Justia Government & Administrative Law Opinion Summaries

Prinkey served in the Army, 1969 to 1970, including time in Vietnam. He was diagnosed with diabetes in 1996. Diabetes mellitus type II is presumed to be service connected if the veteran was exposed to Agent Orange, 38 U.S.C. 1116(a)(2)(H) (2002). In 2003, the VA received Prinkey’s claim for benefits on account of his diabetes, asserting exposure to Agent Orange. The VA Regional Office grantedservice connection for diabetes, evaluated at 20%, and lesser rated service connection for other disabilities secondary to diabetes. Prinkey sought to reopen his claim. During reexamination, the VA concluded that his diabetes more likely than not resulted from the surgery that removed most of his pancreas following years of alcohol abuse, not from his exposure to Agent Orange. Ultimately the Board of Veterans’ Appeals sustained severance of service connection for diabetes and related disabilities and denied entitlement to a total disability rating based on individual unemployability. The Veterans Court affirmed. The Federal Circuit affirmed. Under 38 C.F.R. 3.105(d) “service connection will be severed only where evidence establishes that it is clearly and unmistakably erroneous; the VA may consider medical evidence and diagnoses that postdate the original award of service connection. View "Prinkey v. Shinseki" on Justia Law

The City of Gadsden and certain members of the State Employees' Insurance Board appealed two circuit court orders that granted injunctive relief to John Boman. Boman worked as a Gadsden police officer from 1965 until he retired in 1991. In 2000, Gadsden elected to join the 'Local Government Health Insurance Plan,' a health benefit plan administered by the Board. When Boman turned 65 in 2011, he was receiving medical care for congestive heart failure and other ailments. After his 65th birthday, Blue Cross began denying his claims for medical treatment based on the failure to provide Blue Cross with a 'record of the Medicare payment.' However, Boman had no Medicare credits. When the dispute over coverage arose, Boman sought review by the Board. The Board denied Boman's request for an appeal. Boman and 18 other active and retired Gadsden police officers sued Gadsden, alleging, among other things, that they had 'been deprived of Social Security and Medicare protection which other police officers have been provided' and that, after 20 years of service, they were being required to pay a higher pension charge or percentage of base pay than their counterparts who were hired after April 1, 1986. In 2011, Boman filed a 'motion for immediate relief for medical care.' The Supreme Court found that the circuit court issued preliminary injunctive relief against Gadsden without requiring Boman to give security and without making any specific findings. As such, the Supreme Court had "no alternative but to reverse" the preliminary injunction issued against Gadsden and remanded the case for further proceedings. View "City of Gadsden v. Boman " on Justia Law

Petitioner filed to receive food stamp benefits under the Supplemental Nutrition Assistance Program as a separated spouse in a one-person household. The Department of Health and Human Resources (DHHR) determined that Petitioner and her husband (Husband) were living together for seventeen months after Petitioner filed to receive food stamps and sent Petitioner a notice of overpayment. Petitioner requested a hearing, and a hearing examiner affirmed the DHHR's overpayment claim. The circuit court affirmed, finding that Petitioner had not submitted sufficient evidence to support her claim that she and Husband had separate residences. The Supreme Court reversed the judgment of the circuit court and remanded for entry of an order granting Petitioner's petition for a writ of certiorari and dismissing the DHHR's overpayment claim, holding that the DHHR failed to prove that Petitioner and Husband lived together during the seventeen month time period of the overpayment claim, and the claim should have been dismissed at the conclusion of DHHR's evidence. View "Hudson v. Bowling" on Justia Law

The Office of the Medicaid Inspector General (OMIG) terminated a physician's participation in the Medicaid program on the basis of a Bureau of Professional Medical Conduct (BPMC) consent order, in which the physician pleaded no contest to charges of professional misconduct and agreed to probation. Supreme Court annulled the OMIG's determination. The Appellate Division affirmed, concluding (1) the agency acted arbitrarily and capriciously in barring the physician from treating Medicaid patients when the BPMC permitted him to continue to practice; and (2) the OMIG was required to conduct an independent investigation before excluding a physician from Medicaid on the basis of a BPMC consent order. The Court of Appeals affirmed but for another reason, holding (1) the OMIG is authorized to remove a physician from Medicaid in reliance solely on a consent order between the physician and the BMPC, regardless of whether BPMC chooses to suspend the physician's license or OMIG conducts an independent investigation; but (2) because OMIG did not explain why the BPMC consent order caused it to exclude the physician from the Medicaid program, the agency's determination was arbitrary and capricious. View "Koch v. Sheehan" on Justia Law

Philpot, former Clerk of Lake County, Indiana, took $25,000 in incentive payments from a federally funded child‐support fund (42 U.S.C. 658a(a)) without the required approval of the county fiscal body. The Indiana Department of Child Services disburses those federal funds to the counties, Ind. Code 31‐25‐4‐23(a), which have a relatively free hand in directing the money, although “amounts received as incentive payments may not, without the approval of the county fiscal body, be used to increase or supplement the salary of an elected official.” Philpot had used the funds to provide himself and staff members with bonuses. Convicted of mail fraud, 18 U.S.C. 1341, and theft from a federally funded program 18 U.S. 666(a)1A, he was sentenced to 18 months in prison. The Seventh Circuit affirmed, despite claims concerning whether Philpot “knowingly” violated the statute and the fact that Philpot had voluntarily returned the funds. View "United States v. Philpot" on Justia Law

The U.S. Department of Health and Human Services approved a 2008 amendment to Pennsylvania’s state plan for administering its Medicaid program. Private nursing facilities that provide services to Medicaid recipients challenged the amendment as violating Title XIX of the Social Security Act, 42 U.S.C. 1396, by adjusting Pennsylvania’s method for determining Medicaid reimbursement rates to private nursing facilities for the 2008-09 fiscal year without considering quality of care, which they claim violates 42 U.S.C. 1396a(a)(30)(A) and without satisfying the public process requirements of 42 U.S.C. 1396a(a)(13)(A). The district court rejected the claims on summary judgment. The Third Circuit affirmed in part, finding the state immune from the requested relief under the Eleventh Amendment. The district court erred in granting summary judgment to the federal defendants. By approving the amendment without any assurance that the amended plan would produce payments that are consistent with quality of care, HHS acted arbitrarily. View "Christ the King Manor, Inc. v. Sec'y, U.S. Dep't of Health & Human Servs." on Justia Law

Former U.S. Forest Service employee King had long-term relationships with two women, both of whom claimed federal survivor benefits upon his death. Kathryn believed she had married King in a civil ceremony in 2002. Diana, who had been legally married to and divorced from King twice, but had continued to live with him until 2002, maintained that she was the common law wife of King at the time he married Kathryn. Before his death, Diana had initiated proceedings in Montana to dissolve their common law marriage. The women subsequently entered settlement agreements and engaged in state court litigation. Kathryn received benefits from May 27, 2004 until February 2007. Diana subsequently received the survivor benefits. Kathryn transferred to Diana the funds that she received ($41,939.13), as she believed was required by a Montana court decree. Kathryn challenged the OPM’s effort to recover the improper payments, having transferred the money to Diana, but the government affirmed its decision and determined that collection of the $41,939.13 would not cause Kathryn financial hardship. The Merit Systems Protection Board affirmed, holding that Kathryn did not meet the definition of “widow” under the Civil Service Retirement Act, 5 U.S.C. 8341(A)(1), and had not proved that she was entitled to waiver for the overpayment. The Federal Circuit reversed. The Board failed to credit substantial evidence demonstrating that Kathryn detrimentally relied on the overpayment of survivor annuity funds. View "King v. Office of Pers. Mgmt." on Justia Law

Plaintiff and his wife appealed the denial of his application for Medicaid benefits, arguing that the Department wrongfully denied the application because it had improperly counted against the wife's eligibility an annuity owned by the wife. The district court ruled in favor of plaintiffs and the Department appealed. The court concluded that, because the wife had no right, authority, or power to liquidate the annuity, the annuity benefits were not a resource, but rather was income indicated by the federal statute defining "unearned income." Therefore, the Department applied a more restrictive methodology under state law by classifying the annuity benefits as a resource that counted against plaintiff's eligibility for Medicaid benefits. The court rejected the Department's counter-arguments and the remaining arguments, and affirmed the judgment of the district court. View "Geston, et al. v. Anderson" on Justia Law

The Secretary appealed the district court's order certifying a nationwide class of Medicare beneficiaries and granting summary judgment in the beneficiaries' favor. The beneficiaries raised two claims: (1) the Secretary's practice of demand "up front" reimbursement for secondary payments from beneficiaries who have appealed a reimbursement determination or sought waiver of the reimbursement obligation was inconsistent with the secondary payer provisions of the Medicare statutory scheme; and (2) the Secretary's practice violated their due process rights. The court concluded that Patricia Haro had Article III standing on behalf of the class; John Balentine, as counsel for Haro, had Article III standing on his individual claim; and the beneficiaries' claims for injunctive relief were not moot and Article III's justiciability requirements were satisfied. The court concluded, however, that the beneficiaries' claim was not adequately presented to the agency at the administrative level and therefore the district court lacked subject matter jurisdiction under 42 U.S.C. 405(g). On the merits of Balentine's claim, the court concluded that the Secretary's interpretation of the secondary payer provisions was reasonable. Therefore, the court vacated the district court's injunctions, reversed the district court's summary judgment order, and remanded for consideration of the beneficiaries' due process claim. View "Haro v. Sebelius" on Justia Law

Relators brought a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729(a)(1)(A) and (B), alleging that the Mayo Foundation and others billed Medicare for surgical pathology services it did not provide. The government intervened and the parties settled. Relators then filed a Second Amended Complaint asserting additional claims. On appeal, relators challenged the district court's dismissal of their additional claim that Mayo fraudulently billed for services it did not provide whenever it prepared and read a permanent tissue slide but did not prepare a separate written report of that service. As a preliminary issue, the court concluded that relators satisfied their burden of showing that the public disclosure bar did not deprive the court of jurisdiction over relators' claim. On the merits, the court concluded that nowhere in the Medicare regulations or in the American Medical Association Codebook has the court found a requirement that physicians using the CPT codes for surgical pathology services must prepare the additional written reports that relators claimed Mayo fraudulently failed to provide. Accordingly, the court affirmed the judgment of the district court. View "Ketroser, et al. v. Mayo Foundation, et al." on Justia Law