View "Morris v. McDonough" on Justia Law

In 2016, the Secretary of Health and Human Services (“HHS”) issued a final rule that implemented The Protecting Access to Medicare Act of 2014 (“PAMA” or “Act”), definition of “applicable laboratory” (“2016 Rule”). The American Clinical Laboratory Association (“ACLA”) filed a lawsuit challenging the 2016 Rule as arbitrary and capricious under the Administrative Procedure Act (“APA”) on the basis that it depresses Medicare reimbursement rates by excluding most hospital laboratories from PAMA’s reporting requirements. ACLA contended that because hospital laboratories tend to charge higher prices than standalone laboratories, their exclusion from reporting obligations results in an artificially low weighted median.   On remand, the parties cross-moved for summary judgment. The district court declined to reach the merits of ACLA’s APA challenge to the 2016 Rule, based on its determination that the Secretary had issued a new rule (“2018 Rule”) that superseded the 2016 Rule and mooted ACLA’s lawsuit.   The DC Circuit concluded that the case is not moot. Accordingly, the court reversed the district court’s dismissal for lack of subject matter jurisdiction and reached the merits of ACLA’s APA claim. The court explained that the 2016 Rule is arbitrary and capricious because the agency “failed to consider an important aspect of the problem.” The court wrote that PAMA provides that an applicable laboratory “means a laboratory that” receives “a majority” of its Medicare revenues from the Physician Fee Schedule or Clinical Laboratory Fee Schedule. Thus, hospital laboratories that provide outreach services may, in some instances, constitute “applicable laboratories” under PAMA. View "American Clinical Laboratory Association v. Xavier Becerra" on Justia Law

Illinois moved its Medicaid program from a fee‐for‐service model, where a state agency pays providers’ medical bills, to one dominated by managed care, where private insurers pay medical bills. Most patients of Saint Anthony Hospital are covered by Medicaid, so Saint Anthony depends on Medicaid payments. Over the last four years, it has lost roughly 98% of its cash reserves, allegedly because managed‐care organizations have repeatedly and systematically delayed and reduced Medicaid payments to it. Saint Anthony sued, arguing that Illinois officials owe it a duty under the Medicaid Act to remedy the late and short payments.The Seventh Circuit reversed the dismissal of the suit, concluding that Saint Anthony has alleged a viable claim for relief under 42 U.S.C. 1396u‐ 2(f) and may seek injunctive relief under 42 U.S.C. 1983 against the state official who administers the Medicaid program in Illinois. Illinois has tools available to remedy systemic slow payment problems—problems alleged to be so serious that they threaten the viability of a major hospital and even of the managed‐care Medicaid program as administered in Illinois. If Saint Anthony can prove its claims, the chief state official could be ordered to use some of those tools to remedy systemic problems that threaten this literally vital health care program. View "Saint Anthony Hospital v. Eagleson" on Justia Law