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

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

In 2007, the HHS Office of Inspector General conducted a nationwide audit to determine whether states were complying with the requirements to reimburse the federal share of recovered AFDC overpayments made before October 1, 1996. The audit found that the Pennsylvania DPW had recovered $10,598,095 in AFDC overpayments from October 1, 1996 through June 30, 2006, but had not reimbursed ACF for the federal share of $5,609,572. DPW appealed a reimbursement request, challenging HHS authority to conduct the audit, but not the audit findings. The appeals board and district court upheld the HHS determination, rejecting an argument that the Personal Responsibility and Work Opportunity Reconciliation Act, 42 U.S.C. 601, designates a procedure established by the Single Audit Act, 31 U.S.C. 7501-7507 as the exclusive audit procedure. Under the SAA, "[e]ach non-Federal entity" that expends at least $300,000 of federal awards in a fiscal year "shall have either a single audit or a program-specific audit made for such fiscal year in accordance with the requirements of this chapter." The Third Circuit affirmed, also rejecting claims under FOIA and that DPW was entitled to retain the federal share of the AFDC overpayment recoveries under substantive law. View "Commonwealth of PA v. Sebelius" on Justia Law

Petitioner, a bookkeeper, part-time receptionist, and house-cleaner, developed reflexive sympathetic dystrophy after she fell. After reducing her hours, she stopped working in April 2008. Her application for disability benefits and SSI was denied in June 2008. In June 2009, she had a hearing before an ALJ, who denied her applications, finding that she was not disabled because she had the residual functional capacity to perform sedentary work with certain limitations and that jobs meeting those criteria were available. Eight months later, the Appeals Council denied review. The district court held that the ALJ's RFC determination was not supported by substantial evidence. The Third Circuit reversed, holding that the ALJ adequately explained the decision and properly relied on a 2008 report by the state agency medical consultant. View "Chandler v. Comm'r of Soc. Sec." on Justia Law

An employee, injured on the job, returned to work and presented a specialist's note, restricting her lifting. After five days her supervisor told her that her restrictions made it impossible for her to work and advised her to seek permanent disability. She submitted copies of additional doctors' notes in an effort to be reinstated, but the company concluded that the notes contained conflicting dates, contradictory answers on whether the medical condition was work related, ambiguities about the employee's ability to lift, and illegible content. The employee did not respond to requests for clarification, but filed a Workers' Compensation lawsuit and contacted the EEOC. She then filed suit, and, during discovery, turned over new copies of the notes. After plaintiff failed to produce originals at trial, there was conflicting testimony about the existence and location of originals. The district court declared a mistrial. Plaintiff sent the original notes to the court five days later. The court dismissed the case with prejudice, based on spoliation of evidence. The Third Circuit reversed and remanded. It is not clear that plaintiff intentionally withheld the documents or that the company suffered severe harm. View "Bull v. United Parcel Serv., Inc." on Justia Law

Husband worked as a miner from 1970 to 1987. In 2000, he was found to be totally disabled by coal workers' pneumoconiosis and was awarded benefits under the Black Lung Benefits Act, 30 U.S.C. 901. He died in 2005. His widow sought survivor’s benefits. At the time, she was required to prove that pneumoconiosis caused, contributed to, or hastened husband's death. An ALJ denied the claim. The Board vacated. On remand, the ALJ again denied benefits. While appeal was pending, Congress amended the Act, retroactively applicable to claims filed after January 1, 2005. The Board reversed and remanded for an order awarding survivor's benefits, holding that section 932(l), as amended, entitled the widow to benefits because husband was receiving black lung benefits at the time of his death and her claim was filed after January 1, 2005. The First Circuit denied the company's petition for review. Under the amendment, the widow is entitled to benefits without having to file a new claim or otherwise revalidate husband's claim because she filed her claim after January 1, 2005. The company's claim that she failed to establish the cause of death is irrelevant. Section 932(l) as amended does not violate the Due Process Clause or Takings Clause. View "B&G Constr. Co Inc. v. Dir., Office of Workers Comp. Programs" on Justia Law

A 51-year-old man with a history of violent crime and drug abuse, applied for SSI (42 U.S.C. 1381). He alleged disability beginning in April 2002 due to bipolar disorder and anxiety. The application was denied in October 2006. An ALJ determined that petitioner was not disabled because he has been capable of making a successful adjustment to other work that exists in significant numbers in the national economy. The appeals council denied review. The district court upheld the decision and the Third Circuit affirmed. Any error in the district court's articulation of the standard of review was harmless, and the commissioner's determination was supported by substantial evidence.

Defendants are health service providers that receive reimbursement from Medicare and Medicaid under 42 U.S.C. 1395, 1396. Plaintiffs, former employees of defendants, filed a qui tam action, alleging violations of various federal laws. After investigation, the government declined to intervene. The district court dismissed. The Third Circuit affirmed dismissal of False Claims Act, 31 U.S.C. 3729 claims based on violation of Medicare marketing regulations and reversed with respect to allegations that the defendants submitted false claims to the government by violating the Anti-Kickback Statute, 42 U.S.C. 1320. Payment of Medicare claims was not conditioned on compliance with marketing regulations.

This appeal involved a putative class action filed by three Pennsylvania Medicaid beneficiaries subject to the Pennsylvania Department of Public Welfare's (DPW) liens against future settlements or judgments. At issue was whether state agencies responsible for administering the Medicaid program have the authority to assert such liens and, if so, whether Pennsylvania's statutory framework was consistent with the Supreme Court's decision in Arkansas Department of Health and Human Services v. Ahlborn. The court examined the text, structure, history, and purpose of the Social Security Act, 42 U.S.C. 301 et seq., and held that liens limited to medical costs were not prohibited by the anti-lien and anti-recovery provisions of the Act, 42 U.S.C. 1396p(a)-(b). Accordingly, the court upheld Pennsylvania's longstanding practice of imposing such liens. The court also held that Pennsylvania's current statutory framework, which afforded Medicaid recipients a right of appeal from the default allocation, was a permissible default apportionment scheme.

Under Medicaid, the federal government reimburses between 50% and 83% of state costs for patient care for eligible low-income individuals, including developmentally-disabled individuals receiving care in home- and community-based settings.42 U.S.C.1396n(c). In 2001 Pennsylvania obtained a waiver that authorized reimbursement of state expenses for "habilitation services" for developmentally-disabled individuals. Until 2006, Pennsylvania did not seek reimbursement for occupancy costs for Medicaid recipients living in nonprofit and county facilities, but paid for room and board using state funds and the residents' Supplemental Security Income. The Center for Medicare and Medicaid Services rejected the state's 2006 claim that more than 54 percent of the occupancy costs were for reimbursable habilitation services. The appeals board and district court upheld the denial. The Third Circuit affirmed, based on the plain meaining of the statutory exclusion of costs for "room and board," and noting consistent interpretation of the statute