Justia Government & Administrative Law Opinion Summaries

Prater was denied Social Security Disability Insurance benefits when she was 47-years-old and weighed about 400 pounds at 64 inches tall. X-rays showed mild-to-moderate degenerative joint disease in her feet and knees and degenerative disc disease in her spine. She was diabetic and had a history of gout. Prater stated that at her last job she experienced pain and fatigue “all the time.” None of her treating physicians indicated that she must alternate between sitting and standing. A vocational expert testified that a hypothetical individual with Prater's vocational background, education, and age, limited to sedentary work with restrictions on lifting, carrying, climbing, driving, and more, who could stand and walk no more than two hours of an eight-hour day and would need to change positions during the day but could remain in place for at least 30 minutes, whether sitting or standing, could not do any of Prater’s past jobs but could perform other jobs available in the national economy.The ALJ concluded that Prater was not disabled, finding that she had the residual functional capacity (RFC) to perform sedentary work with numerous restrictions; that her statements about the intensity, persistence, and limiting effects of her symptoms were “not entirely consistent” with the evidence; and that, although Prater was morbidly obese, “her physical examination was otherwise unremarkable.” The Appeals Council, the district court, and the Seventh Circuit upheld the decision. The sit/stand limitation in the RFC assessment is not too vague. The ALJ’s finding that she could sit and stand for 30 minutes at a time does not lack medical support; the ALJ did not improperly discredit her testimony that she could remain in position for only 20 minutes. View "Prater v. Saul" on Justia Law

Changes to the Pennsylvania Human Services Code terminated a cash assistance program for certain low-income individuals administered by the Department of Human Services ("DHS"). Appellants, being aggrieved by the termination of Cash Assistance, filed in the Commonwealth Court’s original jurisdiction, a Class Action Petition for Review on behalf of themselves and others similarly situated, seeking a preliminary injunction to prevent that aspect of the law from taking effect until a final merits determination as to the constitutionality of the act as a whole could be reached. The Commonwealth Court denied the request. After review, the Pennsylvania Supreme Court concluded the Commonwealth Court did not abuse its discretion in determining Appellants failed to carry their burden with regard to the likelihood-of-success-on-the-merits aspect of the standard for preliminary injunctive relief. That being the case, the Supreme Court did not not address whether the court erred in finding that Appellants failed to demonstrate irreparable harm. View "Weeks v. DHS" on Justia Law

Following a 2019 Federal Circuit decision and enactment of the Blue Water Navy Vietnam Veterans Act of 2019 133 Stat. 966, the petitioners, who served on open sea ships off the Vietnamese shore during the Vietnam War believed that they may be entitled to a presumption of service connection for diseases covered by 38 U.S.C. 1116. The Secretary of Veterans Affairs stayed pending disability compensation claims until January 1, 2020. Petitioners assert that many Blue Water Veterans are dying and filed a petition for expedited review under 38 U.S.C. 502 challenging the Secretary’s authority to stay pending disability compensation claims. The Federal Circuit denied the petition. The court concluded that it had jurisdiction 5 U.S.C. 552(a)(1)(D) because the Secretary’s memorandum amounts to an “interpretation[] of general applicability formulated and adopted by the agency.” The Act unambiguously authorizes the Secretary to stay disability compensation claims described in section 2(c)(3)(B) of the Act “until the date on which the Secretary commences the implementation of [] section 1116A,” 133 Stat. at 968. View "Procopio v. Secretary of Veterans Affairs" on Justia Law

McCord injured his back while serving in the Army and was discharged with a 20% disability rating. Because his rating was below 30% and he served for less than 20 years, McCord received severance pay instead of ongoing military retirement pay and received monthly VA benefits. The Army Board for Correction of Military Records later corrected his record to reflect a 30% disability rating and entitlement to medical retirement pay, rather than severance pay. McCord later challenged the government’s calculation of his entitlement to military retirement back pay and its claimed right to recover the severance pay and requested damages for medical expenses that he incurred because he was not afforded TRICARE coverage before the correction. The Claims Court rejected McCord’s approach to back pay calculation as “double-dipping,” denied relief regarding the recoupment of severance pay “as not ripe,” and held that McCord failed to exhaust administrative procedures for securing TRICARE benefits. The Federal Circuit affirmed except as to the out-of-pocket medical expenses. The court cited 10 U.S.C. 1201, 1203, 1212(d)(a), and 2774, as defining entitlement to retirement pay or severance pay, VA benefits, and the circumstances for recoupment of severance pay. A veteran receiving VA benefits may face a disadvantage if he also secures an award of military retirement pay because he would not be entitled to severance pay but military retirement pay includes TRICARE coverage. View "McCord v. United States" on Justia Law

Tennessee family medicine physicians, mostly in rural areas, received increased Medicaid payments in 2013-2014. In 2015 Tennessee’s Medicaid agency, TennCare, brought an administrative action to “recoup” an average of more than $100,000 per physician, alleging that the physicians had not met the 60-percent requirement of the Final Medicaid Payment Rule. Under 42 U.S.C. 13961(a)(13(C), a state plan for medical assistance must provide payment for primary care services furnished in 2013 and 2014 by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine at a specified rate; “primary specialty designation” was interpreted to mandate that the physician either show board certification in that specialty or that 60 percent of her recent Medicaid billings were for certain primary care services. The Sixth Circuit affirmed summary judgment in favor of the physicians, declaring the Rule invalid. The Centers for Medicare and Medicaid Services interpreted “a physician with a primary specialty designation” to have different meanings in parallel provisions of the Affordable Care Act although the context was the same. There is no 60-percent-of-billings requirement in 42 U.S.C. 1396a(a). The phrase “a physician with a primary specialty designation” means in section 1396a(a) the same thing that the agency said it means in section 1395l(x): a physician who has himself designated, as his primary specialty, one of the specialties recited in those provisions. View "Averett v. United States Department of Health & Human Services" on Justia Law

For four years, nurse practitioner Jordan treated Clanton’s severe hypertension. Jordan, an employee of the U.S. Public Health Service, failed to properly educate Clanton about his disease or to monitor its advancement. Clanton’s hypertension developed into Stage V kidney disease requiring dialysis and a transplant. Clanton successfully sued the government under the Federal Tort Claims Act. The court determined that Clanton had not contributed at all to his own injuries, noting that Clanton did not understand why it was important to take his medication and to attend appointments. The court awarded $30 million in damages. The Seventh Circuit vacated, finding that the court erred in its analysis of comparative negligence. Clanton’s subjective understanding does not end the inquiry. Illinois law requires the court to take the additional step of comparing Clanton’s understanding of his condition to that of a reasonable person in his situation. Clanton was in the position of a person whose caregiver failed to provide information about the severity of his condition but he had external clues that he was seriously unwell: two employment-related physicals showed that he had dangerously high blood pressure. The court upheld the court’s method of calculating damages and agreed that Clanton’s Medicare benefits are collateral to his damages award under Illinois law, so the government is not entitled to a partial offset. View "Clanton v. United States" on Justia Law

Brooke Rojas received food stamp benefits to which she was not legally entitled. The prosecution charged her with two counts of theft under the general theft statute, section 18-4-401(1)(a), C.R.S. (2019). Rojas moved to dismiss these charges, arguing that she could only be prosecuted under section 26-2-305(1)(a), C.R.S. (2019), because it created the specific crime of theft of food stamps. The trial court denied the motion, and a jury convicted Rojas of the two general theft counts. Rojas contended on appeal that the trial court erred by denying the motion to dismiss because section 26-2-305(1)(a) abrogated the general theft statute in food stamp benefit cases. A split division of the court of appeals agreed with her. The Colorado Supreme Court, however, disagreed with Rojas and the division majority. Based on the statute’s plain language, the Supreme Court held the legislature didn’t create a crime separate from general theft by enacting section 26-2-305(1)(a). View "Colorado v. Rojas" on Justia Law

Chang filed a qui tam action against the Center, asserting claims on behalf of the United States and the state under the False Claims Act (FCA). and the Delaware False Claims Act. Chang alleged that the Center had sought and received funding from the state and federal governments by misrepresenting material information. Both governments declined to intervene as plaintiffs. Chang filed an amended complaint and the Center answered. Nearly three years after Chang filed his original complaint, the U.S. and Delaware moved to dismiss the case, asserting that they had investigated Chang’s allegations and discovered them to be “factually incorrect and legally insufficient.” The court granted the motions without conducting an in-person hearing or issuing a supporting opinion. The Third Circuit affirmed. If the government chooses not to intervene, the relator may still “conduct the action” but the government may still “dismiss the action notwithstanding the objections of the person initiating the action if the person has been notified by the Government of the filing of the motion and the court has provided the person with an opportunity for a hearing on the motion,” 31 U.S.C. 3730(c)(2)(A). Chang never requested a hearing; the FCA does not guarantee an automatic in-person hearing to relators before their cases may be dismissed. View "Chang v. Children's Advocacy Center of Delaware" on Justia Law

Plaintiff-relator Matthew Omlansky, by virtue of knowledge gleaned as a state employee involved with the Medi-Cal program, brought this qui tam action in the name of the State of California alleging that defendant Save Mart Supermarkets (Save Mart) had violated the False Claims Act in its billings to Medi-Cal for prescription and nonprescription medications, charging a higher price than cash customers paid in violation of 2009 statutory provisions capping Medi-Cal charges at a provider’s usual and customary price (“statutory cap”). Per the trial court, the gist of the alleged fraud upon Medi-Cal, Save Mart generally offered a lower price for medications to cash customers, and would also match a lower price that a competitor was offering (although it appears from an exhibit to the complaint that the latter applied only to prescriptions), but did not apply these discounts from its list prices in the billings it submitted to Medi-Cal. The State declined to intervene. The trial court sustained a demurrer to the original complaint because all of the alleged violations occurred during a period when the 2009 statutory cap was subject to a federal injunction. Plaintiff then filed an essentially identical amended complaint. The only significant change was an allegation in paragraph 45 that Save Mart’s billing practices favoring cash customers continued from December 2016 to March 2017 after the expiration of the injunction, specifying six examples of “illegal pricing.” The court sustained Save Mart’s demurrer to this pleading as to two of the six grounds raised, and denied leave to amend. It entered a judgment of dismissal. Plaintiff timely appealed, but the Court of Appeal concurred with the grounds for the trial court’s ruling, thereby affirming dismissal of Plaintiff’s complaint. View "Omlansky v. Save Mart Supermarkets" on Justia Law

Plaintiff appealed the denial of his application for Social Security disability benefits, claiming that he had various physical impairments and that he suffered from bipolar disorder. The Eleventh Circuit held that, although plaintiff's claim of bias was forfeited, the ALJ's conclusion contained errors that must be addressed. In this case, the ALJ failed to articulate good cause for discounting two treating physicians' opinions; substantial evidence does not support the finding that plaintiff's bipolar disorder was non-severe; and the ALJ failed to consider plaintiff's mental impairments when assessing his residual functional capacity. Accordingly, the court affirmed in part, reversed in part, and remanded with instructions. View "Schink v. Commissioner of Social Security" on Justia Law