Justia Public Benefits Opinion Summaries

Appellant, a medicare provider, appealed its notice of program reimbursement for the fiscal year ending in 2001 to the Provider Reimbursement Review Board ("Board"), which dismissed the appeal because appellant missed its deadline to file a preliminary position paper. After the Board denied appellant's motion for reinstatement of its appeal, appellant filed the current action and subsequently appealed from the district court's order granting summary judgment for appellee. The court affirmed summary judgment and held that the Board's Instructions requiring dismissal of claims due to failure to timely submit preliminary position papers did not violate the Medicare Act, 42 U.S.C. 1395, and the Board's dismissal of appellant's claim was neither arbitrary or capricious.

Petitioner was awarded disability insurance benefits for a period beginning in 1983. In 2002 the Social Security Administration produced evidence he had engaged in substantial gainful employment; the Appeals Council accordingly reopened and remanded to an administrative law judge, who determined that petitioner was not entitled to disability benefits. The district court and Sixth Circuit affirmed. Petitioner's subsequent application for supplemental security income benefits was denied; the district court and Sixth Circuit affirmed. The petitioner then sought a writ of mandamus to compel the SSA to reopen his case and reinstate benefits. The Sixth Circuit dismissed for lack of jurisdiction to issue a writ directly to the agency.

Under Medicaid, the federal government reimburses between 50% and 83% of state costs for patient care for eligible low-income individuals, including developmentally-disabled individuals receiving care in home- and community-based settings.42 U.S.C.1396n(c). In 2001 Pennsylvania obtained a waiver that authorized reimbursement of state expenses for "habilitation services" for developmentally-disabled individuals. Until 2006, Pennsylvania did not seek reimbursement for occupancy costs for Medicaid recipients living in nonprofit and county facilities, but paid for room and board using state funds and the residents' Supplemental Security Income. The Center for Medicare and Medicaid Services rejected the state's 2006 claim that more than 54 percent of the occupancy costs were for reimbursable habilitation services. The appeals board and district court upheld the denial. The Third Circuit affirmed, based on the plain meaining of the statutory exclusion of costs for "room and board," and noting consistent interpretation of the statute

Plaintiff received disability insurance benefits under the Social Security Act 42 U.S.C. 301 et seq., between September 1994 and March 2004. After an investigation, the Social Security Administration ("SSA") notified plaintiff that she was ineligible for disability benefits because her employment income had exceeded SSA limits and determined that she was required to repay more than $60,000 in over paid benefits. At issue was whether the district court properly entered judgment for the SSA and denied plaintiff's waiver of over payment recovery and affirmed the ALJ's conclusion that it lacked authority to consider plaintiff's new argument contesting the amount of the overpayment itself. The court held that plaintiff failed to meet the administrative exhaustion requirement because she did not timely challenge her overpayment. Accordingly, since no final decision was made, the district court lacked jurisdiction under 42 U.S.C. 405(g) to consider plaintiff's challenge to the overpayment. The court also held that plaintiff was not entitled to a waiver of overpayment recovery because substantial evidence showed that she was not without fault in causing the overpayment and that the ALJ properly found that plaintiff knew or should have known that her work information was material because of her agreement to report such work in her benefit applications. Accordingly, the court affirmed the judgment of the district court.

Plaintiff Angela Weigel appealed a district court order that denied her supplemental Social Security Income benefits. On appeal to the Tenth Circuit, she challenged the court's findings that she was able to work despite her documented disabilities. Upon consideration of the administrative record, the Tenth Circuit found that the Administrative Law Judge's analysis of Plaintiff's case did not make the requisite findings required by law to justify the denial of benefits. The Court vacated the lower court's order and remanded the case for further proceedings.

Claimant appealed the district court's judgment upholding the Commissioner of Social Security's denial of her application for disability insurance. Appellant raised several issues of error on appeal. The court held that a certain physician's post-hearing letter did not contain any additional information and was not relied upon in the decision making process, and its receipt did not violate claimant's due process rights; that the ALJ did not err in finding claimant retained the residual functional capacity to perform certain kinds of low-stress work; that there was no error in the decision not to order a consultative examination regarding claimant's mental impairments; and that a hypothetical question posed to the Vocation Expert adequately addressed impairments supported by the record. Accordingly, the court affirmed the judgment where substantial evidence on the record as a whole supported the ALJ's decision.

The employee developed bilateral cubital tunnel syndrome while working at a supermarket, then worked as a greeter until she was laid off in 2003 because she was unable to perform the job. She subsequently started and left a dental hygiene, radiology technology, and electroencephalography training programs because of problems related to her hands and vision. At age 45 she had an extensive medical history, including fibromyalgia, degenerative disc disease, bilateral mild ulnar neuropathy, and multiple eye surgeries with dry eye syndrome. In 2008 an ALJ rejected her claim for social security disability benefits. The appeals council denied review and the district court affirmed. The Seventh Circuit affirmed, noting that the ALJ failed to acknowledge a physician report contrary to her conclusion and to explain the weight she gave that opinion, but stating that remand would serve no purpose in light of the overwhelming evidence supporting the denial.

Plaintiff applied for disability benefits based on combined impairments including bullous emphysema, depression, anxiety, and bipolar disorder and alleged that her disability began when her right lung collapsed. Plaintiff appealed the district court's decision affirming the Commissioner of Social Security's denial of her application for disability insurance benefits and supplemental security income benefits under Titles II and XVI of the Social Security Act, 42 U.S.C. et seq. The court held that the administrative law judge ("ALJ") erred by failing to follow the requirements of 20 C.F.R. 404.1520(a) in determining whether plaintiff's mental impairments were severe and, if severe, whether they met or equaled a listed impairment. Accordingly, the court reversed the judgment of the district court with instructions to remand to the ALJ to conduct a proper review of plaintiff's mental impairments.

Plaintiff brought action under the False Claims Act, 31 U.S.C. 3729, claiming that the company used a kickback scheme and knowingly caused submission of false Medicare, Medicaid, and TRICARE claims by hospitals and doctors. The district court held that hospital claims at issue were not false or fraudulent, and that doctor claims were false or fraudulent, but not materially so. The First Circuit reversed. If kickbacks affected the transactions underlying the claims, the claims failed to meet a condition of payment and were false, regardless of the hospital's participation in or knowledge of the kickbacks. It cannot be said, as a matter of law, that the alleged misrepresentations were not capable of influencing Medicare's decision to pay the claims.

The veteran, active in the Navy 1968-1971, reported traumatic events during a 1991 psychiatric evaluation. In 1993-1994 he sought benefits for post-traumatic stress disorder, again reporting an incident involving the death of a friend. In 1999 the VA awarded 100% disability, effective as of 1993. The veteran's complaints about how his claim was handled led to an OIG inspection in 2004, which disclosed that the veteran was not present at the accident that killed his friend. The veterans' court upheld a decision to severe benefits on the basis of fraud. The veteran had already receive about $320,000 and was subsequently convicted of fraud and sentenced to 48 months in prison and ordered to pay restitution. The federal circuit affirmed the veterans' court. The veteran had only claimed one stressor, so the VA was not required to investigate other possible stressors before terminating benefits. The VA properly followed its own procedures after determining that the matter exceeded the jurisdictional cap under the Program Fraud Civil Remedies Act, 31 U.S.C. 3801. The Act is not an exclusive remedy and the veteran was afforded due process.