Justia Public Benefits Opinion Summaries

The government alleges that Medicare overpaid Plaintiff and his medical practice approximately $5.31 million. While the third level of administrative review, a hearing before an Administrative Law Judge (“ALJ”), was pending, Medicare began to recover the overpaid funds by withholding new reimbursements. Plaintiff argued that recovery prior to an ALJ hearing and decision violates procedural due process. He moved for a preliminary injunction to prevent Medicare from recovering payments prior to the ALJ decision. The district court denied the preliminary injunction and Plaintiff appealed.   The Eighth Circuit affirmed the denial of the preliminary injunction finding that Plaintiff has not satisfied the requirements for a preliminary injunction. Further, he has not shown that he is likely to prevail on the merits of his procedural due process claim nor that he is likely to suffer irreparable harm. The court explained that if an audit shows that a provider has been overpaid, Medicare may seek to recover the overpaid funds. Moreover, if a Medicare contractor determines a provider has been overpaid, the provider may challenge that decision through administrative and judicial review.   Here, Plaintiff’s interest in avoiding erroneous recoupment outweighs the government’s interest in prompt repayment. However, there is no evidence in the record that any delay in recovery against Plaintiff will cause long-term harm to Medicare or prevent Medicare from providing services to other beneficiaries. Further, Plaintiff’s claims of irreparable harm are undercut by his apparent failure to try to ease the burdens of recoupment. View "Gurpreet Padda v. Xavier Becerra" on Justia Law

George joined the Marine Corps in 1975 without disclosing his history of schizophrenic episodes. His medical examination noted no mental disorders. George suffered an episode during training. The Marines medically discharged him. George applied for veterans’ disability benefits based on his schizophrenia, 38 U.S.C. 1110. The Board of Veterans’ Appeals denied his appeal from a regional office denial in 1977. In 2014, George asked the Board to revise its final decision. When the VA denies a benefits claim, that decision generally becomes “final and conclusive” after the veteran exhausts the opportunity for direct appeal. George sought collateral review under an exception allowing revision of a final benefits decision at any time on grounds of “clear and unmistakable error,” 38 U.S.C. 5109A, 7111. He claimed that the Board applied a later-invalidated regulation to deny his claim without requiring the VA to rebut the statutory presumption that he was in sound condition when he entered service.The Veterans Court, Federal Circuit, and Supreme Court affirmed the denial of relief. The invalidation of a VA regulation after a veteran’s benefits decision becomes final cannot support a claim for collateral relief based on clear and unmistakable error. Congress adopted the “clear and unmistakable error doctrine” developed under decades of prior agency practice. The invalidation of a prior regulation constitutes a “change in interpretation of law” under historical agency practice, not “clear and unmistakable error.” That approach is consistent with the general rule that the new interpretation of a statute can only retroactively affect decisions still open on direct review. The fact that Congress did not expressly enact the specific regulatory principle barring collateral relief for subsequent changes in interpretation does not mean that the principle did not carry over. View "George v. McDonough" on Justia Law

The formula that the Department of Health and Human Services must employ annually to set reimbursement rates for certain outpatient prescription drugs provided by hospitals to Medicare patients, 42 U.S.C. 1395l(t)(14)(A)(iii), provides two options. If HHS has conducted a survey of hospitals’ acquisition costs for each covered outpatient drug, it may set reimbursement rates based on the hospitals’ “average acquisition cost” for each drug, and may “vary” the reimbursement rates “by hospital group.” Absent a survey, HHS must set reimbursement rates based on “the average price” charged by manufacturers for the drug as calculated and adjusted by the Secretary. For 2018 and 2019, HHS did not conduct a survey but issued a final rule establishing separate reimbursement rates for hospitals that serve low-income or rural populations through the “340B program” and all other hospitals. The district court concluded that HHS had acted outside its statutory authority. The D.C. Circuit reversed. A unanimous Supreme Court reversed. The statute does not preclude judicial review of HHS’s reimbursement rates. Absent a survey of hospitals’ acquisition costs, HHS may not vary the reimbursement rates only for 340B hospitals; HHS’s 2018 and 2019 reimbursement rates for 340B hospitals were therefore unlawful. HHS’s power to increase or decrease the price is distinct from its power to set different rates for different groups of hospitals and HHS’s interpretation would make little sense given the statute’s overall structure. Congress, when enacting the statute, was aware that 340B hospitals paid less for covered prescription drugs and may have intended to offset the considerable costs of providing healthcare to the uninsured and underinsured in low-income and rural communities. View "American Hospital Association v. Becerra" on Justia Law

Appellants, Medicaid providers and former members of public-sector unions, challenge the district courts’ dismissals of two cases, consolidated on appeal. When Appellants joined the unions, they authorized the California State Controller to deduct union dues from their Medicaid reimbursements. Appellants now contend that, when the Controller made these deductions, she violated the “anti-reassignment” provision of the Medicaid Act, which prohibits state Medicaid programs from paying anyone other than the providers or recipients of covered services.   The Ninth Circuit affirmed the district court’s dismissal. The court explained that California uses some of its Medicaid funding to provide assistance with daily activities to elderly and disabled beneficiaries under a program called In-Home Support Services (IHSS). The recipients of these services are responsible for employing and overseeing the work of their IHSS providers, who are often family members. The Controller makes a variety of standard payroll deductions, including for federal and state income tax, unemployment compensation, and retirement savings. California law also authorizes the Controller to deduct union dues from the paychecks of IHSS providers.   Thus, the court held that the Medicaid Act’s anti-reassignment provision, 42 U.S.C. Section 1396a(a)(32), does not confer a right on Medicaid providers enforceable under Section 1983. The text and legislative history of the anti-reassignment provision make clear that Congress was focused on preventing fraud and abuse in state Medicaid programs rather than on serving the needs of Medicaid providers. Because Congress did not intend to benefit Medicaid providers, the anti-reassignment provision did not confer a right as enforceable under Section 1983. View "DELORES POLK V. BETTY YEE" on Justia Law

Gallardo suffered catastrophic injuries resulting in permanent disability when a truck struck her as she stepped off her Florida school bus. Florida’s Medicaid agency paid $862,688.77 to cover Gallardo’s initial medical expenses and continues to pay her medical expenses. Gallardo’s suit against the truck’s owner and the School Board resulted in an $800,000 settlement, with $35,367.52 designated as compensation for past medical expenses. The settlement did not specifically allocate any amount for future medical expenses.The Medicaid Act requires participating states to pay for certain individuals’ medical costs and to make reasonable efforts to recoup those costs from liable third parties, 42 U.S.C. 1396k(a)(1)(A). Under Florida’s Medicaid Third-Party Liability Act, a beneficiary who accepts medical assistance from Medicaid automatically assigns to the state any right to third-party payments for medical care; Florida was entitled to $300,000--presumptively representing the portion of the recovery that is for past and future medical expenses.The Supreme Court affirmed the Eleventh Circuit. The Medicaid Act permits a state to seek reimbursement from settlement payments allocated for future medical care. The Act’s anti-lien provision, prohibiting states from recovering medical payments from a beneficiary’s “property,” does not foreclose recovery from settlement amounts other than those allocated for past medical care paid for by Medicaid. Florida’s statute is expressly authorized by section 1396k(a) and is within the recognized exception to the anti-lien provision. The relevant distinction is between medical and nonmedical expenses, not between past and future medical expenses. Section 1396k(a)(1)(A) does not authorize a “lifetime assignment” covering any rights acquired in the future but covers only rights the individual possesses while on Medicaid. View "Gallardo v. Marstiller" on Justia Law

The Supreme Court affirmed the judgment of the court of appeals affirming the district court's denial of Appellant's postconviction petition in which she argued that her restitution order should be reduced, holding that there was no error or abuse of discretion.Appellant was convicted of medical assistance fraud for submitting fraudulent Medicaid claims to the Minnesota Department of Human Services through a company she owned and operated. The district court convicted Appellant of racketeering and ordered her to pay a $2.64 million restitution award. In her postconviction motion Appellant argued that her restitution award should be reduced because DHS's economic loss had to account for the economic benefit it received from her offense. The district court denied relief. The Supreme Court affirmed, holding (1) Minn. Stat. 611A.045, subd. 1(a)(1) requires a district court to consider the value of any economic benefits a defendant conferred on a victim when calculating a restitution award; and (2) the district court did not abuse its discretion when it calculated DHS's economic loss. View "State v. Currin" on Justia Law

In denying Plaintiff’s request for Social Security disability benefits, an Administrative Law Judge (ALJ) relied on the testimony of a vocational expert to conclude that a person with Plaintiff’s limitations, age, education, and work experience could still perform jobs that exist in significant numbers in the national economy. On appeal, Plaintiff claimed that the ALJ erred in not addressing competing job numbers that her counsel provided using his own methodology.   The Ninth Circuit affirmed the district court’s judgment upholding the Commissioner of Social Security’s denial of a claimant’s application. The court held in the context of similar challenges to ALJ decisions that an ALJ need only explain his rejection of significant probative evidence. The court reasoned that in accordance with Social Security Act regulations, an administrative law judge (“ALJ”) is entitled to rely on a vocational expert’s testimony to support a finding that the claimant can perform occupations that exist in significant numbers in the national economy.     The court reasoned that to engage in a meaningful review of a disability claim, an ALJ may not ignore significant probative evidence that bears on the disability analysis, but an ALJ need not discuss all evidence that was presented.  Here, Plaintiff’s attorney did not replicate the VE’s methodology, and Plaintiff’s different approach led to different numbers. There is no basis to conclude that these results qualified as significant probative evidence that the ALJ was required to address. View "SARAHROSE KILPATRICK V. KILOLO KIJAKAZI" on Justia Law

Plaintiff filed a lawsuit alleging state law claims arising from SelectHealth’s administration of her deceased husband’s MA plan and his death. Under Part C of the Medicare Act, beneficiaries can enroll in an MA plan and receive Medicare benefits through private MA organizations instead of the government. SelectHealth removed the action to federal court on the basis of diversity jurisdiction.   The Ninth Circuit affirmed the district court’s summary judgment in favor of SelectHealth, Inc. because the Medicare Act’s express preemption provision, 42 U.S.C. Section 1395w-26(b)(3), barred Plaintiff’s state law claims.   The court held that Section 1872 of Title XVIII of the SSA provides that Section 205(h) is applicable to cases under the Medicare Act to the same extent as in cases under Title II. The court concluded that enrollees in an MA plan must likewise first exhaust their administrative remedies before seeking judicial review of a claim for benefits.   Next, the court concluded that Plaintiff’s claims were not subject to the SSA’s exhaustion requirement because the dispute was not whether Plaintiff’s husband received a favorable outcome from the internal benefits determination process but rather whether he should have received the services earlier.   Further, the court held that Plaintiff’s claim that SelectHealth breached a duty to process timely her husband’s October 7, 2016, appeal was expressly preempted. Because the standards established under Part C supersede any state law duty that would impose obligations of MA plans on the same subject. View "NAOMI AYLWARD V. SELECTHEALTH, INC." on Justia Law

Plaintiff was civilly confined by court order pursuant to California’s Sexually Violent Predator Act (“SVPA”), after a probable cause hearing, but before a full civil commitment trial. While confined by court order in a state hospital, Plaintiff applied for Social Security disability benefits. The Social Security Administration (SSA) approved his application, and he received benefits.   In May 2014, the SSA notified Plaintiff that these benefits had been issued in error, and required him to refund the benefits previously paid. Plaintiff challenged that determination and requested a hearing before an Administrative Law Judge (ALJ). After a hearing, the ALJ determined that Section 402(x)(1)(A)(iii) made Plaintiff ineligible for benefits, and ordered him to repay the benefits to the SSA. Plaintiff sought judicial review of the ALJ’s decision and the district court concluded that Plaintiff was not eligible for disability benefits   The Ninth Circuit affirmed and held that the Commissioner did not err in concluding that Plaintiff was not eligible for benefits. The court reasoned the Social Security Act provides that no monthly benefits shall be paid to individuals who are confined at public expense, including someone who “immediately upon completion of confinement” for a criminal sexual offense “is confined in an institution at public expense pursuant to a finding that the individual is a sexually dangerous person or a sexual predator or a similar finding.”  Here, the state trial court’s confinement order in Plaintiff’s case was pursuant to a finding that he was a sexually dangerous person or a sexual predator or a similar finding. View "GEORGE ALLEN V. KILOLO KIJAKAZI" on Justia Law

Plaintiff appealed a judgment of the district court upholding an agency decision to deny her application for social security disability insurance benefits. Plaintiff argued that the administrative law judge (ALJ) who denied her claim erred by giving “little weight” to the opinion of one of her treating physicians.  The Eighth Circuit concluded that the ALJ permissibly weighed the evidence and affirmed the decision. The court held that the agency’s decision is supported by substantial evidence. On the record as a whole, the ALJ was justified in declining to give controlling weight to the conclusory opinion of Plaintiff’s treating physician.   The court reasoned that the doctor’s opinion was entitled to relatively little evidentiary value on its face because it was rendered on a check-box and fill-in-the-blank form. Further, the doctor’s opinion is also in tension with her own treatment notes. The treatment notes refer only to “evidence of elevated blood pressure levels and occasional skin abnormalities,” while observing “otherwise normal heart, lungs, and extremities.” Additionally, some of Plaintiff’s daily activities also undermined her doctor’s opinion of severe limitations. View "Deborah Swarthout v. Kilolo Kijakazi" on Justia Law