Justia Government & Administrative Law Opinion Summaries

Groups of hospitals in the Cincinnati area and in rural Iowa, challenged the Secretary of Health and Human Services’ calculation of how much to pay those hospitals for inpatient services under Medicare Part A. The hospitals objected to the agency’s decision to include in the calculation the hours associated with a short-term disability program paid from a hospital’s general funds through its payroll system and a program offering a full-time salary for part-time weekend work. The district court entered summary judgment for the Secretary. The Sixth Circuit affirmed, finding the agency’s interpretation was not arbitrary or capricious and referring to “the most completely impenetrable texts within human experience,” statutes and regulations that “one approaches ... at the level of specificity herein demanded with dread.” View "Atrium Medical Ctr. v. U.S. Dep't of Health & Human Servs." on Justia Law

This appeal related to petitioner Linda Hendron's third application for disability benefits. She filed the first in 1999 and was denied on the merits. She applied again in 2001, and was denied on res judicata grounds. This latest application was filed in 2009, claiming a disability onset date of November 1, 1995. After the Social Security Administration denied the claim on res judicata grounds, requested a hearing before an administrative law judge (ALJ). The ALJ heard testimony from petitioner, and considered 19 medical exhibits that had not been submitted in petitioner's previous applications. The ALJ issued a written decision finding that petitioner was not disabled before the expiration of her insured status. The Appeals Council denied review, and petitioner took her appeal to the district court, which concluded the ALJ failed to develop a sufficient record on which to base a disability decision. The Commissioner appealed the district court's decision. Finding ample evidence in the record that the ALJ developed the record on which he denied petitioner's claim, the Tenth Circuit reversed and remanded the case for entry of judgment in favor of the Commissioner. View "Hendron v. Colvin" on Justia Law

Relator filed a qui tam action against Planned Parenthood, alleging that it violated the False Claims Act (FCA), 31 U.S.C. 3729-3733, and the Iowa False Claims Act (IFCA), Iowa Code Ann. 685.1-.7, by submitting false or fraudulent claims for Medicaid reimbursement. The district court dismissed the complaint under Rule 9(b). The court concluded that relator has pled sufficiently particularized facts to support her allegations that Planned Parenthood violated the FCA by filing claims for (1) unnecessary quantities of birth control pills, (2) birth control pills dispensed without examinations or without or prior to a physician's order, (3) abortion-related services, and (4) the full amount of services that had already been paid, in whole or in part. The court affirmed the dismissal of relator's claim that Planned Parenthood violated the FCA by instructing patients who experienced abortion-related complications to give false information to medical professionals at other hospitals, causing those medical professionals to unknowingly file claims for services performed in connection with abortions. Because relator failed to provide a factual basis for her knowledge of these alleged false claims, the court was unable to infer that false claims were submitted. Further, the court affirmed the dismissal of relator's upcoding claim. The court's holding with respect to the Rule 9(b) issue, however, should not be read as in any way expressing a view on Planned Parenthood's Rule 12(b)(6) arguments. View "Thayer v. Planned Parenthood" on Justia Law

Scrogham, then age 53, applied for disability benefits under the Social Security Act, submitting medical conditions including degenerative discs, spinal stenosis, sleep apnea, hypertension, arthritis, atrial fibrillation and restless leg syndrome. An ALJ denied the application and the Appeals Council denied his request for review. The district court affirmed, holding that the ALJ did not err in giving less weight to the opinion of a treating physician than to the opinions of nontreating physicians, that the ALJ permissibly found Scrogham not to be credible and that the ALJ’s decision otherwise was supported by substantial evidence. The Seventh Circuit reversed and remanded. The ALJ impermissibly ignored a line of evidence demonstrating the progressive nature of Scrogham’s degenerative disc disease and arthritis and inappropriately undervalued the opinions of Scrogham’s treating physicians, whose longitudinal view of Scrogham’s ailments should have factored prominently into the ALJ’s assessment of his disability status. Even considering only “the snapshots of evidence that the ALJ considered,” that limited evidence does not build the required logical bridge to her conclusions. The ALJ apparently misunderstood or at least considered only partially some of the evidence about Scrogham’s daily activities, rehabilitation efforts and physicians’ evaluations. View "Scrogham v. Colvin" on Justia Law

Two nurses, formerly employed by Momence, alleged that, during their employment at Momence, they uncovered evidence that Momence knowingly submitted "thousands of false claims to the Medicare and Medicaid programs” in violation of the False Claims Act (FCA) and Illinois Whistleblower Reward and Protection Act. They filed a qui tam action on behalf of the government and alleged that Momence retaliated against them for reporting its fraud. A jury awarded the government more than $3 million in compensatory damages and imposed about $19 million in fines for the qui tam claims. Pursuant to the FCA, the compensatory damages were trebled to more than $9 million. The district court set aside the fines as violating the Excessive Fines Clause of the Eighth Amendment. The jury also awarded the nurses $150,000 and $262,320, respectively, on their retaliation claims. The Seventh Circuit vacated. Both claims failed as a matter of law. Rejecting claims of “worthless services” and false certification, the court stated that, at best, a reasonable jury might be able to say that some of Momence’s claims were false, but that is not enough to satisfy the burden of proof. The employment of one nurse was not terminated, the other’s employment was terminated for an unrelated matter. View "Absher v. Momence Meadows Nursing Ctr., Inc." on Justia Law

An MRI had revealed plaintiff’s herniated disc in 1998. The medical record is blank from then until 2007, when she complained to an emergency room physician that she had been suffering from lower-back pain. She mentioned the herniated disc, and was prescribed Vicodin. Almost a year later she was examined by an anesthesiologist who specializes in pain management, who prescribed Lyrica. The plaintiff subsequently sought disability benefits and testified that her pain, combined with the drowsiness induced by the pain medication, limited her daily activities to eating, caring for her dogs, taking naps, and watching television. The anesthesiologist opined that the plaintiff was “unable to work” because of “lumbar disc protrusion.” Another anesthesiologist reviewed her records, and concluded that she was able to work full time despite the diagnoses of lumber disk herniation, lumbar radiculopathy, and myofascial pain, and a Social Security field officer’s observation that “she had a hard time sitting in the chair during the interview.” He did not identify evidence supporting his conclusion. The district court affirmed the agency’s denial of benefits. The Seventh Circuit remanded, stating that the plaintiff deserves a more careful evaluation than she has received to date. The ALJ’s critical error was failure to obtain a medical report on the results of a 2010 MRI. View "Goins v. Colvin" on Justia Law

The Washington Department of Retirement Services (DRS) and the State of Washington appealed an order granting summary judgment to a class of public employee unions and unaffiliated employees and holding that the 2011 repeal of legislation granting future uniform cost of living adjustments (UCOLA) to the respondents' monthly pension payments was an unconstitutional impairment of the State's contractual obligation with its employees. The Supreme Court found that because the legislature reserved its right to repeal the pension rights at issue and the original enactment of UCOLA did not impair any existing contract rights of state employees. Accordingly, the Supreme Court reversed. View "Wash. Educ. Ass'n v. Dep't of Ret. Sys." on Justia Law

The issue this case presented to the Supreme Court was whether the Washington legislature's 2007 repeal of gain sharing-a pension enhancement provided in years of extraordinary investment return-unconstitutionally impaired the contract between the State and its employees. The Court held that the legislature reserved its right to repeal a benefit in the original enactment of that benefit and the enactment did not impair any preexisting contractual right. As to the employees' alternative argument, the Court held that the explanatory materials provided by the Department of Retirement Systems (DRS) do not rise to the level of making a promise or creating an inconsistent statement and thus reject the employees' contention that the state was estopped from repealing the gain-sharing benefit at issue in this case. Accordingly, the Court reversed the trial court's award of summary judgment to the employees. View "Wash. Educ. Ass'n v. Dep't of Ret. Sys." on Justia Law

The Hospital filed suit against various federal agencies and officials, seeking a declaratory judgment that 18 U.S.C. 4006(b)(1), where Congress has elected to impose the Medicare rate as full compensation for medical services rendered to federal detainees, is unconstitutional as applied. The court concluded that the Hospital voluntarily opted into the Medicare program and is, as a result, required to provide emergency services to federal detainees. Consequently, the Hospital was foreclosed from challenging this compensation scheme as an unconstitutional taking under the Fifth Amendment. The court noted that the Hospital's most effective remedy may lie with Congress rather than the courts. Accordingly, the court affirmed the district court's dismissal of the action. View "Baker County Medical Services v. U.S. Attorney General, et al." on Justia Law

Moon was a 26-year-old mother who had worked as a cashier, bank teller, and certified nursing assistant. She suffered from documented back and joint problems, mild sleep apnea, depression, and migraine headaches. Most of these problems are related to exceptional obesity: at a height of 5’5”, she weighs more than 400 pounds. In support of her application for disability benefits, Moon submitted extensive medical records. Her migraine headaches were diagnosed as early as 2005 and she saw doctors about her headaches many times. She was taking Imitrex and Motrin at the time of her May 2010 hearing. In his written decision denying benefits, the ALJ went through the standard five-step analysis and found that Moon was no longer engaged in substantial gainful activity and that her combination of impairments qualified as “severe,” but that she was still capable of doing sedentary work if she would be permitted to sit or stand at will. The ALJ relied on the opinions of two doctors who had reviewed medical records but had not examined Moon. The ALJ referred to “alleged headaches” dismissively. The Appeals Council and the district court upheld the denial. The Seventh Circuit reversed. The ALJ improperly discounted evidence of chronic migraine headaches. Because Moon is receiving disability benefits based on a later application, the only issue on remand will be whether she was disabled between August 2008 and the later date from which benefits have been paid.View "Moon v. Colvin" on Justia Law