Justia Government & Administrative Law Opinion Summaries

Access Behavioral Health appeals from the district court’s judgment upholding an order of the Idaho Department of Health and Welfare that demanded recoupment of Medicaid payments made to Access. The Department sought to recoup certain payments made to Access because it failed to meet the Department’s documentation requirements. Following an audit of provider billings, the Department found Access billed Medicaid for two codes for services provided to the same patient on the same day without documentation to support its use of the codes. The Department concluded the documentation deficiencies violated IDAPA Rule 16.03.09.716 and the Handbook. The Idaho Supreme Court determined the Department had legal authority to issue recoupment demands to Access. Access failed to demonstrate an entitlement to payment of those funds sought to be recouped. The False Claims Act's materiality requirement was inapplicable to the Department’s administrative action. Finally, laches did not bar the Department’s administrative actions. Judgment was thus affirmed. View "Access Behavioral Health v. IDHW" on Justia Law

Jarnutowski sought Social Security disability benefits, claiming she could not work due to a foot condition, neck and leg pain, obesity, and mental health issues. Jarnutowski underwent multiple surgeries, X-rays, and CT scans on her foot between 2011-2015. An ALJ awarded Jarnutowski found that she was disabled during September 2013-January 2016, with only the ability to perform light work with some limitations; her foot condition, neck issues, and obesity were severe impairments; and, she was disabled by direct application of the Medical-Vocational Guidelines due to her age. The ALJ concluded that Jarnutowski’s disability ended when she regained the ability to perform medium work after her foot surgery and was again able to perform her past work as a store manager. The ALJ did not explicitly address Jarnutowski’s functional capabilities related to medium work, including Jarnutowski’s ability to lift objects weighing up to 50 pounds and frequently lift or carry objects weighing up to 25 pounds, emphasizing Jarnutowski’s ability to walk.The Seventh Circuit reversed. In Social Security disability determinations, the lifting and carrying weight requirements associated with medium work are more than double those of light work. The ALJ found that Jarnutowski’s “residual functional capacity” was limited to light work with some restrictions before her final foot surgery, but increased to medium work after the surgery without explaining how, after surgery, Jarnutowski could lift or carry objects more than twice the weight that she lifted or carried before surgery. View "Jarnutowski v. Kijakazi" on Justia Law

Class Counsel discovered the Social Security Administration's (SSA’s) systemic failure to perform “Subtraction Recalculations” and recovered over $106 million in past-due disability benefits. After performing the Subtraction Recalculations for all the claimants, the SSA argued that the district court did not have authority under the Social Security Act’s judicial-review provision, 42 U.S.C. 405(g), to order the Subtraction Recalculations and that Class Counsel cannot recover attorney fees under section 406(b) for representation of the claimants.The Sixth Circuit affirmed the award of $15.9 million in attorney fees to Class Counsel. SSA “may not hide behind” the statutory provisions merely because it erred at the end, rather than at the beginning, of the benefits-award process. The district court appropriately exercised judicial review under section 405(g), properly ordered the SSA to perform the Subtraction Recalculations, and properly awarded reasonable attorneys’ fees. The SSA failed to award claimants additional past-due benefits to which they were entitled. Counsel successfully sought judicial assistance to obtain those benefits. Congress did not create a statute that allows attorneys to recover fees when the SSA initially fails to award benefits, only to foreclose fee recovery when the SSA later unlawfully withholds additional benefits. View "Steigerwald v. Commissioner of Social Security" on Justia Law

Clemons worked as a coal miner for 10 years and smoked two packs per day for 30 years. Clemons suffered and died from COPD. His claims for federal black-lung benefits (30 U.S.C. 901) were denied. An ALJ awarded Mrs. Clemons survivor’s benefits after considering three medical opinions. Dr. Sikder diagnosed Clemons with legal pneumoconiosis in the form of COPD that resulted from both cigarette smoking and from coal-mine dust exposure. Doctros Habre and Broudy attributed Clemons’s COPD solely to his cigarette smoking. The ALJ credited Sikder’s opinion as well-documented, well-reasoned, and supported by substantial evidence, irrespective of the length of coal mine employment she considered, so that opinion was accorded “probative weight” while the other opinions did not sufficiently explain why Clemons’s coal-mine dust exposure did not contribute “at least in part” to his COPD. The Benefits Review Board affirmed, concluding that the evidence was sufficient to establish the presence of legal pneumoconiosis.The Sixth Circuit denied a petition for review, finding that the ALJ took the coal mine employment discrepancy into account when he weighed Dr. Sikder’s opinion, and acted within his discretion in explaining that the discrepancy was not so great as to detract from the opinion’s probative value. View "Huscoal, Inc. v. Director, Office of Workers’ Compensation Programs, United States Department of Labor" on Justia Law

The Ninth Circuit reversed in part and vacated in part the district court’s grant of Defendants’ motion to dismiss, and remanded for further proceedings, in an action in which federally-qualified health centers operating in Arizona and their membership organization alleged that the Arizona Health Care Cost Containment System, which administers Arizona’s Medicaid program, and its director violated 42 U.S.C. Section 1396a(bb) and binding Ninth Circuit precedent by failing or refusing to reimburse Plaintiffs for the services of dentists, podiatrists, optometrists, and chiropractors.   First, the panel held that the court’s precedent in California Ass’n of Rural Health Clinics v. Douglas (“Douglas”), 738 F.3d 1007 (9th Cir. 2013), established that FQHC services are a mandatory benefit under Section 1396d(a)(2)(C) for which Plaintiffs have a right to reimbursement under Section 1396a(bb) that is enforceable under 42 U.S.C. Section 1983. The panel rejected Defendants’ interpretation of Section 1396d(a)(2)(C)’s phrase “which are otherwise included in the plan” as applying to both the phrases “FQHC services” and “other ambulatory services offered by a [FQHC.]” The panel, therefore, rejected Defendants’ assertion that Section 1396d(a)(2)(C) only required states to cover FQHC services that are included in the state Medicaid plan.   The panel recognized that Douglas held that the mandatory benefit of “FQHC services” under § 1396d(a)(2)(C) includes “services furnished by . . . dentists, podiatrists, optometrists, and chiropractors” as well as doctors of medicine and osteopathy. The panel held that Arizona’s categorical exclusion of adult chiropractic services violated the unambiguous text of the Medicaid Act as interpreted in Douglas. View "AACHC V. AHCCCS" on Justia Law

The Mississippi Division of Medicaid (DOM) and Yalobusha County Nursing Home (YNH) disputed four costs submitted for reimbursement by YNH in its fiscal year 2013 Medicaid cost report. The DOM appealed a Chancery Court’s judgment ordering the DOM to reverse the four adjustments at issue. Because the DOM correctly interpreted the appropriate statutes and because its decisions were supported by substantial evidence, the Mississippi Supreme Court reversed the chancery court’s order and rendered judgment reinstating the decisions of the DOM. View "Mississippi Division of Medicaid v. Yalobusha County Nursing Home" on Justia Law

When Plaintiff-appellant Linda Smith purchased a prescribed continuous blood glucose monitor (CGM) and its necessary supplies between 2016 and 2018, she sought reimbursement through Medicare Part B. Medicare administrators denied her claims. Relying on a 2017 ruling issued by the Centers for Medicare and Medicaid Services (CMS), Medicare concluded Smith’s CGM was not “primarily and customarily used to serve a medical purpose” and therefore was not covered by Part B. Smith appealed the denial of her reimbursement claims through the multistage Medicare claims review process. At each stage, her claims were denied. Smith then sued the Secretary of the Department of Health and Human Services in federal court, seeking monetary, injunctive, and declaratory relief. Contending that her CGM and supplies satisfied the requirements for Medicare coverage. Instead of asking the court to uphold the denial of Smith’s claims, the Secretary admitted that Smith’s claims should have been covered and that the agency erred by denying her claims. Rather than accept the Secretary’s admission, Smith argued that the Secretary only admitted error to avoid judicial review of the legality of the 2017 ruling. During Smith’s litigation, CMS changed its Medicare coverage policy for CGMs. Prompted by several adverse district court rulings, CMS promulgated a formal rule in December 2021 classifying CGMs as durable medical equipment covered by Part B. But the rule applied only to claims for equipment received after February 28, 2022, so pending claims for equipment received prior to that date were not covered by the new rule. Considering the new rule and the Secretary’s confession of error, the district court in January 2022 remanded the case to the Secretary with instructions to pay Smith’s claims. The district court did not rule on Smith’s pending motions regarding her equitable relief claims; instead, the court denied them as moot. Smith appealed, arguing her equitable claims were justiciable because the 2017 ruling had not been fully rescinded. The Tenth Circuit agreed with the Secretary that Smith’s claims were moot: taken together, the December 2021 final rule and the 2022 CMS ruling that pending and future claims for CGMs would be covered by Medicare deprived the Tenth Circuit jurisdiction for further review. View "Smith v. Becerra" on Justia Law

Robert Procive appealed when a district court dismissed his appeal of an Administrative Law Judge’s order that denied his claim for Workforce Safety and Insurance (“WSI”) benefits. Procive submitted his first claim in 2020, alleging he suffered carpal tunnel syndrome due to injuries to both wrists, elbows, and shoulders resulting from repetitive digging, hammering and driving stakes, steel posts, and iron rods into the ground. He claimed his original injury occurred in western North Dakota, and he notified his employer of his injury in November 2004 and October 2016. WSI accepted liability for Procive’s right carpal tunnel injury, but denied for the left. Later WSI issued its order reversing its acceptance of liability for the right carpal tunnel, finding Procive willfully made false statements about whether he had prior injuries or received treatment. WSI ordered Procive to repay past benefits he received. After a hearing the ALJ affirmed WSI’s decisions denying coverage. Procive appealed to the district court in Stutsman County. WSI moved to dismiss the appeal, arguing the district court lacked subject matter jurisdiction because Procive was required to file his appeal in the county where the injury occurred or the county where he resided. To this, the North Dakota Supreme Court affirmed, finding the district court did not have jurisdiction. View "Procive v. WSI" on Justia Law

Grant Bauserman, Karl Williams, and Teddy Broe, on behalf of themselves and all others similarly situated, brought a putative class action in the Michigan Court of Claims against the Unemployment Insurance Agency, alleging that the Agency violated their due-process rights, and that the Agency also engaged in unlawful collection practices. Plaintiffs, who were all recipients of unemployment compensation benefits, specifically alleged defendant had used an automated fraud-detection system, the Michigan Integrated Data Automated System (MiDAS), to determine that plaintiffs had received unemployment benefits for which they were not eligible and then garnished plaintiffs’ wages and tax refunds to recover the amount of the alleged overpayments, interest, and penalties that defendant had assessed without providing meaningful notice or an opportunity to be heard. Among other remedies for this constitutional violation, plaintiffs sought monetary damages. Although the Michigan Supreme Court had never specifically held that monetary damages were available to remedy constitutional torts, the Court now held that they were. “Inherent in the judiciary’s power is the ability to recognize remedies, including monetary damages, to compensate those aggrieved by the state, whether pursuant to an official policy or not, for violating the Michigan Constitution unless the Constitution has specifically delegated enforcement of the constitutional right at issue to the Legislature or the Legislature has enacted an adequate remedy for the constitutional violation. Because enforcement of Const 1963, art 1, § 17 has not been delegated to the Legislature and because no other adequate remedy exists to redress the alleged violations of plaintiffs’ rights, we agree that plaintiffs have alleged a cognizable constitutional-tort claim for which they may recover money damages and we agree with the lower courts that defendant was properly denied summary disposition.” View "Bauserman v. Unemployment Insurance Agency" on Justia Law

Illinois moved its Medicaid program from a fee‐for‐service model, where a state agency pays providers’ medical bills, to one dominated by managed care, where private insurers pay medical bills. Most patients of Saint Anthony Hospital are covered by Medicaid, so Saint Anthony depends on Medicaid payments. Over the last four years, it has lost roughly 98% of its cash reserves, allegedly because managed‐care organizations have repeatedly and systematically delayed and reduced Medicaid payments to it. Saint Anthony sued, arguing that Illinois officials owe it a duty under the Medicaid Act to remedy the late and short payments.The Seventh Circuit reversed the dismissal of the suit, concluding that Saint Anthony has alleged a viable claim for relief under 42 U.S.C. 1396u‐ 2(f) and may seek injunctive relief under 42 U.S.C. 1983 against the state official who administers the Medicaid program in Illinois. Illinois has tools available to remedy systemic slow payment problems—problems alleged to be so serious that they threaten the viability of a major hospital and even of the managed‐care Medicaid program as administered in Illinois. If Saint Anthony can prove its claims, the chief state official could be ordered to use some of those tools to remedy systemic problems that threaten this literally vital health care program. View "Saint Anthony Hospital v. Eagleson" on Justia Law