Justia Public Benefits Opinion Summaries

When Medicare overpays hospitals, it offsets that mistake by reducing future payments. By 2013, Medicare was out $11 billion because of new diagnostic codes and bookkeeping that did not keep up. Congress required that the Secretary of Health and Human Services recoup that amount by the end of fiscal year 2017 by reducing the base rate (standardized amount) paid for inpatient care and directed the Secretary to adjust the base rate by 0.5% each year through 2023, 129 Stat. 87, 163 (2015). Subsequently, while reviewing the 2017 budget, the Secretary realized that a -3.2% adjustment would leave the agency short of its $11 billion goal and announced a -3.9% adjustment. Congress then told the Secretary to increase the base rate by 0.4588% (not 0.5%) in 2018, 130 Stat. 1033, 1320 (2016). In 2017, the Secretary adjusted the base rate -3.9%. The agency met its goal. In 2018, the Secretary adjusted the base rate -3.4412%.Medicare providers sued, arguing that the Secretary should have reversed that expedient at the end of 2017 rather than carry it over into 2018, costing the hospitals $840 million in lost payments. The D.C. Circuit affirmed the dismissal of the suit. While the hospitals felt a “significant financial impact” from the -0.7% adjustment, Section 7(b)(5) bars judicial review of adjustments made under the Act. View "Fresno Community Hospital and Medical Center v. Cochran" on Justia Law

The Eighth Circuit affirmed the denial of social security benefits to plaintiffs, rejecting plaintiffs' claim that the ALJs who denied their claims were not properly appointed under the Appointments Clause of the Constitution. The court held that plaintiffs' unexhausted claims are foreclosed by Davis v. Saul, 963 F.3d 790 (8th Cir. 2020), cert. granted, 2020 WL 6551772 (Nov. 9, 2020) (No. 20-105). View "Smith v. Saul" on Justia Law

Plaintiffs, former recipients of Social Security disability benefits and former clients of an attorney who orchestrated one of the largest fraud schemes in the history of the SSA, argued in consolidated appeals that SSA's categorical exclusion of allegedly fraudulent medical evidence during the redetermination process was unlawful because they were never afforded any opportunity to rebut the allegation that their evidence was tainted by fraud.The Fourth Circuit joined its sister circuits and held that the SSA's redetermination procedures violate the Administrative Procedure Act (APA) and the Due Process Clause of the Fifth Amendment. The court agreed with plaintiffs that it is arbitrary and capricious for the agency to deny beneficiaries an opportunity to contest the Office of the Inspector General's fraud allegations as to their cases, while permitting other similarly situated beneficiaries to challenge similar allegations arising from SSA's own investigations. The court also agreed with plaintiffs that the SSA's redetermination procedures violated their due process rights under the Fifth Amendment because they were denied the opportunity to contest the Office of the Inspector General's fraud allegations against them. In this case, the court considered each Mathews factor and concluded that each factor supports a finding that the SSA's redetermination procedures violated plaintiffs' due process rights. Accordingly, the court affirmed in No. 19-1989 and reversed in No. 19-2028. View "Kirk v. Commissioner of Social Security Administration" on Justia Law

For many years, attorney Conn obtained social security benefits for his clients by submitting fraudulent reports and bribing an Administrative Law Judge. After the government discovered this fraud, the SSA decided to redetermine whether each of Conn’s 1,500 claimants was actually eligible for disability benefits. The SSA held hearings and allowed the claimants to submit evidence but categorically excluded medical reports created by the doctors with whom Conn had conspired because it had “reason to believe” fraud was involved in the creation of the reports (42 U.S.C. 1383(e)(7)(A)(ii))). The claimants were not permitted to challenge that finding. After the denials of their claims, 57 plaintiffs filed suit.The Sixth Circuit held that the exclusion of the reports violated the Due Process Clause and the APA. On remand, the district courts concluded that remand to the SSA was proper because “the Commissioner erred in some respect in reaching the decision to deny benefits.”The Sixth Circuit affirmed the subsequent denial of the plaintiffs’ motions for attorney’s fees under the Equal Access to Justice Act. The government’s position in the litigation was “substantially justified,” in light of the precedent cited by the government, the rationale for the decision, and the fact that district courts across the country have split on this issue. The case involved numerous issues of first impression. Despite the fact that the government’s arguments were rejected, a reasonable person could have believed them to be correct. View "Wireman v. Commissioner of Social Security" on Justia Law

The Fifth Circuit affirmed the district court's decision upholding the Commissioner's denial of supplemental security income and disability insurance benefits to plaintiff. The court explained that, although the ALJ did not mention the Stone standard, it did cite Social Security Ruling (SSR) 85-28, 1985 WL 56856 (Jan. 1, 1985), a policy statement issued to clarify the agency’s process for determining non-severe impairments. The court held that SSR 85-28 comports with the Stone standard. The court also held that, even if the ALJ failed to properly apply the Stone standard, the error is harmless. In this case, plaintiff does not meaningfully address how the ALJ's application of SSR 85-28 (instead of citing Stone) produced a different outcome in her case. View "Keel v. Saul" on Justia Law

The Supreme Court affirmed the decision of the court of appeals affirming the judgment of the district court reversing a transfer penalty imposed by the Commissioner of the Minnesota Department of Human Services on David Pfoser, a disabled Medicaid recipient who resided in a long-term care facility, after he transferred partial proceeds from the sale of a house into a pooled special-needs trust, holding that Pfoser made a satisfactory showing that he intended to receive valuable consideration for his transfer of assets.State and federal law impose a penalty on recipients, like Pfoser, of Medical Assistance for Long-Term Care benefits if they transfer assets for less than fair market value, but no penalty is imposed if the recipient makes a satisfactory showing that he intended to dispose of the assets either at fair market value or for other valuable consideration. See Minn. Stat. 256B.0595, subd. 4(a)(4). The Commissioner affirmed the transfer penalty imposed on Pfoser. The district court reversed, concluding that Pfoser received adequate compensation in the form of his vested equitable interest in the trust assets. The Supreme Court affirmed, holding that substantial evidence did not support the Commissioner's decision to uphold the penalty. View "Pfoser v. Harpstead" on Justia Law

The Fourth Circuit reversed the district court's decision affirming the ALJ's determination that plaintiff's disability had ceased as of March 31, 2013. The court concluded that the ALJ committed two legal errors: first, the ALJ erred by failing to consider each of the factors listed in 20 C.F.R. 404.1527(c) before affording only negligible weight to the medical opinion of one of plaintiff's treating physicians; and second, the ALJ erred by assessing plaintiff's residual functional capacity (RFC) pursuant to an incorrect framework and without explaining his RFC-related findings in the manner required by Social Security regulations. Accordingly, the court remanded for further administrative proceedings. View "Dowling v. Commissioner of Social Security Administration" on Justia Law

Zellweger applied for disability benefits in 2013, claiming a per se disabling spinal condition equivalent to Listing 1.04. His amended onset date was August 28, 2013. His last-insured status expired on September 30, 2013, so the application presented a narrow question: whether he was disabled during the one-month period from August 28 to September 30 (42 U.S.C. 416(i)(3)(B)). The primary medical basis for his application was cervical and lumbar degenerative disc disease.An ALJ denied his claim, concluding that the medical evidence did not meet the criteria for Listing 1.04 and that Zellweger could perform light work. A magistrate reversed, ruling that the ALJ’s discussion was too cursory at step three of the sequential analysis prescribed in the agency regulations: assessing whether the claimant has an impairment that meets or medically equals one of the Listings. Although the ALJ explained his reasoning more thoroughly later in his decision, the magistrate refused to consider that discussion.The Seventh Circuit reversed and remanded. The sequential process is not so rigidly compartmentalized. Nothing prohibits a reviewing court from reading an ALJ’s decision holistically. The ALJ thoroughly analyzed the medical evidence at the step in the sequential analysis that addresses the claimant’s residual functional capacity. That analysis elaborated on the more cursory discussion at step three and was easily adequate to support the ALJ’s rejection of a per se disability under Listing 1.04. View "Zellweger v. Saul" on Justia Law

James-Cornelius sought compensation under the National Vaccine Injury Compensation Program, alleging that her 17-year-old son, E.J., had suffered dysautonomia, postural orthostatic tachycardia syndrome (POTS), and other symptoms as a result of receiving three shots of the HPV vaccine, Gardasil®. While there are no records of medical visits between his first and second vaccinations, the records document his medical visits, symptoms, and diagnoses after his third vaccination. The petition identified medical articles hypothesizing that HPV vaccines can cause dysautonomia and POTS and alleged that the increasing severity of his symptoms is “evidence of re-challenge” and that the pattern of worsening reactions is “strongly probative of a causal relationship” between the vaccine and E.J.’s symptoms, some of which were listed as potential Gardasil® side effects.James-Cornelius unsuccessfully attempted to obtain medical records relating to urgent care visits that she believed occurred before E.J.’s second vaccination. She eventually dismissed her petition, explaining that “she [would] likely be unable to prove" entitlement to compensation. James-Cornelius sought $17,111.12 in attorneys’ fees and costs under 42 U.S.C. 300aa-15(e)(1), asserting that she had filed her petition in good faith and with a reasonable basis. . The Federal Circuit vacated the denial of the petition. The Special Master failed to consider relevant objective evidence. E.J.’s medical records support for James-Cornelius’s reasonable basis claim even without an express medical opinion on causation. The Special Master erroneously concluded that petitioners’ affidavits are categorically “not ‘objective" for evaluating reasonable basis. View "James-Cornelius v. Secretary of Health and Human Services" on Justia Law

Lothridge applied for disability insurance benefits and supplemental security income in 2013 when she was 33 years old. She asserted that she was disabled by fibromyalgia, COPD, asthma, and hypertension. She was diagnosed with bipolar disorder, learning disabilities, significant problems with decision-making, moderate problems with social functioning, and problems with remote memory. She had worked as a CNA, a daycare worker, a cashier, and a telemarketer. She had tried, unsuccessfully. to earn her GED. Hip and back pain caused her to stop working in 2009.After an ALJ denied her application, a district judge remanded for further explanation of how the ALJ considered Lothridge’s periodic non-compliance with treatments. The ALJ again denied the application, finding that Lothridge could still perform light work with certain limitations. A district judge affirmed.The Seventh Circuit vacated. In assessing Lothridge’s impairments using the five-step disability analysis, the ALJ found moderate limitations in concentration, persistence, and pace. In determining her residual functional capacity, the ALJ failed to take those limitations into account. The jobs that the ALJ determined that Lothridge could still perform would require the ability to stay on-task for at least 90% of the workday and would have little tolerance for tardiness or absences. The ALJ made no determination of whether Lothridge is capable of meeting these requirements. View "Lothridge v. Saul" on Justia Law