Justia Government & Administrative Law Opinion Summaries

Reimbursement providers for inpatient services rendered to Medicare beneficiaries is adjusted upward for hospitals that serve disproportionate numbers of patients who are eligible for Supplemental Security Income. The Centers for Medicare & Medicaid Services annually submit the SSI fraction for eligible hospitals to a “fiscal intermediary,” a Health and Human Services contractor, which computes the reimbursement amount and sends the hospitals notice. A provider may appeal to the Provider Reimbursement Review Board within 180 days, 42 U. S. C. 1395oo(a)(3). The PRRB may extend the period, for good cause, up to three years, 42 CFR 405.1841(b). A hospital timely appealed its SSI fraction calculations for 1993 through 1996. The PRRB found that errors in CMS’s methodology resulted in a systematic under-calculation. When the decision was made public, hospitals challenged their adjustments for 1987 through 1994. The PRRB held that it lacked jurisdiction, reasoning that it had no equitable powers save those granted by legislation or regulation. The district court dismissed the claims. The D. C. Circuit reversed. The Supreme Court reversed. While the 180-day limitation is not “jurisdictional” and does not preclude regulatory extension, the regulation is a permissible interpretation of 1395oo(a)(3). Applying deferential review, the Court noted the Secretary’s practical experience in superintending the huge program and the PRRB. Rejecting an argument for equitable tolling, the Court noted that for nearly 40 years the Secretary has prohibited extensions, except as provided by regulation, and Congress not amended the 180-day provision or the rule-making authority. The statutory scheme, which applies to sophisticated institutional providers, is not designed to be “unusually protective” of claimants. Giving intermediaries more time to discover over-payments than providers have to discover underpayments may be justified by the “administrative realities” of the system: a few dozen intermediaries issue tens of thousands of NPRs, while each provider can concentrate on its own NPR. View "Sebelius v. Auburn Reg'l Med. Ctr." on Justia Law

Roddy, born in 1964, suffers from several serious medical problems, including severe lower back pain attributable to degenerative disc disease. When her pain became unbearable, she stopped working and applied for disability insurance benefits. She was unsuccessful before the Social Security Administration. An administrative law judge found that there were jobs in the national economy within her capabilities, although she no longer could perform her old job as a shift manager at a Taco Bell restaurant. The district court affirmed. The Seventh Circuit vacated and remanded. The ALJ improperly discounted the opinion of a physician and improperly considered Roddy’s testimony about her ability to do housework. View "Roddy v. Astrue" on Justia Law

Harris served on active duty in the U.S. Army from 1963 to 1966 and from 1967 to 1970. In 1985, he had a VA Medical Center examination; an “Agent Orange” form associated with that examination indicates that Harris complained of “skin rashes on trunk and arms.” Another form, listing his service in Vietnam, is an “Application for Medical Benefits,” stated that it “will be used to determine your eligibility for medical benefits.” In 2002, Harris, pro se, sought service-connected disability compensation for contact dermatitis and latex allergy. The DVA regional office ultimately granted the claims and assigned an effective date of 2002. Harris sought an effective date of 1985. The Board held that the report of the Agent Orange Registry examination did not constitute a claim. The Veterans Court affirmed The Federal Circuit vacated, stating that pro se filings must be read liberally; the Veterans Court did not apply the proper legal standard for determining whether the Board had correctly determined the earliest applicable date for the claim. View "Harris v. Shinseki" on Justia Law

Plaintiff appealed the district court's decision affirming the Commissioner's denial of social security benefits. The court rejected plaintiff's contention to the extent that she alleged the ALJ failed to develop the record or make explicit findings regarding the mental and physical demands of her past relevant work as a factory packer and assembler. The court concluded that the ALJ had sufficient evidence on the record as a whole to reach his determination where the ALJ adequately compared the demands of plaintiff's past with her residual functioning capacity to perform light work, including with her manipulative limitations. Accordingly, the court affirmed the denial of benefits. View "Young v. Astrue" on Justia Law

Plaintiff Pamela Mattison, gave birth to twins who were conceived by artificial insemination after their father, Jeffery Mattison, had died. She sought social security survivors' benefits for the children based on Jeffery's earnings. The Social Security Administration denied her application, and an administrative law judge affirmed that decision. Plaintiff then filed an action in the United States District Court for the Western District of Michigan challenging the decision. That court has asked the Michigan Supreme Court to rule on whether the children could inherit from Jeffery under Michigan intestacy law. Having heard oral argument, the Supreme Court granted the district court's request to answer the question and held that under Michigan intestacy law, plaintiff's children could not inherit from Jeffery. The matter was returned to the district court for further proceedings. View "In re Mattison v. Social Security Comm." on Justia Law

This appeal by Dorothy Knight arose from a 2011 circuit court order. In it, the circuit court affirmed an administrative decision by the Public Employees Retirement System (PERS) denying disability benefits. Upon review, a majority of the Supreme Court concluded that Knight met her burden, and that PERS' decision to deny her claim was not supported by substantial evidence. Accordingly, the Court reversed the appellate and circuit courts' rulings and remanded the case for further proceedings. View "Knight v. Public Employees' Retirement System of Mississippi" on Justia Law

In the four cases giving rise to these eleven consolidated appeals, the Secretary of the Department of Health and Human Services (HHS) and the Director of the California Department of Health Care Services (DHCS), appealed the district court's grant of preliminary injunctions to plaintiffs, various providers and beneficiaries of California's Medicaid program (Medi-Cal). At issue was the implementation of Medi-Cal reimbursement rate reductions. The court held that Orthopaedic Hospital v. Belshe did not control the outcome in these cases because it did not consider the key issue here - the Secretary's interpretation of 42 U.S.C. 1396a(a)(30)(A); the Secretary's approval of California's requested reimbursement rates were entitled to Chevron deference; and the Secretary's approval complied with the Administrative Procedures Act, 5 U.S.C. 500 et seq. The court further held that plaintiffs were unlikely to succeed on the merits on their Supremacy Clause claims against the Director because the Secretary had reasonably determined that the State's reimbursement rates complied with section 30(A). The court finally held that none of the plaintiffs had a viable takings claim because Medicaid, as a voluntary program, did not create property rights. View "Managed Pharmacy Care, et al v. Sebelius, et al" on Justia Law

Petitioner Vincent James Hogg, Sr. sought review of a Workers' Compensation Court order which denied his workers' compensation benefits based upon the court's interpretation of 85 O.S. 2011, section 312 (3). Petitioner was employed by the Oklahoma County Juvenile Detention Center when in late 2011, he sustained an injury to his right shoulder and neck while subduing an unruly and combative juvenile. Petitioner was given a post-accident drug screen and a follow-up screen the next day. Both screens showed a "positive" result for the presence of marijuana in his system. Petitioner did not dispute the test results but Petitioner denied ever smoking marijuana. The trial court ultimately found there was no evidence presented to establish Petitioner was "high," nor was there any evidence to establish the marijuana in his system was the "major cause" of the accidental injury. The trial court did, however, deny Petitioner's eligibility for workers' compensation benefits by reason of its interpretation of the newly created 85 O.S. 2011, section 312 (3). The dispositive issue presented to the Supreme Court was whether the trial court erred in its interpretation of the statute. The trial court found the last sentence of paragraph 3 expressed the legislative intent of the entire paragraph without giving any weight to the other sentences in the same paragraph. In its order, the trial court indicated this sentence created an irrebuttable presumption. Upon review, the Supreme Court disagreed. The Court concluded that Petitioner overcame the rebuttable presumption of ineligibility for workers' compensation benefits. The case was reversed and remanded for further proceedings. View "Hogg v. Oklahoma Cty. Juvenile Bureau" on Justia Law

The Commonwealth appealed a superior court order that reversed an order denying appellee's petition for post conviction relief and for remanding for an evidentiary hearing. Appellee Joseph Abraham was accused of soliciting a former student for sex, and for allegedly sexually assaulting her. When the allegations surfaced, the then 67-year-old Appellee retired from teaching and began receiving pension payments. Pursuant to a negotiated agreement, appellee pled guilty to corruption of a minor and indecent assault of a person less than 16 years of age. He was sentenced to probation; no direct appeal was filed. Because the crime of indecent assault of a person less than 16 years of age is one of the enumerated offenses in the Public Employee Pension Forfeiture Act (PEPFA), appellee forfeited his pension when he pled guilty to this charge. He filed a motion to withdraw his plea nunc pro tunc, alleging he was not informed of his right to seek withdrawal of his plea or of the possible sentences he faced. The trial court denied the motion. Appellee filed a timely PCRA petition alleging plea counsel was ineffective for failing to inform him he would forfeit his pension upon pleading guilty. The PCRA court dismissed the petition without a hearing. On appeal, the Superior Court reversed. "Because counsel cannot be deemed ineffective for failing to advise a defendant regarding the collateral consequences of a plea, appellee's ineffectiveness claim fails." Therefore, the Supreme Court reversed the order of the Superior Court granting appellee a PCRA hearing on the issue of prejudice, and remanded the case to reinstate the PCRA court's order denying appellee relief. View "Pennsylvania v. Abraham" on Justia Law

A VA regional office awarded King disability compensation for residuals of a left knee surgery and right knee arthritis. King later sought disability compensation for disabilities of the back and hips on a direct basis and as secondary to his service-connected knee disabilities. Records revealed no treatment for back or hip problems during King's active duty service 1973-1974. King underwent a VA spine examination in 2000. The examiner diagnosed minimal degenerative joint disease of both hips and lumbosacral spine, related to age. A private physician disagreed. In 2007, the Board of Veterans denied King's appeal. The Veterans Court remanded. Additional evidence was developed and, in 2008, the Board obtained an opinion from a Veterans Hospital Administration orthopedist that it was not likely that King’s back and bilateral hip disabilities were directly caused or permanently worsened by the service-connected knee disabilities. The Board and Court of Appeals for Veterans Claims affirmed the denial. The Federal Circuit affirmed, rejecting an argument that the Veterans Court erred by discounting lay testimony offered by King and his wife. The Veterans Court did not fail to consider the proffered lay evidence, so King’s appeal was merely a challenge to the weight given his evidence.View "King v. Shinseki" on Justia Law