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This case was a qui tam action alleging violations of the False Claims Act (“FCA”) involving fraudulent reimbursements under the Medicare Act. Plaintiff Gerald Polukoff, M.D., was a doctor who worked with Defendant Sherman Sorensen, M.D. After observing some of Sorensen’s medical practices, Polukoff brought this FCA action, on behalf of the United States, against Sorensen and the two hospitals where Sorensen worked (collectively, “Defendants”). Polukoff alleged Sorensen performed thousands of unnecessary heart surgeries and received reimbursement through the Medicare Act by fraudulently certifying that the surgeries were medically necessary. Polukoff further alleged the hospitals where Sorensen worked were complicit in and profited from Sorensen’s fraud. The district court granted Defendants’ motions to dismiss, reasoning that a medical judgment could not be false under the FCA. The Tenth Circuit reversed and remanded, holding that a doctor’s certification to the government that a procedure is “reasonable and necessary” is “false” under the FCA if the procedure was not reasonable and necessary under the government’s definition of the phrase. View "Polukoff v. St. Mark's Hospital" on Justia Law

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The Eighth Circuit affirmed the denial of social security disability insurance benefits on remand. The court held that the ALJ did not err in discounting the opinion of plaintiff's treating physician as not supported by objective medical evidence in the administrative record. Furthermore, the opinion was contrary to medically supported opinions of two specialists. The court agreed with the district court that the vocational expert identified another job plaintiff could perform with limited hand functioning, and there was nothing in the record suggesting that his impairments require that he be limited to occasional rather than frequent handling. View "Winn v. Commissioner" on Justia Law

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Under federal law, the Agency for Health Care Administration (AHCA) may only reach the past medical expenses portion - and not the future medical expenses portion - of a Medicaid recipient’s tort recovery to satisfy its Medicaid lien. Florida’s Medicaid program, administered by AHCA, paid $322,222 for Juan Villa’s medical care after Villa was injured in an accident. Villa settled with an alleged tortfeasor for $1 million. AHCA calculated the presumptively appropriate amount of its lien at $321,720 and asserted a lien in that amount against Villa’s settlement. An administrative law judge affirmed AHCA’s lien amount. The First District Court of Appeal affirmed, concluding that both Florida law and the federal Medicaid Act allow AHCA to secure reimbursement for its Medicaid expenses from the portions of Villa’s third-party settlement recovery allocated to both past and future expenses. The Supreme Court quashed the decision below, holding that the federal Medicaid Act prohibits AHCA from placing a lien on the future medical expenses portions of a Medicaid beneficiary’s third-party tort recovery to satisfy its Medicaid lien. View "Giraldo v. Agency for Health Care Administration" on Justia Law

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In 2010, Earley applied for disability benefits, 42 U.S.C. 423(d)(2)(A), 1382c(a)(3)(B) . In 2012, an ALJ rejected the application on the ground that Earley, who suffered from fibromyalgia, mild carpal tunnel syndrome, panic disorder, degenerative disk disease, and major depression, did not have a covered disability. She applied again for a new period of time. The same ALJ denied her benefits, citing Sixth Circuit precedent (Drummond) as requiring him to give preclusive effect to the work-capacity finding he had made during the first proceeding absent “new and material evidence documenting a significant change in the claimant’s condition.” The district court reversed, concluding that the Drummond “principles of res judicata” apply only when they favor an individual applicant, not the government. The Sixth Circuit disagreed. The key principles protected by Drummond—consistency between proceedings and finality with respect to resolved applications—apply to individuals and the government but do not prevent the agency from giving a fresh look to a new application containing new evidence or satisfying a new regulatory threshold that covers a new period of alleged disability while being mindful of past rulings and the record in prior proceedings. View "Earley v. Commissioner of Social Security" on Justia Law

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The Office of the Medicaid Inspector General (OMIG) may withhold payments to recover from Petitioner, the operator of a methadone clinic and provider of Medicaid-covered services, the full $1,857,401 in overpayments assessed following an audit. OMIG notified Petitioner than it had been overpaid $1,857,401 in claims from 2003 through 2007. OMIG informed Petitioner that it had twenty days to agree to settle these claims for a lower amount or OMIG would begin to withhold a percentage of Petitioner’s payments. When Petitioner did not agree to settle after twenty days and failed timely to commence an administrative appeal to challenge the audit findings, OMIG commenced withholding. Petitioner commenced this article 78 proceeding seeking to prohibit OMIG from liquidating the full amount in overpayments and a declaration that OMIG can collect only $1,460,914, the amount for which Petitioner declined to settle. The Court of Appeals held that OMIG was not precluded from seeking to withhold the full $1,857,401 amount. View "West Midtown Management Group, Inc. v. State" on Justia Law

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At issue in this mandamus proceeding was whether the proportionate-responsbility scheme in Chapter 33 of the Texas Civil Practice and Remedies Code applies to a civil-remedy action under the Texas Medical Fraud Prevention Act (TMFPA). The State sued Xerox Corporation and Xerox State HealthCare, LLC (collectively, Xerox), which administered the Texas Medicaid program, for a civil remedy under the TMFPA. Xerox sought to unite the TMFPA proceedings for purposes of shifting liability to the service providers sued by the State who had directly received disputed Medicaid payments. The trial court granted the State’s motion to strike Xerox’s third-party petition seeking contribution under Chapter 33, holding Chapter 33 inapplicable to the TMFPA action. The court also denied Xerox’s motion to designate responsible third parties under Chapter 33. The Supreme Court denied Xerox’s petition for writ of mandamus, holding that Chapter 33 does not apply to a TMFPA action because (1) the statutory remedy does not constitute “damages” subject to apportionment under Chapter 33; and (2) an irreconcilable conflict exists between the proportionate-responsibility statute and the TMFPA’s mitigation and fault-allocation scheme. View "In re Xerox Corp." on Justia Law

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In this interlocutory appeal, the Supreme Court held that sovereign immunity barred the counterclaims filed by Defendants against the State and that it lacked interlocutory jurisdiction to address the trial court’s dismissal of the Defendants’ third-party claims. The State brought this enforcement action under the Texas Medicaid Fraud Prevention Act, alleging that Defendants - several dentists and their professional associations and employees - fraudulently obtained Medicaid payments for providing dental and orthodontic treatments to children. Defendants asserted counterclaims and third-party claims alleging that the State and its contractor mismanaged the payment-approval process and misled Defendants regarding the requirements imposed by the Texas Medical Program. The trial court granted the State’s plea to the jurisdiction against the counterclaims and motion to dismiss the third-party claims. Defendants filed this interlocutory appeal. The court of appeals affirmed the trial court’s order dismissing Defendants’ counterclaims and concluded that it lacked jurisdiction over the order dismissing the third-party claims. The Supreme Court affirmed, holding (1) sovereign immunity barred the counterclaims, and (2) this Court lacked interlocutory jurisdiction to address the order dismissing the third-party claims. View "Nazari v. State" on Justia Law

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Plaintiffs were 23 federally qualified health centers (FQHC’s) and rural health clinics (RHC’s) that served medically underserved populations (the Clinics). The dispute before the Court of Appeal centered on coverage for adult dental, chiropractic, and podiatric services the FQHC’s and RHC’s provided to Medi-Cal patients for a period between 2009 and 2013. Prior to July 1, 2009, the Department processed and paid claims for these services. In 2009, in a cost-cutting measure due to budget problems, the Legislature enacted Welfare and Institutions Code section 14131.101 to exclude coverage for these services (and others) “to the extent permitted by federal law.” After the Department stopped paying claims for these services, various FQHC’s and RHC’s challenged the validity of section 14131.10, claiming it conflicted with federal Medicaid law. In California Assn. of Rural Health Clinics v. Douglas, 738 F.3d 1007 (9th Cir. 2013), the Ninth Circuit held section 14131.10 was invalid to the extent it eliminated coverage for these services when provided by FQHC’s and RHC’s because the federal Medicaid Act imposed on participating states the obligation to cover these services by these providers. In response to CARHC, the Department announced it would reimburse FQHC’s and RHC’s for these services for dates of service only on or after September 26, 2013, the date of the Ninth Circuit’s mandate. Seeking reimbursement for services provided prior to September 26, 2103, the Clinics petitioned for a writ of mandate to compel the Department to accept, process, and pay claims for these services for the period July 1, 2009, to September 26, 2013. The trial court granted the petition in part and entered judgment for the Clinics. The Department appeals. Characterizing the Clinics’ writ petition as a suit for damages, it contended: (1) sovereign immunity barred the Clinics’ claims for retroactive payment; (2) the CARHC decision was retroactive because the Medicaid Act is spending clause legislation and its terms were not sufficiently clear as to the requirement to cover adult dental, chiropractic, and podiatric services provided by FQHC’s and RHC’s; and (3) retroactive relief violated the separation of powers doctrine because it forces the Legislature to appropriate money. The Court of Appeal disagreed with the Department’s characterization of the Clinics’ lawsuit. "Rather than a suit for damages, the lawsuit seeks an order to compel performance of a mandatory duty and did not result in a money judgment. Under well-settled California law, such a mandamus proceeding is not barred by sovereign immunity. The Department’s contentions based on spending clause legislation and separation of powers are new arguments raised for the first time on appeal. We exercise our discretion to consider only the spending clause argument. We reject it because the Department has not shown its obligations under Medicaid law, as determined by CARHC, came as a surprise. The separation of powers argument raises factual issues about appropriations that should have been presented in the trial court and we decline to consider this new argument." Accordingly, the Court affirmed the judgment. View "American Indian Health etc. v. Kent" on Justia Law

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The Fifth Circuit reversed the denial of social security benefits for plaintiff, a former physician and army veteran, who was diagnosed with post traumatic stress disorder (PTSD), depression, and bipolar disorder. The court held that the ALJ's decision was not supported by substantial evidence where the ALJ erred in finding for step two of the five-step approach that plaintiff's impairments were not severe. Accordingly, the court remanded for further consideration. View "Salmond v. Berryhill" on Justia Law

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The IHSS program (Welf. & Inst. Code 12300) provides in-home services to elderly or disabled persons so that they may avoid institutionalization. For purposes of the state unemployment insurance system, IHSS service recipients are considered employers of their service providers if the providers are directly paid by the program or the recipient receives IHSS funds to pay their providers (Unemp. Ins. Code 683.) Generally, an employee of a close family member (child, parent or spouse) is excluded from unemployment insurance coverage. The California Unemployment Insurance Appeals Board ruled that, because a close-family-member IHSS service provider under the Direct Payment Mode is employed by the recipient, the provider is subject to the exclusion of Unemployment Insurance Code 631 (Caldera). Skidgel, an IHSS provider for her daughter, challenged the validity of Caldera, arguing government entities were joint employers with the recipient, thereby qualifying providers for unemployment insurance coverage despite the close-family-member exclusion. The court of appeal rejected the challenge, concluding that the Legislature, in enacting Unemployment Insurance Code section 683, intended to designate the recipient as the IHSS provider’s sole employer for purposes of unemployment insurance coverage. View "Skidgel v. California Unemployment Insurance Appeals Board" on Justia Law