Articles Posted in Public Benefits

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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

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Hartgrove, a psychiatric hospital, is enrolled with the Illinois Department of Healthcare and Family Services to receive Medicaid reimbursement. Hartgrove agreed to comply with all federal and state laws and “to be fully liable for the truth, accuracy and completeness of all claims submitted.” Upon receipt of Medicaid reimbursements, Hartgrove is required to certify that the services identified in the billing information were actually provided. On 13 occasions in 2011, adolescent patients suffering from acute mental illness were placed in a group therapy room, rather than patient rooms, sleeping on roll-out beds until patient rooms were available. Hartgrove submitted Medicaid claims for inpatient care for those patients. Bellevue, a Hartgrove nursing counselor until 2014, voluntarily provided the information on which his allegations are based to federal and state authorities, then filed a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729, and the Illinois False Claims Act. Both declined to intervene. The district court dismissed and denied Bellevue’s motion to reconsider in light of the Supreme Court’s 2016 “Universal Health” holding that an implied false certification theory is a viable basis for FCA liability. The Seventh Circuit affirmed. Bellevue’s allegations fall within the FCA's public‐disclosure bar; the information was available in audit reports and letters. View "Bellevue v. Universal Health Services of Hartgrove, Inc." on Justia Law

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Plaintiffs purchased Illinois nursing homes and obtained new state licenses and federal Medicare provider numbers. Most of the residents in the 10 homes qualify for Medicaid assistance. The Illinois Department of Healthcare and Family Services (IDHFS) administers Medicaid funds under 42 U.S.C. 1396-1396w-5, reimbursing nursing homes for Medicaid-eligible expenses on a per diem basis. The rate must be calculated annually based on the facility's costs. When ownership of a home changes, state law requires IDHFS to calculate a new rate based on the new owner’s report of costs during at least the first six months of operation. The Medicaid Act requires states to use a public process, with notice and an opportunity to comment, in determining payment rates. The owners allege that IDHFS failed to: recalculate their reimbursement rates; provide an adequate notice-and-comment process; and comply with the state plan, costing them $12 million in unreimbursed costs. The Seventh Circuit affirmed denial of a motion to dismiss. Section 1396a(a)(13)(A) confers a right that is presumably enforceable under 42 U.S.C. 1983; it benefits the owners and is not so amorphous that its enforcement would strain judicial competence. While the Eleventh Amendment may bar some of the requested relief, if it appears that owners have been underpaid, that does not deprive the court of jurisdiction over the case as a whole. View "BT Bourbonnais Care, LLC v. Norwood" on Justia Law

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In 2009, Lanigan injured his back at his job and hurt his neck in a car accident; in 2011 he was diagnosed with diabetes. Since then his medical impairments have been complicated by mental illness. Lanigan applied for Supplemental Security Income and Disability Insurance Benefits in 2012 when he was 38 years old. At a hearing, the ALJ asked a vocational expert to assess whether competitive employment would be available to a person: capable of performing low-stress jobs constituting light work if those jobs involve only routine tasks; do not require more than occasional interaction with coworkers or the public; do not involve piece work or a rapid assembly line; is limited to occasional stooping, crouching, kneeling, or crawling; and can be off task up to 10% of the workday in addition to regularly scheduled breaks. The ALJ did not explain the source of the 10% figure. The ALJ found his impairments to be severe but not disabling and denied benefits. The Appeals Council denied review. The district court upheld the ALJ’s decision. The Seventh Circuit remanded for further proceedings because the ALJ misinformed a vocational expert about Lanigan’s residual functional capacity, thus undermining the expert’s testimony that Lanigan could engage in competitive employment. View "Lanigan v. Berryhill" on Justia Law

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By 2009 Vanprooyen’s physician had prescribed Xanax to treat her panic attacks. She was treated for anxiety, depression, and bipolar disorder. She had a history of addiction. In 2010, Vanprooyen, then age 26, fell down a flight of stairs and suffered a brain hemorrhage. She claimed post-traumatic stress disorder, short-term memory loss, attention-deficit hyperactivity disorder, seizures, and fibromyalgia. She was prescribed medication for pain, migraine headaches, and seizures. Vanprooyen applied for Disability Insurance Benefits and Supplemental Security Income. An administrative law judge found her impairments to be severe but not disabling and denied benefits. The district court upheld the ALJ’s decision. The Seventh Circuit reversed, finding “serious deficiencies” in the ALJ’s analysis, which failed to mention that a state consultative examiner who had given Vanprooyen a mental-status examination concluded that she was unable to manage her own money because of her “emotional adjustment and medical difficulties,” although at least two of the three jobs that the ALJ found that Vanprooyen could do involve handling money. Without explanation, the ALJ gave substantial weight to the opinions of consulting physicians who had never examined Vanprooyen. An ALJ can reject an examining physician’s opinion only for reasons supported by substantial evidence; a contradictory opinion of a non-examining physician does not, alonef, suffice. View "Vanprooyen v. Berryhill" on Justia Law

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Summers was fired from her job as an Elkhart, Indiana production-line worker. She applied for disability insurance benefits, alleging that she became disabled on the date she was fired. The Social Security Administration denied the application. Summers attended a hearing with counsel and testified that she was unable to work because of headaches, difficulty breathing, atrial fibrillation, and dizziness with blackouts. She submitted medical evidence that she suffered from depression, anxiety, obesity, and sleep apnea. Summers made several inconsistent statements during the hearing, mostly about her work history and her use of drugs and alcohol. A Vocational Expert testified that a hypothetical individual who was limited to a restricted range of light work could perform Summers’s past job as an assembler, as well as other jobs (inspector, hand packager, photocopy machine operator, and palletizer) that exist in significant numbers in the national economy. The ALJ concluded that Summers retained the Residual Functional Capacity to perform a substantially limited range of light work; that Summers was not entirely credible; and that Summers was not disabled from the time of her alleged onset date through the date of the ALJ’s decision. The Appeals Council, the district court, and the Seventh Circuit affirmed the denial as supported by substantial evidence. View "Summers v. Berryhill" on Justia Law

Posted in: Public Benefits

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Moshiri, other physicians, and hospital administrators were charged (42 U.S.C. 1320a-7b(b)) based on a kickback scheme. The former director of the podiatry residency program (Noorlag) testified that teaching contracts were a vehicle to pay physicians for referrals. Moshiri received $2,000 per month and was named as the Director of External Podiatric Office Rotations. Another doctor was named to that position at the same time. According to Noorlag, neither doctor was considered to hold that position, and neither performed the related duties. The Chair of the Counsel on Podiatric Medical Education, which oversees and certifies residency programs nationally and publishes standards, offered an expert opinion that teaching stipends are uncommon for attending physicians at residency programs and that he had never heard of such a physician being paid $2,000 per month. According to multiple witnesses, Moshiri did not conduct workshops and did not manage external rotations. Moshiri worked with residents about three times per month, while 11 other program physicians averaged 10 cases per month with residents. During the period at issue, the Hospital billed Medicare and Medicaid $482,000 for patients Moshiri treated. The Hospital’s Chief Operating Officer had recorded conversations in which Moshiri discussed his referrals. The agent who arrested Moshiri testified that Moshiri said that “the contract turned into basically paying for patients.” The Seventh Circuit upheld Moshiri’s conviction, rejecting challenges to the sufficiency of the evidence and to the expert testimony. View "United States v. Moshiri" on Justia Law

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Substantial evidence supported finding that hospital’s contracts with physicians violated Anti-Kickback statute. Novak and Nagelvoort participated in a scheme under which Sacred Heart Hospital paid illegal kickbacks to physicians in exchange for patient referrals. Novak was the Hospital’s owner, President, and Chief Executive Officer. Nagelvoort was an outside consultant, and, at various times. served as the Hospital’s Vice President of Administration and Chief Operating Officer. Federal agents secured the cooperation of physicians and other Hospital employees, some of whom recorded conversations. Agents executed warrants and searched the Hospital and its administrative and storage facilities. The prosecution focused on direct personal services contracts, teaching contracts, lease agreements for the use of office space, and agreements to provide physicians with the services of other medical professionals. The Seventh Circuit affirmed their convictions under 42 U.S.C. 1320a-7b(b)(2)(A) and 18 U.S.C. 371, rejecting arguments that there was insufficient evidence to prove that they acted with the requisite knowledge and willfulness under the statute; that the government failed to prove that certain agreements fell outside the statute’s safe harbor provisions; and that Nagelvoort withdrew from the conspiracy when he resigned his position, so that any subsequent coconspirator statements were not admissible against him. View "United States v. Naglevoort" on Justia Law

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In 2005, while serving in the Army National Guard, Bird injured a tendon in his right shoulder. He was operated on in 2006. He reported to Veterans Affairs doctors that he suffered hearing loss, migraines, and stiffness and pain in his hands, back and right shoulder, as well as anxiety, weakness in gripping objects, and ringing in his ears. The medical records include contradictory opinions from treating physicians. The Department of Veterans Affairs gave Bird a 70% service-connected disability rating but pays him at the 100% rate because they found him unemployable. The Social Security Administration denied Douglas Bird’s application for disability insurance benefits. The district court remanded. The Seventh Circuit affirmed. The VA’s finding that Bird is 70% disabled and unemployable does not establish that he is entitled to SSA benefits. There are differences in how the agencies evaluate claims: the VA’s evaluation is pro-claimant rather than neutral. The grounds for the VA’s decision finding Bird to be 70% disabled and unemployable were not available to the ALJ and neither were the results of Bird’s x-ray and MRI. The record even includes evidence conflicting with a finding of disability. View "Bird v. Berryhill" on Justia Law

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In 2009, the Social Security Administration notified Casey that he needed to repay about $334,000 in disability benefits he should not have received. Casey unsuccessfully sought a waiver. Six months later, Casey submitted an untimely request for review to the Appeals Council, arguing that he had good cause for his delay. The Appeals Council extended Casey’s deadline to submit evidence or a statement in support of his waiver claim; 15 months later, the Council reversed course, informing Casey that it had dismissed his review request because there was “no good cause to extend the time for filing.” Casey then sued the Acting Commissioner of Social Security. The district judge dismissed. The Seventh Circuit reversed. The Council's action in first granting and then retroactively denying Casey’s good cause request was arbitrary, having the effect of an unfair bureaucratic bait‐and‐switch. The Council had discretion to determine initially whether Casey offered good cause for his late administrative appeal, but, having granted Casey’s request, the Council could not simply change its mind on the theory that he had not adequately justified his delay, after leading him on for over a year without suggesting he needed to provide more information, an affidavit, or anything else by way of support. View "Casey v. Berryhill" on Justia Law