Justia U.S. 1st Circuit Court of Appeals Opinion Summaries

Articles Posted in Public Benefits
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The district court properly placed the burden of proof on a grocery store (Store) in this action brought by Plaintiffs alleging that the Store unlawfully trafficked in Supplemental Nutrition Assistance Program (SNAP) benefits.The Food and Nutrition Service (FNS), the bureau within the United States Department of Agriculture (USDA) charged with administering the SNAP regime, concluded that the Store had engaged in trafficking and permanently disqualified the Store from SNAP participation. The Store brought an action in Maine’s federal district court challenging the agency’s final decision. The district court granted summary judgment for the USDA. The First Circuit affirmed, holding (1) the burden of proof is imposed on the claimant - here, the Store; and (2) no rational fact-finder could conclude that the Store had demonstrated by a preponderance of the evidence that the finding of trafficking was incorrect. View "Irobe v. United States Department of Agriculture" on Justia Law

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The First Circuit affirmed the district court’s ruling that the “set-off rule” announced by the United States Secretary of Health and Human Services (Secretary) in the form of answers to Frequently Asked Questions (FAQs) posted on medicaid.gov represented a substantive policy decision that could not be adopted without notice and comment.In 1981, Congress authorized the payment of sums in addition to Medicaid payments hospitals that treat indigent patients receive in order to cover the full costs of care. Congress later passed a law seeking to cap those payments at each hospital’s “costs incurred.” At issue was to what extent “costs incurred” equals the total costs of service rather than the costs net of payments from sources such as Medicare and private insurance. With two exceptions, Congress stated that “costs incurred” are “as determined by the Secretary.” In 2010, the Secretary made its FAQs announcement that the payments to be offset against total costs in calculating “costs incurred” also included reimbursements received from Medicare and private insurance. The First Circuit held that the Secretary’s rule was procedurally improper for having failed to observe the notice-and-comment procedures prescribed by the Administrative Procedure Act. View "New Hampshire Hospital Ass’n v. Hargan" on Justia Law

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The First Circuit affirmed the district court’s decision affirming an administrative law judge’s (ALJ) finding that Appellant was not disabled within the meaning of the Social Security Act and thus not entitled to Supplemental Security Income benefits, holding that the ALJ’s determination was supported by substantial evidence. Specifically, the Court held (1) the ALJ did not err in according only slight weight to the testimony of an orthopedic physician who treated Appellant for a non-displaced fracture of her left femur; and (2) the ALJ was entitled to rely on testimony of an impartial vocational expert presented by the Commissioner of the Social Security Administration about available jobs that Appellant was entitled to perform. View "Purdy v. Berryhill" on Justia Law

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The First Circuit affirmed the district court’s dismissal of Plaintiffs’ suit challenging the Social Security Administration’s (SSA) termination of tier disability benefits for lack of subject matter jurisdiction based on Plaintiffs’ failure to have exhausted their administrative remedies.After the SSA terminated the disability benefits that Plaintiffs had been receiving, Plaintiffs challenged that decision administratively. Before they had exhausted the administrative review process, however, Plaintiffs filed suit in federal court seeking various kinds of relief based presumably on the same grounds as the claims that had presented to the SSA in seeking to continue to receive their benefits. The district court granted the government’s motion to dismiss for lack of subject matter jurisdiction, concluding that Plaintiffs failed to exhaust their administrative remedies. The First Circuit affirmed, holding that Plaintiffs failed to show that they could not obtain a restoration of their benefits through the administrative review process, despite evidence suggesting that they would have a substantial chance of doing so. View "Justiniano v. Social Security Administration" on Justia Law

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The First Circuit held that the five-day grace period outlined in 20 C.F.R. 422.210(c) does not apply to final decisions on remand where the individual does not file any written exceptions to the administrative law judge's decision and the Appeals Council does not assume jurisdiction of the case.Plaintiff applied for Title II disability benefits with the Social Security Administration. On remand, an ALJ issued a partially favorable decision on Plaintiff’s claim. Plaintiff did not file any written exceptions to the ALJ’s decision, and the Appeals Council did not review the ALJ’s decision. Therefore, the ALJ’s decision became the final decision of the Commissioner of Social Security. Plaintiff then filed a civil action challenging the ALJ’s decision on remand. The Commissioner moved to dismiss Plaintiff’s claim as untimely. The district court ruled against Plaintiff and dismissed her complaint for being untimely filed. Plaintiff appealed, asking the First Circuit to hold that the five-day grace period outlined in section 422.210(c) applies to final decisions on remand. The First Circuit declined Plaintiff’s request, holding that Plaintiff cannot apply the five-day grace period under section 422.210(c) to save her civil claim from being untimely. View "Walker-Butler v. Berryhill" on Justia Law

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Plaintiff filed filed a qui tam action against a corporation and its subsidiary, both of whom manufacture and market medical devices, alleging that Defendants violated the False Claims Act in selling two particular medical devices to hospitals that seek reimbursement from the federal government through, for example, the Center for Medicare and Medicaid Services. Through two subsequent amendments, both with permission of the court, Plaintiff added several defendants and retooled his claims. Plaintiff then requested leave to amend fourth amended complaint. The district court applied the “good cause” standard from Fed. R. Civ. P. 16(b) to that request and struck the amended complaint. The First Circuit originally held that the district court should have evaluated Plaintiff’s fourth amended complaint under the standard set forth in Fed. R. Civ. P. 15(a). On remand, the district court concluded that Plaintiff’s desired amendment failed under that standard. The First Circuit affirmed, holding that Plaintiff’s request for leave to file his fourth amended complaint was properly denied as futile because none of the claims in Plaintiff’s fourth amended complaint was adequately pled. View "D'Agostino v. EV3, Inc." on Justia Law

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The Centers for Medicare & Medicaid Services (CMS) terminated its Provider Agreement with Parkview Adventist Medical Center after finding that Parkview was no longer a “hospital” under the Medicare statute. Parkview, which had filed for bankruptcy, attempted to use the Bankruptcy Code to challenge the actions of CMS in terminating the agreement. Parkview filed a motion to compel post-petition performance of executory contracts, arguing that the Provider Agreement was an “executory contract” under 11 U.S.C. 365 and accordingly within the bankruptcy court’s jurisdiction and, as such, CMS’s termination of the agreement was a post-petition termination without court authority in violation of the Bankruptcy Code. Further, Parkview argued that CMS’s termination of the Provider Agreement violated the automatic stay in 11 U.S.C. 362(a)(3) and the non-discrimination provision in 11 U.S.C. 525(a). The bankruptcy court concluded that it lacked jurisdiction over the motion and that CMS had not violated either the automatic stay or the non-discrimination provision. The district court affirmed. The First Circuit affirmed, holding (1) the automatic stay did not bar CMS’s termination of the Provider Agreement; and (2) CMS’s termination of the Provider Agreement was not impermissible discrimination. View "Parkview Adventist Medical Center v. United States" on Justia Law

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Relators’ daughter died of a seizure after receiving mental health treatment at Arbour Counseling Services, a facility in Massachusetts owned and operated by Universal Health Services (UHS). When Relators learned that Arbour had employed unlicensed and unsupervised personnel, in violation of state regulations, they brought a qui tam action against UHS under the False Claims Act (FCA), alleging that UHS had fraudulently submitted reimbursement claims to the Commonwealth despite knowing that it was in violation of state regulations (a theory of FCA liability known as the “implied false certification theory”). The district court dismissed the complaint, concluding that the regulatory violations were not conditions of payment as required for a claim to be actionable under the FCA. The First Circuit reversed, holding that the regulatory violations at issue were conditions for payment and that Relators appropriately stated a claim with particularity under the FCA. On certiorari, the Supreme Court held that the implied false certification theory can be a basis for FCA liability but remanded the case for further consideration of whether the complaint sufficiently alleged that the regulatory violations were material to the government’s payment decision. The First Circuit again reversed the district court’s grant of UHS’s motion to dismiss after applying the Supreme Court’s guidance on the question of whether UHS’s misrepresentations were material, holding that Relators’ complaint sufficiently stated a claim under the FCA. View "United States, ex rel. Escobar v. Universal Health Services, Inc." on Justia Law

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The consolidated appeals in this case involved a dispute between the Secretary of Health and Human Services and a group of Maine hospitals about certain payments - called disproportionate share payments (DSH payments) - the hospitals had received in reimbursement from the federal government for charity care for fiscal years dating as far back as 1993. Generally speaking, the more low-income patients a hospital services, the higher the hospital’s DSH payment. In this case, the Secretary maintained that the Hospitals were overinclusive in their DSH payment calculations. An intermediary reassessed the DSH payments and recouped from the Hospitals approximately $22 million in alleged overpayments. The Provider Reimbursement Review Board, in turn, ordered the intermediary to restore approximately $17 million to the Hospitals. The Secretary reversed. The Hospitals sought judicial review, but neither side was satisfied with the district court’s ruling. On appeal, the First Circuit reversed in part and affirmed in part, holding (1) the Secretary properly reopened the disputed years and adequately demonstrated that the Hospitals had received substantial overpayments of DSH funds; and (2) the Hospitals’ defenses to repayment were unavailing. View "Maine Medical Center v. Burwell" on Justia Law

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In 2012, Plaintiff applied for disability insurance benefits under the Social Security Act, alleging a disability onset date of 1995. Plaintiff’s date last insured (DLI) was in 1998. An administrative law judge (ALJ) denied benefits, concluding that Plaintiff was not disabled prior to her DLI and was thus not eligible to receive benefits. The district court vacated the Commissioner’s decision and remanded for further proceedings, ruling that the ALJ failed to comply with Social Security Ruling (SSR) 83-20 and consult a medical advisor before drawing inferences as to whether Plaintiff’s onset date preceded the expiration of her insured status. In making its ruling, the district court relied upon Social Security Ruling (SSR) 83-20, which instructs an ALJ to consult a medical expert when the ALJ must infer a claimant’s date of disability onset on the basis of ambiguous medical evidence. The First Circuit vacated the judgment of the district court, holding that SSR 83-20 did not require the ALJ to consult a medical expert because the medical evidence was not ambiguous, and thus, the ALJ did not need to infer Plaintiff’s date of disability onset. Remanded for consideration of Plaintiff’s remaining claims. View "Fischer v. Colvin" on Justia Law