Justia U.S. 11th Circuit Court of Appeals Opinion Summaries

MSPA, a firm that obtains Medicare Secondary Payer Act (MSP Act) claims and brings them on behalf of Medicare Advantage Organizations (MAOs), filed suit against Tenet over a delayed reimbursement of $286. The Eleventh Circuit affirmed the district court's grant of Tenet's motion to dismiss. The court held that MSPA had standing to invoke a federal court's jurisdiction because it suffered an injury in fact when it had to wait seven months for appropriate reimbursement and it validly assigned the right to vindicate that injury to La Ley Recovery Systems, who in turn validly assigned it to MSPA.On the merits, the court held that the MSP Act's private cause of action was only available in the case of a primary plan which fails to provide for primary payment (or appropriate reimbursement). In this case, MSPA did not sue a primary plan, but instead, it sued two medical services providers. Because private MSP Act plaintiffs could only sue primary plans, and MSPA had not done so, its claim was not plausible on its face. Therefore, the district court correctly dismissed MSPA's complaint for failure to state a claim. View "MSPA Claims 1, LLC v. Tenet Florida, Inc." on Justia Law

Pursuant to the terms of Social Security Ruling 00-4p, and in light of the overall regulatory scheme that governs disability claims, the ALJs within the SSA have an affirmative duty to identify apparent conflicts between the testimony of a Vocational Expert (VE) and the DOT and resolve them. The Eleventh Circuit held that this duty requires more of the ALJ than simply asking the VE whether his testimony is consistent with the DOT. The court explained that, once the conflict has been identified, the Ruling requires the ALJ to offer a reasonable explanation for the discrepancy, and detail in his decision how he has resolved the conflict. Furthermore, the failure to discharge this duty means that the ALJ's decision, when based on the contradicted VE testimony, is not supported by substantial evidence.In this case, the ALJ failed to meet his obligations to identify, explain, and resolve an apparent conflict between the testimony of the VE and the DOT on a matter of considerable importance. Accordingly, the court reversed and remanded with instructions. View "Washington v. Commissioner of Social Security" on Justia Law

Plaintiff filed a civil rights action under 42 U.S.C. 1983, alleging that the termination of her housing voucher violated the Due Process Clause of the Fourteenth Amendment and regulations promulgated by the United States Department of Housing and Urban Development. The Eleventh Circuit vacated the district court's grant of summary judgment for the Authority, holding that indictments and evidence of an arrest did not constitute sufficient evidence to support the decision of a public housing authority to terminate housing subsidies provided under Section 8 of the Housing and Community Development Act of 1937. View "Yarbrough v. Decatur Housing Authority" on Justia Law

The SSA determined that because plaintiff was also receiving civil service disability retirement payments, his Social Security benefits should be reduced under the windfall elimination provision. At issue was the boundaries of "payment based wholly on service as a member of a uniformed service" for the purpose of social security benefit calculations.The Eleventh Circuit, accounting for the unique nature of the dual status technician position and applying Skidmore deference, held that plaintiff did not perform his dual status technician employment wholly as a member of a uniformed service. Consequently, payments based on that employment did not qualify for the exception. The court did not think the requirements of the dual status technician position were sufficient to place dual status technicians within the sweep of the exception—especially given the provision's use of the word "wholly." Therefore, the uniformed services exception did not apply in plaintiff's case. View "Martin v. Social Security Administration" on Justia Law

The Eleventh Circuit sua sponte vacated its prior decision and substituted the following decision, which again affirmed the district court's denial of plaintiff's application for disability insurance benefits and supplemental security income. This decision added a discussion about the 2015 physical capacities form completed by Dr. Jane Teschner and explained why that form did not warrant a remand to the Social Security Administration. View "Hargress v. Social Security Administration" on Justia Law

The Eleventh Circuit sua sponte vacated its prior decision and substituted the following decision, which again affirmed the district court's denial of plaintiff's application for disability insurance benefits and supplemental security income. This decision added a discussion about the 2015 physical capacities form completed by Dr. Jane Teschner and explained why that form did not warrant a remand to the Social Security Administration. View "Hargress v. Social Security Administration" on Justia Law

The Eleventh Circuit affirmed the denial of disability insurance benefits and supplemental security income (SSI) to plaintiff. The court held that substantial evidence supported the ALJ's decision to give little weight to the treating physician's opinion because it was inconsistent with his own medical records and the records as a whole; the ALJ's finding that plaintiff had the residual functioning capacity (RFC) to perform a full range of unskilled sedentary work was supported by substantial evidence; Social Security Ruling 16-3p applied only prospectively and did not provide a basis for remand; and the Appeals Council was not required to consider new evidence because it was not chronologically relevant. View "Hargress v. Social Security Administration" on Justia Law

The Eleventh Circuit affirmed the district court's dismissal of the Hospitals' suit to recover recoupments. At issue was whether, under the Medicare Act, 42 U.S.C. 1395w-21 to 1395w-29, the Hospitals must exhaust their administrative remedies before bringing suit for underpayment by the Medicare Advantage Organization (MAO) that manages enrollee benefits. The court held that the Hospitals, who were challenging CIP's recoupment decision, were parties to an "organization determination" who were subject to the administrative exhaustion requirements of the Medicare Act. The court noted that although it was sympathetic to the concern HHS has expressed in amicus briefs, the language of the Medicare Act and its implementing regulations was clear that billing disputes between MAOs and noncontract provider assignees qualify as "organization determinations" and were thus subject to the Act's exhaustion requirement. View "Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Co." on Justia Law

The Eleventh Circuit affirmed the district court's dismissal of the Hospitals' suit to recover recoupments. At issue was whether, under the Medicare Act, 42 U.S.C. 1395w-21 to 1395w-29, the Hospitals must exhaust their administrative remedies before bringing suit for underpayment by the Medicare Advantage Organization (MAO) that manages enrollee benefits. The court held that the Hospitals, who were challenging CIP's recoupment decision, were parties to an "organization determination" who were subject to the administrative exhaustion requirements of the Medicare Act. The court noted that although it was sympathetic to the concern HHS has expressed in amicus briefs, the language of the Medicare Act and its implementing regulations was clear that billing disputes between MAOs and noncontract provider assignees qualify as "organization determinations" and were thus subject to the Act's exhaustion requirement. View "Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Co." on Justia Law

Richard Culbertson was counsel for the four plaintiffs in these consolidated Social Security disability benefits cases. At issue in this appeal was the attorney's fees for Culbertson under 42 U.S.C. 406 and the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d). The Eleventh Circuit held that the district court did not err in its interpretation and application of Dawson v. Finch, 425 F.2d 1192 (5th Cir. 1970) and by imposing a 24% cap on section 406 fees; it was necessary for the district court to add the requested section 406(b) fee together with his EAJA award; and the district court did not abuse its discretion and did not exceed its authority. Accordingly, the court affirmed the judgment. View "Wood v. Commissioner of Social Security" on Justia Law