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

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

The seven consolidated cases in this appeal all involve attempts by assignees of a health maintenance organization (HMO) to recover conditional payments via the Medicare Secondary Payer Act's (MSP Act), 42 U.S.C. 1395y(b)(2)(B)(ii), (b)(3)(A), private cause of action. At issue is whether a contractual obligation, without more (specifically, without a judgment or settlement agreement from a separate proceeding), can satisfy the “demonstrated responsibility” requirement of the private cause of action provided for by the MSP Act. The court held that a plaintiff suing a primary plan under the private cause of action in the MSP Act may satisfy the demonstrated responsibility prerequisite by alleging the existence of a contractual obligation to pay. A judgment or settlement from a separate proceeding is not necessary. Therefore, the court vacated the district courts' judgments and remanded for further proceedings. View "MSP Recovery LLC v. AllState Ins. Co." on Justia Law

The Secretary determined that Bayou Shores was not in substantial compliance with the Medicare program participation requirements, and that conditions in its facility constituted an immediate jeopardy to residents’ health and safety. The bankruptcy court assumed authority over Medicare and Medicaid provider agreements as part of the debtor’s estate, enjoined the Secretary from terminating the provider agreements, determined for itself that Bayou Shores was qualified to participate in the provider agreements, required the Secretary to maintain the stream of monetary benefit under the agreements, reorganized the debtor’s estate, and finally issued its Confirmation Order. The district court upheld the Secretary’s jurisdictional challenge and reversed the Confirmation Order with respect to the assumption of the debtor’s Medicare and Medicaid provider agreements. The court concluded that the statutory revision in this case does not demonstrate Congress's clear intention to vest the bankruptcy courts with jurisdiction over Medicare claims. Therefore, the court agreed with the district court that the bankruptcy court erred as a matter of law when it exercised subject matter jurisdiction over the provider agreements in this case. The bankruptcy court was without 28 U.S.C. 1334 jurisdiction under the 42 U.S.C. 405(h) bar to issue orders enjoining the termination of the provider agreements and to further order the assumption of the provider agreements. Accordingly, the court affirmed the judgment. View "Florida Agency for Health Care Admin. v. Bayou Shores" on Justia Law

VRC filed suit against HHS and the Secretary, seeking the recoupment of payments VRC returned to Medicare after it was issued notice of an overpayment. At issue is the reimbursement rate of the intravitreal injection of Lucentis. VRC did not follow the Lucentis label’s instructions limiting dosage to one per vial. Instead, VRC treated up to three patients from a single vial. Because VRC was extracting up to three doses from a single vial, it was reimbursed for three times the average cost of the vial and three times the amount it would have received had it administered the drug according to the label. The court affirmed the denial of recoupment, concluding that VRC's charge to Medicare did not reflect its expense and was not medically reasonable; the Secretary's decision was supported by substantial evidence; and VRC is liable for the overpayment. View "Vitreo Retinal Consultants v. U.S. Dep't of Health & Human Servs." on Justia Law

Plaintiff appealed the denial of her application for disability insurance benefits, contending in part that the district court should have remanded the case to the Commissioner for further proceedings to consider new evidence. The court agreed with the Sixth Circuit's rejection of the notion that the mere existence of a subsequent decision in the claimant's favor, standing alone, warranted reconsideration of the first application. In this case, the only “new evidence” plaintiff cites in support of her request for remand is the later favorable decision. The court concluded that the later decision is not evidence for purposes of 42 U.S.C. 405(g). Because plaintiff does not offer any other new evidence, she has not established that remand is warranted. The court also concluded that the ALJ's conclusion that plaintiff was able to perform light work was supported by substantial evidence and that the ALJ gave adequate weight to the opinion of her treating physician, finding it inconsistent with the medical records and other evidence. Accordingly, the court affirmed the judgment. View "Hunter v. SSA" on Justia Law

Plaintiff appealed the denial of his application for disability insurance benefits and supplemental security income. The court held that the Appeals Council committed legal error when it failed to consider materials from a psychologist who examined plaintiff. Accordingly, the court reversed and remanded with instructions. View "Washington v. SSA" on Justia Law

Plaintiff appealed the denial of his application for disability insurance benefits and supplementary security income, arguing that the ALJ erred in refusing to give proper weight to the opinion of a consultative examining physician, and in finding that plaintiff's 2012 testimony was not credible and failing to consider his vision limitations when evaluating his residual functioning capacity. The court agreed that the ALJ erred in both respects and reversed the judgment of the district court, remanding for further proceedings. View "Henry v. Commissioner" on Justia Law

Petitioner Rachel Parks appealed an administrative law judge's denial of her application for supplemental security income on behalf of her minor son, D.P. D.P. suffered from attention deficit hyperactivity disorder and borderline intellectual functioning. An administrative law judge denied Parks’s application because D.P. did not suffer from a condition that entitled him to supplemental security income. Parks filed a request for review with the Appeals Council, and she submitted new evidence of D.P.’s academic struggles. The Appeals Council supplemented the record with the new evidence, but denied review. Parks then filed a complaint in the district court, which affirmed the denial of her application. She argued on appeal to the Eleventh Circuit: (1) the administrative law judge's denial of Parks's application was not supported by substantial evidence; and (2) the Social Security Appeals Council needed to make explicit findings of fact about new evidence that it added to the record when it denied review. Because the administrative law judge’s decision was supported by substantial evidence and the Appeals Council was not required to make specific findings about Parks’s new evidence, the Eleventh Circuit affirmed. View "Parks v. Commissioner, Social Security Administration" on Justia Law