Justia Public Benefits Opinion Summaries

Appellant filed suit in the district court when the Commissioner of the Social Security Administration (SSA) denied his application for disability benefits. At issue was whether the district court had authority to permit additional evidence to be taken on remand where the SSA asked the district court to remand the case so the agency could supplement the record and the district court obliged. The court held that because the district court misunderstood the full reach of its remedial authority, the court vacated the judgment and remanded the matter to the district court to consider the issue anew.

In 2006 the claimant sought disability benefits, alleging injury in a construction accident. An ALJ denied the claim and the appeals council denied review. The district court upheld the denial. The Sixth Circuit vacated. The ALJ's decision was incomplete and improperly gave greatest weight to the opinion of a non-treating state agency physician, rather than to the opinion of a treating physician. The ALJ mischaracterized the treating physician's treatment notes.

Plaintiff filed several suits against healthcare groups on behalf of the United States, claiming violation of the Medicare Secondary Payer Act, 42 U.S.C. 1395y(b). No court has ever found that the MSP is a qui tam statute, permitting private attorneys general to sue on behalf of the United States. The Sixth Circuit found plaintiff was on notice of the frivolous nature of his filings from their inception in the Tennessee district courts and remanded for a show-cause hearing on why sanctions should not issue. The district court awarded sanctions to two defendants in amounts of $131,158.50 and $145,431.19. The Sixth Circuit affirmed, but denied an award for the appeal.

West Virginia sued pharmaceutical manufacturers, claiming that the defendants artificially inflated the reimbursement values of certain drugs, in violation of the West Virginia Consumer Credit and Protection Act, W. Va. Code 46A-1-101, and a state statute prohibiting fraud and abuse in the Medicaid program. The complaint alleged that the defendants inflated the average wholesale price of certain drugs and caused the state to pay an artificially inflated amount of reimbursement for the drugs. One company agreed to pay West Virginia $850,000. After learning of the settlement in 2007, the federal Centers for Medicare & Medicaid Services notified West Virginia of a disallowance in federal funding for the state’s Medicaid program for failure to credit the federal government its share of the settlement proceeds. The Appeals Board sustained the disallowance. The district court upheld the decision. The Fourth Circuit affirmed, rejecting an argument the Medicaid Act, 42 U.S.C. 1396b(d)(2)(A), authorizes a disallowance only when the state has recovered from a "provider."

A 51-year-old man with a history of violent crime and drug abuse, applied for SSI (42 U.S.C. 1381). He alleged disability beginning in April 2002 due to bipolar disorder and anxiety. The application was denied in October 2006. An ALJ determined that petitioner was not disabled because he has been capable of making a successful adjustment to other work that exists in significant numbers in the national economy. The appeals council denied review. The district court upheld the decision and the Third Circuit affirmed. Any error in the district court's articulation of the standard of review was harmless, and the commissioner's determination was supported by substantial evidence.

Plaintiff Laurie Harper appealed a district court's order that affirmed the denial of her disability benefits. Plaintiff alleged her disability was based on fibromyalgia and depression. The Social Security Administration denied her applications initially and on reconsideration. The Administrative Law Judge determined that she was not "disabled" within the meaning of the Social Security Act. Upon review of the testimony of the expert witnesses and the record of the Commission's analysis of her case, the Tenth Circuit found sufficient evidence to support Ms. Harper's claim of disability in this case. The Court reversed the district court's order and remanded the case to the Commissioner for further proceedings.

The World War II veteran died in 2004, during litigation of whether a hip injury was service-related. The VA dismissed a pending appeal as moot and rejected the widow's request to be substituted. The Federal Circuit reversed. The widow filed her own claim for accrued benefits. The motion to substitute was denied, but the widow was awarded accrued benefits and sought $87,802.17 in attorney fees and expenses under the Equal Access to Justice Act, 28 U.S.C. 2412. The veterans' court determined that the widow had the right, as representative of the estate, to recover fees for attorney hours expended prior to his death, but had no right to recover fees for work performed after her husband’s death. The Federal Circuit reversed, stating that attorney work performed after the veteran's death was directly related to his claim; it was his claim, not the widow's claim, that was being litigated.

Defendants are health service providers that receive reimbursement from Medicare and Medicaid under 42 U.S.C. 1395, 1396. Plaintiffs, former employees of defendants, filed a qui tam action, alleging violations of various federal laws. After investigation, the government declined to intervene. The district court dismissed. The Third Circuit affirmed dismissal of False Claims Act, 31 U.S.C. 3729 claims based on violation of Medicare marketing regulations and reversed with respect to allegations that the defendants submitted false claims to the government by violating the Anti-Kickback Statute, 42 U.S.C. 1320. Payment of Medicare claims was not conditioned on compliance with marketing regulations.

Martin J. Bradley III and his father, Martin J. Bradley, Jr. (collectively, the Bradleys), owned Bio-Med Plus, Inc. (Bio-Med), a Miami-based pharmaceutical wholesaler that purchased and sold blood-derivatives. This case stemmed from multiple schemes to defraud the Florida and California Medicaid programs by causing them to pay for blood-derivative medications more than once. The Government chose to prosecute the schemes and a grand jury indicted eight individuals, including Albert L. Tellechea, and two companies, Bio-Med, and Interland Associates, Inc. The Bradleys, Bio-Med, and Tellechea subsequently appealed their convictions and raised several issues on appeal. The court affirmed the Bradleys', Bio-Med's, and Tellechea's convictions, and Bradley III's and Bio-Med's sentences. The court vacated Bradley, Jr.'s sentences on Counts I and 54 and Tellechea's sentence on Count 3, and remanded those counts for resentencing. The court reversed the district court's October 4, 2006 order appointing the receiver and monitor, and its supplemental receivership order of May 17, 2007. The court finally held that, as soon as circumstances allowed, the receivership should be brought to an immediate close.

This appeal involved a putative class action filed by three Pennsylvania Medicaid beneficiaries subject to the Pennsylvania Department of Public Welfare's (DPW) liens against future settlements or judgments. At issue was whether state agencies responsible for administering the Medicaid program have the authority to assert such liens and, if so, whether Pennsylvania's statutory framework was consistent with the Supreme Court's decision in Arkansas Department of Health and Human Services v. Ahlborn. The court examined the text, structure, history, and purpose of the Social Security Act, 42 U.S.C. 301 et seq., and held that liens limited to medical costs were not prohibited by the anti-lien and anti-recovery provisions of the Act, 42 U.S.C. 1396p(a)-(b). Accordingly, the court upheld Pennsylvania's longstanding practice of imposing such liens. The court also held that Pennsylvania's current statutory framework, which afforded Medicaid recipients a right of appeal from the default allocation, was a permissible default apportionment scheme.