Justia U.S. 3rd Circuit Court of Appeals Opinion Summaries

After leaving coal mining, Eckman sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901, in 1985. An ALJ awarded benefits in 1993; the Benefits Review Board affirmed the decision. Marmon paid benefits to Eckman until his 2002 death; his widow, Ethel, sought benefits as a dependent survivor. An ALJ denied the claim in 2005, finding that although Eckman had pneumoconiosis, Ethel failed to prove that his death was due to the disease. The Board affirmed. After Congress enacted the 2010 Patient Protection and Affordable Care Act, 124 Stat. 119, and amended the BLBA, Ethel filed a new claim. A Department of Labor district director awarded benefits. An ALJ upheld the award, finding that Ethel satisfied the familial relationship and dependency criteria for survivors under the BLBA and that, based on Eckman’s lifetime disability award and the filing date of Ethel’s claim, Ethel was entitled to benefits under section 932(l), as amended by the ACA. The Board affirmed. The Third Circuit denied the coal company’s petition for review, noting that in Ethel’s second claim, the cause of death was not at issue, her entitlement to benefits turned primarily on an administrative fact: whether her husband had been awarded benefits. View "Marmon Coal Co. v. Dir. Office of Workers Comp. Programs, U.S. Dep't of Labor" on Justia Law

Munir sent his son, O.M., to a private residential facility and a private boarding school after multiple suicide attempts, and sought reimbursement for the cost of the placements from the school district under the Individuals with Disabilities Education Act (IDEA), which requires that states receiving federal education funding ensure that disabled children receive a free appropriate public education, 20 U.S.C. 1412(a)(1) or pay for their education elsewhere if a child require specialized services that the public institution cannot provide. The district court denied the request, reasoning that O.M. had emotional problems, but that those problems were not affecting his ability to learn. The Third Circuit affirmed, finding that O.M.’s placement was to meet his mental health needs; any educational benefit he received from the placement was incidental. O.M. was an above-average student, without serious attendance problems, and socialized well in the district school. An individualized education plan offered by the district satisfied its IDEA obligations. View "Munir v. Pottsville Area Sch. Dist." on Justia Law

States participating in Medicaid in a managed care environment are required to make, at least every fourth month, supplemental “wraparound” payments to federally-qualified health centers (FQHCs) equal to the difference between a rate set by statute multiplied by the number of Medicaid patient encounters, and the amount paid to FQHCs by managed care organizations (MCOs) for all Medicaid-covered patient encounters, 42 U.S.C.1396. Concerned that gaps in FQHC claim verification led to overpayments, the New Jersey Department of Human Services changed its calculation: instead of basing wraparound payments solely on the number of Medicaid encounters and total MCO receipts as self-reported by FQHCs, the state would rely on data reported by MCOs absent receipt of certain additional data from the FQHCs. Because MCOs report only encounters that they have approved and paid, prior MCO payment would be a prerequisite to wraparound reimbursement under the new system. An association of FQHCs sued, claiming that the change violated their due process rights as well as state and federal law, resulting in budget shortfalls. The district court granted the association summary judgment and a preliminary injunction. The Third Circuit affirmed the holding that the requirement that wraparound payments be contingent on prior MCO payment violated the Medicaid statute’s requirement that FQHCs receive timely full wraparound payment for all Medicaid-eligible claims. View "NJ Primary Care Assoc. v. NJ Dep't of Human Servs." on Justia Law

Until 2003, Hagans worked as a security guard and as a sanitation worker. At 44 years old, Hagans required open-heart surgery. Hagans claims additional medical problems relating to his cerebrovascular and respiratory systems, hypertension and dysphagia, insomnia, and back pain. He has been diagnosed with depression. Hagans began receiving disability benefits as of January 30, 2003. In September, 2004, pursuant to an updated Residual Function Capacity assessment showing his condition had improved, SSA determined that Hagans was no longer eligible for benefits. The ALJ considered several evaluations of Hagans’s condition, most of which were completed in mid-2004, and found that he was capable of engaging in substantial gainful activity, although he could not perform his past relevant work. The Appeals Council denied review; the district court affirmed. The Third Circuit affirmed, after determining that “relatively high” deference should be afforded to SSA’s Acquiescence Ruling interpreting the cessation provision of 42 U.S.C. 423(f) as referring to the time of the SSA’s initial disability determination. SSA correctly evaluated Hagans’s condition as of the date on which the agency first found that Hagans’s eligibility for disability benefits ceased. Substantial evidence supported the conclusion that Hagans was not fully disabled as of that date. View "Hagans v. Comm'r of Soc. Sec." on Justia Law

TriCenturion audited Nichole Medical as a Program Safeguard Contractor under the Medicare Integrity Program, 42 U.S.C. 395ddd(a), and concluded that Nichole “might” be improperly billing for medical equipment; that Nichole had received overpayments; and that it had not maintained sufficient medical records to establish reasonableness or medical necessity. TriCenturion directed Nichole’s carrier, HealthNow, to withhold payments. TriCenturion calculated the actual overpayment of several specific claims, used those as a representative sampling, and extrapolated an overpayment amount for all relevant claims. The Attorney General found no evidence of fraud and refused to prosecute; HealthNow stopped withholding payments. TriCenturion instructed HealthNow’s successor to re-institute the offset. Nichole went out of business, but pursued an appeal. An ALJ determined that Nichole was entitled to reimbursement on some, but not all, appealed claims and found that the process for arriving at the extrapolated overpayment was flawed. The Medicare Appeals Council found that all 39 claims had been reopened and reviewed improperly. The district court dismissed Nichole’s suit against TriCenturion, which alleged torts and breach of the statutory duty of care under 42 U.S.C. 1320c-6(b). The Third Circuit affirmed. Defendants are immune from suit as officers or employees of the Secretary of the Department of Health and Human Services. View "Nichole Medical Equip & Supply, Inc. v. Tricenturion, Inc." on Justia Law

The Port Authority’s subsidiary, PATH, operates the Grove Street Station in Jersey City. The Station was built in 1910. In 2000 PATH planned to expand the Station to accommodate larger trains and persons with disabilities, a project that would have involved construction of a new entrance and two elevators. After September 11, 2001, and the resulting closure of two stations, ridership increased at the Station. Concerned about congestion and safety, PATH scrapped its renovation plans and undertook a “fast track” project. Construction began in 2002 and concluded in 2005. Plaintiffs alleged that the renovations triggered an obligation under the Americans with Disabilities Act, 42 U.S.C. 12101–12213, to make the Station accessible to handicapped persons. They also alleged violations under New Jersey’s Law Against Discrimination and certain state construction code provisions. The district court dismissed, state-law claims on the basis that allowing such claims to proceed would violate the interstate compact between New York and New Jersey that created the Authority, but ordered the Authority to make the east entrance accessible. The Third Circuit affirmed dismissal of the state law claims, but remanded the ADA issue for trial on the issue of feasibility. View "Hip Heightened Indep. & Progress, Inc. v. Port Auth. of NY & NJ" on Justia Law

Jewish Home of Eastern Pennsylvania (JHEP) provides nursing care to Medicare beneficiaries and is required to comply with the mandatory health and safety requirements for participation. JHEP must submit to random surveys conducted by state departments of health. In 2005, the Pennsylvania Department of Health conducted a survey that concluded that JHEP had eight regulatory deficiencies, including violations of 42 C.F.R. 483.25(h)(2), which requires a facility to ensure that each resident receives adequate supervision and assistance with devices to prevent accidents. Based on those deficiencies and those found in a 2006 survey, the Center for Medicare and Medicaid Services imposed fines totaling $17,150 and $12,800. JHEP claimed that the allegations of noncompliance were based on the inadmissible disclosure of privileged‖ quality assurance records and that the monetary penalties violated its right to equal protection because they were the product of selective enforcement based on race and religion. An ALJ upheld the fines against JHEP. The Third Circuit denied a petition for review. View "Jewish Home of E. PA v. Centers for Medicare and Medicaid Servs." on Justia Law

Humana sued, alleging that Glaxo was obligated to reimburse Humana for expenses Humana had incurred treating its insureds’ injuries resulting from Glaxo’s drug, Avandia. Humana runs a Medicare Advantage plan. Its complaint asserts that, pursuant to the Medicare Act, Glaxo is in this instance a “primary payer” obligated to reimburse Humana as a “secondary payer.” The district court dismissed, agreeing with Glaxo that the Medicare Act did not provide Medicare Advantage organizations with a private cause of action to seek such reimbursement. The Third Circuit reversed and remanded. The Medicare Secondary Payer Act, in 42 U.S.C. 1395y(b)(3)(A), provides Humana with a private cause of action against Glaxo. Even if the provision is ambiguous, regulations issued by the Centers for Medicare and Medicaid Services make clear that the provision extends the private cause of action to MAOs. View "Humana Med. Plan Inc. v. GlaxoSmithKline LLC" on Justia Law

Plaintiffs brought a putative class action challenging 62 Pa. Stat. 1414, which was enacted to regulate special needs trusts. The comprehensive Medicaid eligibility rules enacted by Congress generally mandate that trusts be counted as assets of those seeking Medicaid, but exempt special needs trusts, which are intended to provide disabled individuals with necessities and comforts not covered by Medicaid. Plaintiffs allege Section 1414 is preempted by 42 U.S.C. 1396p(d)(4). The district court held that all but one of the challenged provisions of Section 1414 was preempted, finding that plaintiffs had a private right of action under both Section 1983 and the Supremacy Clause. The court also held that Section 1414 was severable, certified a class, and appointed class counsel. The Third Circuit affirmed in part, agreeing that the case is justiciable and that plaintiffs have a private right of action. Section 1414's 50% repayment provision, "special needs" provision, expenditure provision, and age restriction are all preempted by federal law. The enforcement provision of Section 1414, however, when used to enforce provisions not otherwise preempted, is a reasonable exercise of the Commonwealth's retained authority to regulate trusts. View "Lewis v. Alexander" on Justia Law

A psychologist challenged the government's claim that he had over-billed Medicare and owed the government more than $600,000 in overpayments. At a hearing on the claim, the doctor presented extensive evidence, but the government neither appeared nor presented argument or advocacy, either written or in person. The ALJ concluded that the overpayment was actually $5,434.48. The doctor moved, under the Equal Access to Justice Act, 5 U.S.C. 504(a)(1), to recoup tens of thousands of dollars in attorneys' fees and expenses incurred in fighting the claim. His request was denied by an administrative appeals council and the district court based on their conclusion that the hearing before the ALJ was not an adversary adjudication, as is required for a fee award under the EAJA. The Third Circuit affirmed denial, finding that the government did not engage in purposeful advocacy.View "Handron v. Sec'y of Health & Human Servs." on Justia Law