Justia U.S. 10th Circuit Court of Appeals Opinion Summaries

Articles Posted in Public Benefits
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In separate claims, appellees Willie Carr and Kim Minor sought disability benefits from the Social Security Administration (“SSA”). In each case, the administrative law judge (“ALJ”) denied the claim, and the agency’s Appeals Council declined to review. While his case was pending in district court, the U.S. Supreme Court held that Securities and Exchange Commission (“SEC”) ALJs were “inferior officers” under the Appointments Clause, and therefore must be appointed by the President, a court, or head of the agency. Shortly thereafter, Minor also sued in district court to challenge the denial of benefits in her case. In response to the Supreme Court case, Lucia v. S.E.C., 138 S. Ct. 2044 (2018), the SSA Commissioner appointed the SSA's ALJs to address any Appointments Clause questions Lucia posed. After the Commissioner’s action, Carr and Minor each filed a supplemental brief, asserting for the first time that the ALJs who had rejected their claims had not been properly appointed under the Appointments Clause. The district court upheld the ALJs’ denials of the claims, but it agreed with the Appointments Clause challenges. The court vacated the SSA decisions and remanded for new hearings before constitutionally appointed ALJs. It held that appellees did not waive their Appointments Clause challenges by failing to raise them in their SSA proceedings. On appeal, the Commissioner argued Appellees waived their Appointments Clause challenges by failing to exhaust them before the SSA. The Tenth Circuit agreed with the Commissioner and reversed. View "Carr v. Commissioner, SSA" on Justia Law

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Plaintiff-Appellants were eleven rural hospitals (the “Hospitals”) who challenged the methodology the U.S. Secretary of Health and Human Services (the “Secretary”) used to calculate their Medicare reimbursements. After the publication of the FY 2010 Final Rule, the Hospitals took issue with the Secretary’s methodology for calculating the hospital-specific rate for new base years. And dissatisfied with their reimbursements under that methodology, the Hospitals filed administrative appeals with the Provider Reimbursement Review Board, an independent panel authorized to hear appeals from the Secretary’s final determinations. The Hospitals then sued the Secretary in the district court, arguing: (1) the Secretary applied the same cumulative budget-neutrality adjustment twice—once by using inflated normalized diagnosis-related group weights as a divisor in step two and then again in step four; (2) the Secretary’s methodology yielded different payments than “would have been made had [he] . . . applied the budget-neutrality adjustments to the DRG weights themselves;" and (3) the Secretary acted arbitrarily and capriciously by not calculating the hospital-specific rate for new base years “based on 100 percent” of a hospital’s base-year “target amount." The district court held it would “not second-guess the Secretary’s policy” just because there may have been “other ways of calculating payments.” And so the court denied the Hospitals’ summary-judgment motion, granted the Secretary’s cross-motion, and entered final judgment.The Tenth Circuit Court of Appeals, in reviewing the Hospitals’ arguments, found that their arguments rested on "flawed assumptions. And the Secretary has long understood his methodology and explained it to the public." The Court concurred with the district court and affirmed its judgment. View "Hays Medical Center et al. v. Azar" on Justia Law

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Plaintiff Steven Kientz spent many years as a "dual status" technician with the Kansas Army National Guard, where he worked as a mechanic on electronic measurement equipment. Plaintiff’s position required him to simultaneously serve as a member of the National Guard, a second job with separate pay and separate responsibilities. In retirement, Plaintiff receives a monthly pension payment under the Civil Service Retirement System based on his service as a dual status technician. Plaintiff also receives Social Security retirement benefits based on contributions he made to the Social Security system from his separate pay as a National Guard member. The issue this case presented for the Tenth Circuit's review centered on whether a dual status service technician’s civil service pension was “based wholly on service as a member of a uniformed service” under 42 U.S.C. 415(a)(7)(A). After review, the Court concluded Plaintiff's civil service pension is not “wholly” based on service as a member of a uniformed service, and his pension payments were therefore subject to the Windfall Elimination Provision ("WEP"). Plaintiff’s dual status technician work was at least partially distinct from the performance of his military duties. And Plaintiff received separate compensation and separate pensions for his performance of those distinct roles. The Court concurred with the district court and Social Security Administration that Plaintiff's Social Security retirement benefits were subject to the WEP. View "Kientz v. Commissioner, SSA" on Justia Law

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Arthur Noreja appeals the denial of his claim for disability benefits. Noreja filed his disability claim in March 2012. In July 2013, following a hearing, an ALJ issued a detailed written order – exceeding 13 pages with single spacing – in which she denied Noreja’s claim. The ALJ found Noreja had several severe impairments, including “arthritis of the left upper extremity and right lower extremity,” “cognitive disorder,” and “headaches.” Nevertheless, the ALJ determined that these impairments (or a combination of the impairments) did not warrant relief. The ALJ found that Noreja had the residual functional capacity (“RFC”) to do “medium” work, subject to various limitations, and that there were “jobs that exist in significant numbers in the national economy” which Noreja could perform. The Appeals Council disagreed with the ALJ’s assessment, and remanded with direction for further proceedings. Once more, however, the ALJ determined that Noreja did not have “an impairment or combination of impairments” that warranted relief, reiterated that Noreja had the RFC to do "medium" work, subject to various limitations, and that there were jobs in existence "in significant numbers" which Noreja could perform. The ALJ did not obtain a new consultative mental examination before issuing her May 2016 decision, but she procured additional evidence regarding Noreja’s impairments. On appeal of the second ALJ decision, Noreja alleged the ALJ failed to follow an instruction in the Appeals Council's remand order. The Tenth Circuit held: (1) it had jurisdiction to determine whether an alleged ALJ violation of an Appeals Council order warranted reversal; but (2) the Court's “usual” review standards remained in force, meaning that the alleged violation was material only if it showed the ALJ meaningfully failed to apply the correct legal standards, or the denial of benefits was unsupported by substantial evidence; and (3) applying those standards here, the ALJ’s denial of Noreja’s application had to be affirmed. View "Noreja v. Commissioner, SSA" on Justia Law

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Stacey Janssen alleged Lawrence Memorial Hospital ("LMH") engaged in two healthcare schemes to fraudulently receive money from the United States. Janssen first contended LMH falsified patients’ arrival times in order to increase its Medicare reimbursement under certain pay-for-reporting and pay-for-performance programs the Government used to study and improve hospitals’ quality of care. Second, Janssen contended LMH falsely certified compliance with the Deficit Reduction Act in order to receive Medicare reimbursements to which it was otherwise not entitled. LMH moved for summary judgment below, arguing Janssen failed to show her allegations satisfied the Act’s materiality requirement - that the alleged falsehoods influenced the Government’s payment decision as required under the FCA. The district court granted LMH summary judgment on all of Janssen’s claims on this basis, and finding no reversible error, the Tenth Circuit affirmed. View "United States ex rel. Janssen v. Lawrence Memorial Hospital" on Justia Law

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Blue Valley Hospital, Inc., (“BVH”) appealed a district court’s dismissal of its action for lack of subject matter jurisdiction. The Department of Health and Human Services (“HHS”) and the Centers for Medicare and Medicaid Services (“CMS”) terminated BVH’s Medicare certification. The next day, BVH sought an administrative appeal before the HHS Departmental Appeals Board and brought this action. In this action, BVH sought an injunction to stay the termination of its Medicare certification and provider contracts pending its administrative appeal. The district court dismissed, holding the Medicare Act required BVH exhaust its administrative appeals before subject matter jurisdiction vested in the district court. BVH acknowledged that it did not exhaust administrative appeals with the Secretary of HHS prior to bringing this action, but argued: (1) the district court had federal question jurisdiction arising from BVH’s constitutional due process claim; (2) BVH’s due process claim presents a colorable and collateral constitutional claim for which jurisdictional exhaustion requirements are waived under Mathews v. Eldridge, 424 U.S. 319 (1976); and (3) the exhaustion requirements foreclosed the possibility of any judicial review and thus cannot deny jurisdiction under Bowen v. Michigan Academy of Family Physicians, 476 U.S. 667 (1986). The Tenth Circuit disagreed and affirmed dismissal. View "Blue Valley Hospital v. Azar" on Justia Law

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This case was a qui tam action alleging violations of the False Claims Act (“FCA”) involving fraudulent reimbursements under the Medicare Act. Plaintiff Gerald Polukoff, M.D., was a doctor who worked with Defendant Sherman Sorensen, M.D. After observing some of Sorensen’s medical practices, Polukoff brought this FCA action, on behalf of the United States, against Sorensen and the two hospitals where Sorensen worked (collectively, “Defendants”). Polukoff alleged Sorensen performed thousands of unnecessary heart surgeries and received reimbursement through the Medicare Act by fraudulently certifying that the surgeries were medically necessary. Polukoff further alleged the hospitals where Sorensen worked were complicit in and profited from Sorensen’s fraud. The district court granted Defendants’ motions to dismiss, reasoning that a medical judgment could not be false under the FCA. The Tenth Circuit reversed and remanded, holding that a doctor’s certification to the government that a procedure is “reasonable and necessary” is “false” under the FCA if the procedure was not reasonable and necessary under the government’s definition of the phrase. View "Polukoff v. St. Mark's Hospital" on Justia Law

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The Acting Commissioner of the Social Security Administration appealed a district court order reversing her decision to deny Marla Vallejo’s application for supplemental security income benefits and remanding the case for further administrative proceedings. Because the district court’s order rested on a misapplication of controlling law, the Tenth Circuit reversed and remanded to the district court for further proceedings. View "Vallejo v. Berryhill" on Justia Law

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Caring Hearts Personal Home Services, Inc. provided physical therapy and skilled nursing services to “homebound” Medicare patients. It sought reimbursement from Medicare for services provided. The definition of who qualified as "homebound" or what services qualified as "reasonable and necessary" was unclear, even to the Centers for Medicare & Medicaid Services (CMS). CMS has developed its own rules on both subjects that had been repeatedly revised and expanded over time. In an audit, CMS purported to find that Caring Hearts provided services to at least a handful of patients who didn’t qualify as “homebound” or for whom the services rendered weren’t “reasonable and necessary.” As a result, CMS ordered Caring Hearts to repay the government over $800,000. It was later found that in reaching its conclusions CMS applied the wrong law: the agency did not apply the regulations in force in 2008 when Caring Hearts provided the services in dispute. Instead, it applied considerably more onerous regulations the agency adopted years later, "[r]egulations that Caring Hearts couldn’t have known about at the time it provided its services." The Tenth Circuit found that Caring Hearts "[made] out a pretty good case that its services were entirely consistent with the law as it was at the time they were rendered" when CMS denied Caring Hearts' request for reconsideration. The Tenth Circuit reversed the district court's judgment affirming CMS' denial to Caring Hearts for reimbursement, and remanded for further proceedings. View "Caring Hearts v. Burwell" on Justia Law

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Plaintiff-appellant Laurie Smith sought review when her Social Security disability benefit claims were denied. She alleged disability based in part on: impingement of her left shoulder; restrictions on her ability to: (1) reach and (2) handle and finger objects; and moderate nonexertional limitations. The administrative law judge concluded that Smith could work as a telequotation clerk, surveillance systems monitor, or call-out operator. As a result, the judge concluded that Smith was not disabled. Ms. Smith appealed to the district court, which upheld the administrative law judge’s determination. After its review, the Tenth Circuit found no reason to disturb the ALJ's or the district court's judgments and affirmed. View "Smith v. Colvin" on Justia Law