Justia Government & Administrative Law Opinion Summaries

Plaintiff applied for disability benefits based on combined impairments including bullous emphysema, depression, anxiety, and bipolar disorder and alleged that her disability began when her right lung collapsed. Plaintiff appealed the district court's decision affirming the Commissioner of Social Security's denial of her application for disability insurance benefits and supplemental security income benefits under Titles II and XVI of the Social Security Act, 42 U.S.C. et seq. The court held that the administrative law judge ("ALJ") erred by failing to follow the requirements of 20 C.F.R. 404.1520(a) in determining whether plaintiff's mental impairments were severe and, if severe, whether they met or equaled a listed impairment. Accordingly, the court reversed the judgment of the district court with instructions to remand to the ALJ to conduct a proper review of plaintiff's mental impairments.

Plaintiff brought action under the False Claims Act, 31 U.S.C. 3729, claiming that the company used a kickback scheme and knowingly caused submission of false Medicare, Medicaid, and TRICARE claims by hospitals and doctors. The district court held that hospital claims at issue were not false or fraudulent, and that doctor claims were false or fraudulent, but not materially so. The First Circuit reversed. If kickbacks affected the transactions underlying the claims, the claims failed to meet a condition of payment and were false, regardless of the hospital's participation in or knowledge of the kickbacks. It cannot be said, as a matter of law, that the alleged misrepresentations were not capable of influencing Medicare's decision to pay the claims.

Plaintiff, on behalf of a class of similarly situated plaintiffs who received Medicaid assistance and were subject to a Medicaid lien pursuant to 53-2-612, MCA, sued defendant alleging that defendant had collected a greater amount than it was entitled from plaintiffs' recoveries from other sources. The parties raised several issues on appeal. The court held that Ark. Dept. of Health & Human Servs. v. Ahlborn applied retroactively to all class members' claims and that defendant must raise affirmative defenses with respect to individual class members to avoid Ahlborn's effect. The court held that the applicable statute of limitations to be 27-2-231, MCA, which provided for a five-year limitations period. The court declined to disturb the district court's order requiring defendant to compile data on individual class members' claims. The court reversed the district court's determination as to interest assessed against defendant, and concluded that no interest could be assessed until two years after any judgment had been entered, under 2-9-317, MCA. The court concluded that the term "third party" in the Medicaid reimbursement statutes included all other sources of medical assistance available to Medicaid recipients, including private health or automobile insurance obtained by the Medicaid recipient. The court reversed the district court's grant of summary judgment to the class on its proffered distinction between "first party" and "third party" sources. The court affirmed the district court's conclusion that plaintiffs' "made whole" claim was immaterial in light of Ahlborn.

The Equal Access to Justice Act entitles a prevailing party to fees only if the position of the United States was not substantially justified. The Seventh Circuit affirmed denial of fees for a remand to an administrative law judge for an explanation of the determination of a precise date on which the social security applicant became disabled. The ALJ did not ignore, mischaracterize, selectively cite, or otherwise bungle a significant body of relevant evidence, but committed the sort of articulation error that ordinarily does not taint the commissionerâs position. A reasonable person could conclude that both the ALJâs opinion and the commissionerâs defense of the opinion had a rational basis in fact and law.

The Second Injury Fund appealed the Arkansas Workers' Compensation Commission (Commission) finding that the Fund was not entitled to a statutory offset for Appellee Cleveland Osborn's Veterans Administration (VA) benefits. The Supreme Court found that the Commission made its decision based on the "plain language" of the statute: "the legislature intended for the amount of workers' compensation benefits payable to an injured worker to be reduced 'dollar-for-dollar' by the amount of benefits that the worker has previously received for the same medical services under any of the listed group plans." Veterans Administration benefits are not listed as one of the "group plans" in the statute. The Court found that the Fund was not entitled to the offset.

Appellant Fairfield City Schools (Fairfield) sought reimbursement for a total disability compensation award given to one of its employees. Edward Carpenter, Jr. had hypertension since 1995. In 2002, he injured his back while at work. Mr. Carpenterâs injury resulted in a considerable amount of disability compensation. In 2008, Fairfield requested handicap reimbursement from the Ohio Bureau of Workersâ Compensation for at least part of the disability payments it made to Mr. Carpenter. Fairfieldâs application alleged that Mr. Carpenterâs pre-existing hypertension is a cardiac disease that delayed his recovery from back surgery, contributing to prolonged disability payments. The Bureau rejected Fairfieldâs application as âinsufficient to establish cardiac disease as a pre-existing condition.â Fairfield appealed the Bureauâs decision multiple times. With every appeal, Fairfield added additional doctorâs reports and Bureau datasheets to support its argument that hypertension is a cardiac disease. The court of appeals eventually denied Fairfieldâs appeal and application for a writ of mandamus. The appellate court found that the Bureau had exclusive authority to weigh the evidence Fairfield submitted, and the Bureau could find Fairfieldâs evidence insufficient to prove hypertension was a cardiac disease. Fairfield appealed to the Supreme Court, and the Court agreed with the Bureauâs and appellate courtâs decisions. The Court affirmed the lower courtâs judgment.

Plaintiff applied for Supplemental Security Income disability benefits alleging disability due to a combination of impairments. At issue was whether plaintiff's hearing before the administrative law judge ("ALJ") was invalid where plaintiff waived his right to representation at his hearing. The court held that there was no agency error where there was no disclosure required other than the disclosure in 42 U.S.C. 406(c) and that section 406(c)'s disclosure requirements were met.

Plaintiff-Appellant Carl Sheppard appealed the district courtâs order which denied his applications for disability insurance and supplemental security income benefits under the Social Security Act. The Administrative Law Judge (ALJ) denied Plaintiffâs applications for benefits in January, 2008 because the part-time work Plaintiff was doing at the time of his application was âsubstantial gainful activity.â The Tenth Circuit found that the ALJ failed to apply the correct legal standards in arriving at his conclusion. Accordingly, the Court reversed the lower court and remanded the case for further proceedings.

Plaintiff applied at age 51 for supplemental security income based on disability. At issue was whether the administrative law judge ("ALJ") erred by failing to develop the record adequately and should have requested more explanation from two of plaintiff's treating physicians at the Department of Veterans Affairs ("VA"). The court held that the ALJ's failure to assist plaintiff in developing the record by getting his disability determination into the record was probably likely to have been prejudicial because the court gave VA disability determinations great weight. Therefore, the court remanded under sentence four of 42 U.S.C. 405(g), concluding that "the agency erred in some respect in reaching a decision to deny benefits."

Josephine Centorbi died intestate in 2007. At the time of her death, Ms. Centorbi received Medicaid benefits. Ms. Centorbiâs sister, Dianne Fiorille administered the estate, and acting without counsel, applied to relieve the estate from administration. When she filed the application, Ms. Fiorille did not check the box on the form to attest that the decedent was over 55 years old and received Medicaid assistance. In addition, as administrator, Ms. Fiorille failed to file some other forms necessary to notify both the probate court and the Ohio Department of Jobs and Family Services (ODJFS) of the decedentâs death. The probate court granted Ms. Fiorilleâs application to relieve the estate from administration on the same day it was filed. Two years later, ODJFS learned of Ms. Centorbiâs death. It filed an application to vacate the probate courtâs order, but its application was denied. The probate court held that because Ms. Fiorille indicated that no notice was required (in the form of the omitted check box), ODJFSâs application was time barred. The appellate court affirmed the probate courtâs decision. The Supreme Court found that failing to check the box on the initial relief-from-administration form tolled the statute of limitations. Without the check, the Medicaid program had not been officially notified of the decedentâs death. The Court reversed the appellate courtâs decision and remanded the case to the probate court for further proceedings.