Articles Posted in Public Benefits

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The Ninth Circuit dismissed for lack of jurisdiction relators' appeal of the district court's dismissal of their qui tam suit against UOPX. The panel held that the appeal was untimely because relators' post-judgment motion, although styled as a Fed. R. Civ. P. 59(e) motion, was in substance a motion only to stay the entry of judgment, which did not toll the time to file a notice of appeal. View "United States ex. rel. Hoggett v. University of Phoenix" on Justia Law

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The Ninth Circuit reversed the dismissal of relators' qui tam action alleging that the College violated the False Claims Act (FCA), 31 U.S.C. 3729-3733, by knowingly providing false progress reports on students in order to keep grant monies. The panel held that the Tribe is not a "person" under the FCA. The panel remanded for further jurisdictional factfinding on whether the College was an arm of the Tribe that shares the Tribe's status for purposes of the FCA. View "United States ex rel Cain v. Salish Kootenai College, Inc." on Justia Law

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The Ninth Circuit reversed the denial of disability benefits and held that the ALJ did not follow the appropriate methodology for weighing a treating physician's medical opinion. In this case, the panel explained that the ALJ should have credited the treating physician's opinion and found that plaintiff was disabled, and the district court erred by developing its own reasons to discount the treating physician's opinion, rather than reviewing the ALJ's reasons for substantial evidence. The panel held that substantial evidence did not support the ALJ's finding that plaintiff's symptoms were not as severe as she testified, particularly in light of the extensive medical record objectively verifying her claims. Because each of the "credit-as-true" factors in Garrison v. Colvin, 759 F.3d 995, 1020 (9th Cir. 2014), was satisfied, remand for the calculation and award of benefits was warranted. View "Trevizo v. Berryhill" on Justia Law

Posted in: Public Benefits

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M.N. filed a due process complaint alleging that the District committed procedural and substantive violations of the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400(d)(1)(A). The ALJ denied all claims and the district court affirmed. The Ninth Circuit filed an amended opinion reversing the district court's judgment, holding that neither the duration of the hearing, the ALJ's active involvement, nor the length of the ALJ's opinion can ensure that the ALJ was thorough and careful in its findings of fact; plaintiffs' claim that the District committed a procedural violation of the IDEA by failing to adequately document its offer of the visually impaired (TVI) services was not waived; the District committed two procedural violations as to the individualized education plan (IEP); the District's failure to specify the assistive technology (AT) devices that were provided infringed M.N.'s opportunity to participate in the IEP process and denied the student a free appropriate education (FAPE); the panel remanded for a determination of the prejudice the student suffered as a result of the District's failure to respond to the complaint and the award of appropriate compensation; in regard to substantive violations, the panel remanded so the district court could consider plaintiffs' claims in light of new guidance from the Supreme Court in Endrew F. v. Douglas Cty. Sch. Dist., 137 S. Ct. 988 (2017); and M.N., as the prevailing party, was entitled to attorneys' fees. View "M.C. v. Antelope Valley Union High School District" on Justia Law

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The Ninth Circuit affirmed the denial of plaintiff's application for attorney fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d)(1)(A), holding that the Commissioner's litigation position was substantially justified. Plaintiff had successfully challenged the Commissioner's denial of her application for disability benefits and obtained a remand of her claim to the agency for further consideration. In this case, the district court did not abuse its discretion in determining that the Commissioner's position was substantially justified because the Commissioner's opposition to remand the claim on the merits was reasonable, even though it turned out to be unsuccessful. Finally, plaintiff's new evidence, though sufficient in the end to persuade the district court to remand the case, did not make that the only reasonable result. View "Decker v. Berryhill" on Justia Law

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The Ninth Circuit affirmed the denial of plaintiff's application for attorney's fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d)(1)(A). Plaintiff presented new evidence to the Appeals Council after she lost her claim for social security disability benefits before the ALJ. The district court remanded for further consideration and the Commissioner did not appeal. The district court denied plaintiff's request for attorney's fees, concluding that the Commissioner was substantially justified in arguing that the new evidence did not undermine the ALJ's denial of benefits. The issue that was before the district court on the original merits appeal of the ALJ's denial of benefits was not whether there was other evidence that could support a denial of benefits to plaintiff, or whether the Commissioner's denial of benefits might ultimately be sustained. The Ninth Circuit explained that it was whether the actual decision that was made by the ALJ could be affirmed at that time by the district court in light of the new evidence in the record. In this case, it should have been plain that it could not have been affirmed, because the ALJ's decision failed to provide a reason that was still viable for giving the opinion of the treating doctor little weight. The doctor's final report, if credited, would have undermined the ALJ's original finding that plaintiff was not disabled. Even if the Commissioner might have had a legitimate basis for opposing plaintiff's claim, she did not have a basis to oppose remand and to argue that the district court should affirm the existing ALJ opinion. View "Gardner v. Berryhill" on Justia Law

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The Centers for Medicare & Medicaid Services (CMS) pays Medicare Advantage organizations fixed monthly amounts for each enrollee. Medicare Advantage organizations have a financial incentive to exaggerate an enrollee’s health risks by reporting diagnosis codes unsupported by the enrollee’s medical records, and therefore, Medicare regulations require a Medicare Advantage organization to certify that the risk adjustment data is submits are accurate and truthful. Qui Tam Relator James Swoben filed a third amended complaint alleging that Medicare Advantage organizations performed biased retrospective medical record reviews, which rendered Defendants’ periodic certifications false, in violation of the False Claims Act. Defendants moved to dismiss Swoben’s claims. In response, Swoben sought to amend his complaint. The district court dismissed the third amended complaint with prejudice, concluding that Swoben failed to allege a claim with particularity as required by Fed. R. Civ. P. 9(b). The court also denied leave to amend, citing both futility of amendment and undue delay. The Ninth Circuit vacated the district court’s judgment, holding that the dismissing Swoben’s third amended complaint without leave to amend based on futility of amendment and undue delay and that leave to amend was proper in this case. View "United States v. United Healthcare Insurance Co." on Justia Law

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In 2012, the Wood plaintiffs, who were recipients of health coverage under Arizona's Medicaid demonstration project, filed suit against the Secretary challenging her approval of a new Arizona project that raised copayments for medical visits and medications and that permitted healthcare providers to refuse non-emergency services based on an inability to pay. At issue on appeal is whether the members of the class action were the prevailing parties for purposes of attorneys’ fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412. The court applied the factors in Buckhannon Bd. & Care Home, Inc. v. W. Va. Dep’t of Health & Human Res., holding that under the EAJA, the Wood plaintiffs are the prevailing party in their procedural Administrative Procedure Act (APA), 5 U.S.C. 706(2)(A), challenge against the Secretary. The court noted that the dispositive question is not whether the plaintiff ultimately obtained some form of substantive relief, but rather whether there is a lasting alteration in the legal relationship between the parties. The court concluded that there was a material alteration in the legal relationship of the parties, to the benefit of the Wood plaintiffs. Finally, the court concluded that the retention of jurisdiction for practical and equitable reasons did not undermine the reality that the Wood plaintiffs were a prevailing party. Therefore, the court reversed and remanded to the district court to consider whether the government’s position was “substantially justified” under the EAJA. View "Wood v. Burwell" on Justia Law

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L.J.’s mother filed suit in federal district court to require the school district to provide L.J. with an Individualized Education Plan (IEP) to provide specialized services to assist with what she contends are serious disabilities. The district court reviewed the record and found that L.J. was disabled under three categories defined by the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400 et seq. Nevertheless, the district court concluded that an IEP for specialized services was not necessary because of L.J.’s satisfactory performance in general education classes. The court concluded that L.J. clearly exhibited behavioral and academic difficulty during the snapshot period where he threatened and attempted to kill himself on three occasions in 2012; in the fall, he frequently acted out at school, and continued to have needs associated with his medication regimen; and the district court should not have discounted these facts. The court concluded that they demonstrate that L.J. required special education services. Because L.J. is eligible for special education, the school district must formulate an IEP. The court also concluded that the school district clearly violated important procedural safeguards set forth in the IDEA. In this case, the school district failed to disclose assessments, treatment plans, and progress notes, which deprived L.J.’s mother of her right to informed consent. The school district also failed to conduct a health assessment, which rendered the school district and IEP team unable to evaluate and address L.J.’s medication and treatment related needs. Accordingly, the court reversed and remanded. View "L. J. V. Pittsburg U.S.D." on Justia Law

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Relator filed a qui tam action under the False Claims Act, 31 U.S.C. 3729-3733, alleging that defendants submitted false certifications under 42 C.F.R. 422.504(l)(l)2), by conducting retrospective reviews of medical records designed to identify and report only under-reported diagnosis codes (diagnosis codes erroneously not submitted to CMS despite adequate support in an enrollee’s medical records), not over-reported codes (codes erroneously submitted to CMS absent adequate record support). The district court denied relator leave to file a proposed fourth amended complaint. The court concluded that the district court erred by concluding that amendment would be futile where relator's proposed fourth amended complaint asserts a cognizable legal theory. Relator alleged that Medicare Advantage organizations design retrospective reviews of enrollees’ medical records deliberately to avoid identifying erroneously submitted diagnosis codes that might otherwise have been identified with reasonable diligence. The court also concluded that the district court abused its discretion by denying leave to amend based on undue delay. In this case, leave to amend is proper given the early stage of litigation, relator does not seek to assert a new legal theory, and this is relator's first attempt to cure deficiencies. Therefore, because the district court abused its discretion in denying leave to amend, the court vacated the district court's dismissal and remanded with instructions. View "Swoben v. United Healthcare" on Justia Law