Justia Government & Administrative Law Opinion Summaries

In 2011, Cosenza sought disability benefits on behalf of her minor son. An ALJ determined that J.M.F. was not disabled. The Appeals Council denied her request for review. Cosenza argued that the ALJ improperly found that her son’s autism and Asperger’s syndrome were not “medically determinable” impairments. The district judge granted Cosenza summary judgment and remanded under 42 U.S.C. 405(g); 5), terminating the case in the district court. On remand, another ALJ conducted a hearing in March 2016. In June Cosenza filed a motion in the closed federal case to hold the Commissioner in contempt “for not following court-ordered remand.” In July the ALJ ruled against Cosenza. Cosenza did not wait for the decision to become final but moved for summary judgment in the closed federal case and filed a letter with the Appeals Council requesting review. The district court granted the agency’s motion to strike, reasoning that it had relinquished jurisdiction over Cosenza’s first case; as to most recent decision, the administrative appeals process had not finished so no final decision existed for judicial review. Cosenza had not shown that the Commissioner violated the court’s remand order. The Seventh Circuit affirmed. A district court lacks jurisdiction under the Social Security Act to review an ALJ’s unfavorable decision until the agency’s decision is final; the Appeals Council has not yet decided whether to review the ALJ’s decision. View "Cosenza v. Berryhill" on Justia Law

Schloesser worked for 23 years as a dry curer in a meat‐processing factory, regularly lifting more than 70 pounds. After undergoing rotator cuff surgery on his left shoulder in 2001 and then a lactimectomy (disc removal in his lower back) in 2002, Schloesser left the factory in 2003. Until 2009, he was self‐employed in construction, until his persistent shoulder and lower back problems prevented him from being able to regularly lift more than 50 pounds as required by his work. In 2012, Schloesser applied for disability insurance benefits under 42 U.S.C. 416(i). The Social Security Administration initially denied his application but an Administrative Law Judge found him disabled and granted benefits in 2014. One month later, sua sponte, the SSA Appeals Council commenced review and reversed the ALJ’s favorable decision. The district court affirmed the Appeals Council’s decision as supported by substantial evidence. The Seventh Circuit affirmed, upholding findings that Schloesser did not suffer from severe impairments of cervical radiculopathy, major joint dysfunction, and history of left shoulder surgery and that his residual functional capacity did not include being off‐task up to 10% of the workday or needing unscheduled breaks. View "Schloesser v. Berryhill" on Justia Law

An employee continued to work for over ten years after a job-related knee injury but had multiple surgeries on her injured knee. Over time, her employer made several permanent partial impairment payments, and she was eventually determined to be permanently and totally disabled because of the work injury. She began to receive Social Security disability at about the same time she was classified as permanently and totally disabled for workers’ compensation. Her employer asked the Alaska Workers’ Compensation Board to allow two offsets to its payment of permanent total disability (PTD) compensation: one related to Social Security disability benefits and one related to the earlier permanent partial impairment (PPI) payments. The Board established a Social Security offset and permitted the employer to deduct the amount of previously paid PPI. The employee appealed to the Alaska Workers’ Compensation Appeals Commission, arguing that the Board had improperly applied one of its regulations in allowing the PPI offset and had incorrectly calculated the amount of the Social Security offset. She also brought a civil suit against the State challenging the validity of the regulation. The State intervened in the Commission appeal; the lawsuit was dismissed. The Commission reversed the Board’s calculation of the Social Security offset and affirmed the Board’s order permitting the PPI offset. The employer appealed the Commission’s Social Security offset decision to the Alaska Supreme Court, and the employee cross- appealed the PPI offset. The Court affirmed that part of the Commission’s decision reversing the Board’s calculation of the Social Security disability offset and reversed that part of the Commission’s decision permitting an offset for permanent partial impairment benefits. The case was remanded back to the Commission for further proceedings. View "Alaska Airlines, Inc. v. Darrow" on Justia Law

Rosewood is a skilled nursing facility, 42 U.S.C. 1395i-3(a), participating in Medicare and Medicaid as a provider. The Secretary of Health and Human Services, which enforces the statutory and regulatory provisions governing nursing homes operating in the Medicare/Medicaid network, assessed a civil monetary penalty against Rosewood on the grounds that it had failed to protect a resident from abuse, failed to timely report or to investigate thoroughly allegations of abuse, and failed to implement its internal policies on abuse, neglect, and misappropriation of property. The Centers for Medicare and Medicaid Services (CMS) determined that these deficiencies placed residents in “immediate jeopardy.” An Administrative Law Judge and the Department Appeals Board affirmed the $6,050 per day penalty imposed by CMS. The Seventh Circuit affirmed. Substantial evidence supports the Agency’s findings. The court noted three specific examples of noncompliance and concluded that there was a systemic failure to implement Rosewood’s policies aimed at conforming to federal regulations View "Rosewood Care Center of Swansea v. Price" on Justia Law

Gazelle served in the U.S. Army, 1962-1965, and incurred service-connected disabilities. He receives compensation for: degenerative disc disease and joint disease of the cervical spine rated at 20 percent; degenerative disc disease and spondylosis of the thoracolumbar spine rated at 20 percent; left upper extremity radiculopathy rated at 10 percent; left lower extremity radiculopathy rated at percent; and post-traumatic stress disorder. In 2009, the VA increased Gazelle’s disability rating for his service-connected PTSD to 100 percent. Gazelle filed a Notice of Disagreement, alleging the VA failed to award him additional special monthly compensation under 38 U.S.C. 1114(s)(1). In 2011, Gazelle was denied entitlement to special monthly compensation because he did not have additional service-connected “disabilities . . . independently ratable as [60 percent] or more disabling.” Instead of adding together Gazelle’s additional service-connected disabilities at their respective amounts, the VA calculated the independent additional rating via the combined ratings table pursuant to 38 C.F.R. 4.25 (2010), which resulted in a combined rating of 50 percent. In 2014, the Board affirmed. The Veterans Court and Federal Circuit affirmed, holding that consistent with the plain meaning of subsection 1114(s), the Board appropriately applied the combined ratings table to determine eligibility for special monthly compensation benefits. View "Gazelle v. Shulkin" on Justia Law

Prime Hospitals provide inpatient services under the Medicare program, submitting payment claims to private contractors, who make initial reimbursement determinations. Prime alleged that many short-stay claims were subject to post-payment review and denied. Prime appealed through the Medicare appeal process. Prime alleged short-stay claims audits were part of a larger initiative that substantially increased claim denials and that the Center for Medicare & Medicaid Services (CMS) was overwhelmed by the number of appeals. CMS began offering partial payment (68 percent) in exchange for dismissal of appeals. Prime alleged that it executed CMS's administrative settlement agreement so that CMS was contractually required to pay their 5,079 Medicare appeals ($23,205,245). CMS ultimately refused to allow the Prime to participate because it was aware of ongoing False Claims Act cases or investigations involving the facilities. Prime alleged that the settlement agreement did not authorize that exclusion. The district court denied a motion to dismiss Prime’s suit but transferred it to the Court of Federal Claims. The Federal Circuit affirmed in part. The breach of contract claim is fundamentally a suit to enforce a contract and does not arise under the Medicare Act, so the Claims Court has exclusive jurisdiction under the Tucker Act, 28 U.S.C. 1491. That court does not have jurisdiction, however, over Prime’s alternative claims seeking declaratory, injunctive, and mandamus relief from an alleged secret and illegal policy to prevent and delay Prime from exhausting administrative remedies. View "Alvarado Hospital, LLC v. Cochran" on Justia Law

The Hospitals challenged HHS's implementation of a Medicare outlier-payment program in the late 1990s and early 2000s. The Hospitals contend that HHS violated the Administrative Procedure Act (APA), 5 U.S.C. 551 et seq., by failing to identify and appropriately respond to flaws in its methodology that enabled certain "turbo-charging" hospitals to manipulate the system and receive excessive payments at the expense of non-turbo-charging hospitals, including the Hospitals. The DC Circuit held that District Hospital Partners, L.P. v. Burwell, 786 F.3d 46 (D.C. Cir. 2015), controlled to the extent that the Hospitals repeated challenges decided in that case. In regard to the remaining challenges, the court affirmed the district court's denials of the Hospitals' motions to supplement the record and to amend their complaint, and its decision that HHS acted reasonably in a manner consistent with the Medicare Act in fiscal years (FYs) 1997 through 2003, and 2007. However, because HHS inadequately explained aspects of the calculations for FYs 2004 through 2006, the court reversed summary judgment in that regard and remanded for further proceedings. View "Banner Health v. Price" on Justia Law

The Hospitals challenged HHS's implementation of a Medicare outlier-payment program in the late 1990s and early 2000s. The Hospitals contend that HHS violated the Administrative Procedure Act (APA), 5 U.S.C. 551 et seq., by failing to identify and appropriately respond to flaws in its methodology that enabled certain "turbo-charging" hospitals to manipulate the system and receive excessive payments at the expense of non-turbo-charging hospitals, including the Hospitals. The DC Circuit held that District Hospital Partners, L.P. v. Burwell, 786 F.3d 46 (D.C. Cir. 2015), controlled to the extent that the Hospitals repeated challenges decided in that case. In regard to the remaining challenges, the court affirmed the district court's denials of the Hospitals' motions to supplement the record and to amend their complaint, and its decision that HHS acted reasonably in a manner consistent with the Medicare Act in fiscal years (FYs) 1997 through 2003, and 2007. However, because HHS inadequately explained aspects of the calculations for FYs 2004 through 2006, the court reversed summary judgment in that regard and remanded for further proceedings. View "Banner Health v. Price" on Justia Law

The Eleventh Circuit affirmed the district court's dismissal of the Hospitals' suit to recover recoupments. At issue was whether, under the Medicare Act, 42 U.S.C. 1395w-21 to 1395w-29, the Hospitals must exhaust their administrative remedies before bringing suit for underpayment by the Medicare Advantage Organization (MAO) that manages enrollee benefits. The court held that the Hospitals, who were challenging CIP's recoupment decision, were parties to an "organization determination" who were subject to the administrative exhaustion requirements of the Medicare Act. The court noted that although it was sympathetic to the concern HHS has expressed in amicus briefs, the language of the Medicare Act and its implementing regulations was clear that billing disputes between MAOs and noncontract provider assignees qualify as "organization determinations" and were thus subject to the Act's exhaustion requirement. View "Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Co." on Justia Law

The Eleventh Circuit affirmed the district court's dismissal of the Hospitals' suit to recover recoupments. At issue was whether, under the Medicare Act, 42 U.S.C. 1395w-21 to 1395w-29, the Hospitals must exhaust their administrative remedies before bringing suit for underpayment by the Medicare Advantage Organization (MAO) that manages enrollee benefits. The court held that the Hospitals, who were challenging CIP's recoupment decision, were parties to an "organization determination" who were subject to the administrative exhaustion requirements of the Medicare Act. The court noted that although it was sympathetic to the concern HHS has expressed in amicus briefs, the language of the Medicare Act and its implementing regulations was clear that billing disputes between MAOs and noncontract provider assignees qualify as "organization determinations" and were thus subject to the Act's exhaustion requirement. View "Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Co." on Justia Law