Justia U.S. 6th Circuit Court of Appeals Opinion Summaries

Under the Medicaid program, the federal government offsets some state expenses for medical services to low-income persons; a state’s plan must cover medical assistance for specific populations, but a state may expand its Medicaid program by obtaining a waiver for an “experimental, pilot, or demonstration project.” In 1993, Tennessee obtained a waiver for TennCare, to cover uninsured and uninsurable individuals. Following approval, hospitals received reimbursement under the umbrella of TennCare. Because hospitals serving large numbers of low-income patients generally incur higher costs than Medicaid flat payment rates reflect, hospitals that treated a disproportionate share of low-income patients could apply for the “DSH” adjustment. A fiscal intermediary processed requests for reimbursement, including DSH adjustment payments. Due to discrepancies between the practices of fiscal intermediaries in different states, the Secretary issued a 2000 rule, providing that eligibility waiver patients were to be included as individuals “eligible for medical assistance” under Medicaid for purposes of DSH adjustment calculations. The 2005 Deficit Reduction Act ratified the rule. Adventist, a not-for-profit hospital network, provided more than 1,200 patient care days to TennCare expansion waiver patients 1995-2000. The fiscal intermediary did not include those days in calculating the adjustment. The Secretary’s Provider Reimbursement Review Board upheld the exclusion. The district court dismissed, concluding that section 1315 provided the Secretary discretion to exclude expansion waiver patient days from the DSH calculation. The Sixth Circuit affirmed. View "Adventist Health Sys./Sunbelt, Inc. v. Sebelius" on Justia Law

MedQuest is a diagnostic testing company that operates more than 90 testing facilities in 13 states. In 2006 a former MedQuest employee, brought a qui tam suit against MedQuest alleging violations of the False Claims Act. The United States intervened and obtained summary judgment ($11,110,662.71) that MedQuest used supervising physicians who had not been approved by the Medicare program and the local Medicare carrier to supervise the range of tests offered at the Nashville-area sites, and after acquiring one facility, MedQuest failed to properly re-register the facility to reflect the change in ownership and enroll the facility in the Medicare program, instead using the former owner’s payee ID number. The Sixth Circuit reversed, stating that the Medicare regulatory scheme (42 U.S.C. 1395x) does not support FCA liability for failure to comply with the supervising-physician regulations. MedQuest’s failure to satisfy enrollment regulations and its use of a billing number belonging to a physician’s practice it controlled do not trigger the hefty fines and penalties created by the FCA. View "United States v. MedQuest Assocs, Inc." on Justia Law

Berrien worked for a civilian contractor (TECOM) at a military base in Michigan. He was fatally injured by a gutter that fell from the liquor store on the base while he was working alone, behind the store. The district court awarded $1.18 million in damages for failure to warn, under the Federal Tort Claims Act, 28 U.S.C. 1346(b)(1). The Sixth Circuit reversed. Because the Act does not waive the immunity of the United States for acts of independent contractors, liability could only be based on the negligence of government employees. There was no evidence that government employees actually knew of the dangerous condition of the liquor store, so that, under applicable Michigan law, any liability for failure to warn an invitee of a dangerous condition would have to have been based on a negligent failure to discover the dangerous condition. Even though the United States retained the right to conduct spot checks under its contract with TECOM, this right does not subject it to FTCA liability. View "Berrien v. United States" on Justia Law

In 2004 the U.S. Department of Health and Human Services promulgated 42 C.F.R. § 412.106(b), concerning the amount that certain hospitals are entitled to receive as enhancements to their regular reimbursement payments from the Medicare program. In connection with the Medicare program, Congress created a statutory formula to identify hospitals that serve a disproportionate number of low-income patients and to calculate the increased payments due such hospitals. Metropolitan Hospital challenged the way that the Secretary of HHS interprets this statutory formula to exclude certain patients who are simultaneously eligible for benefits under both Medicare and Medicaid, claiming that exclusion of dual-eligible patients cost it more than $2.1 million in 2005. The district court ruled that the challenged HHS regulation was invalid as violating the statute that it purported to implement. The Sixth Circuit reversed, upholding HHS’s interpretation of 42 U.S.C. 1395. View "Metro. Hosp. v. U.S. Dept of Health & Human Servs." on Justia Law

In 2004 Taylor, an employee of the IRS, began applying for promotions and transfers, and was rejected until she received a promotion in 2006. In 2004, after being denied a promotion, Taylor filed her first discrimination complaint and was assigned to work in a unit supervised by Shields. While working in this unit, Taylor alleges that Shields took several retaliatory actions against Taylor, including written reprimands, a three-day suspension without pay, and providing negative references for Taylor to prospective employers. Based on these alleged actions, Taylor filed additional complaints for retaliation. In 2005, the IRS and Taylor entered into a settlement agreement. Taylor subsequently alleged noncompliance by the IRS. In 2006 and 2008, the agency issued decisions concluding that although the IRS had breached the agreement, it was currently in compliance. Taylor did not appeal either decision, but filed a complaint alleging retaliation under 42 U.S.C. 2000e-16(a) and breach-of-settlement-agreement. The district court dismissed. The Sixth Circuit affirmed with respect to the breach claim, holding that Congress has not waived sovereign immunity with respect to such claims, but reversed with respect to retaliation.View "Taylor v. Geithner" on Justia Law

Erie County filed a purported class action on behalf of itself and other counties in northern Ohio, claiming that Morton and Cargill conspired to fix the price of rock salt in northern Ohio by geographically dividing the market and excluding competition, in violation of Ohio’s Valentine Act (Ohio Rev. Code 1331.01-1331.15), analogous to federal antitrust statutes, including the Sherman Act (15 U.S.C. 1-7). The district court dismissed, finding that the alleged facts were just as consistent with lawful parallel conduct as with a conspiracy. The Sixth Circuit affirmed. The alleged “failure to compete” indicates no more than a natural and independent desire to avoid a turf war and preserve profits guaranteed by regional dominance. Erie County’s concession that it was not bound by the “Buy Ohio” law defeated its claim of conspiracy evidenced by submission of sham bids. View "Erie Cnty. v. Morton Salt Co." on Justia Law

Taylor owned a convenience store. In 2008, the store received authorization to redeem benefits through the Supplemental Nutrition Assistance Program, a federally funded program providing nutritional assistance to needy individuals. In 2010-2011, the USDA conducted an undercover operation. Taylor allowed undercover police officers and confidential informants working under USDA special agents to redeem SNAP benefits for cash that Taylor knew would be used to purchase illegal drugs. Taylor once exchanged a firearm for SNAP benefits. Taylor pled guilty to conspiracy to defraud the U.S., SNAP fraud, drug distribution, and being a felon in possession of a firearm. Based on the firearm conviction and Taylor’s criminal history, the probation officer recommended an enhanced sentence under the Armed Career Criminal Act, 18 U.S.C. 924(e), resulting in a Guidelines range of 188 to 235 months. The district court sentenced Taylor to 188 months. Graves, a friend of Taylor’s, worked in the store and would stand outside the store and either sell drugs to people who redeemed benefits for cash or tell them where to find drugs. Graves also sold an informant a firearm and split the proceeds with Taylor’s wife. The district court sentenced Graves to 200 months. The Sixth Circuit affirmed. View "United States v. Taylor" on Justia Law

Tasis and his brother ran a sham medical clinic, recruited homeless Medicare recipients who had tested positive for HIV, hepatitis or asthma, paid the “patients” small sums in exchange for their insurance identification, then billed Medicare for infusion therapies that were never provided. During four months in 2006, the Center billed Medicare $2,855,785 and received $827,000 in return. The scheme lasted 15 months, during which Tasis and his collaborators submitted $9,122,159.35 in Medicare claims. An auditor notified the FBI. After an investigation, prosecutors indicted Tasis on fraud and conspiracy claims. Over Tasis’s objection, co-conspirator Martinez testified that she and Tasis had orchestrated a a similar scam in Florida. The court instructed the jury to consider Martinez’s testimony about the Florida conspiracy only as it related to Tasis’s “intent, plan and knowledge.” The jury found Tasis guilty, and the trial judge sentenced him to 78 months in prison and required him to pay $6,079,445.93 in restitution. The Sixth Circuit affirmed, rejecting various challenges to evidentiary rulings. View "United States v. Tasis" on Justia Law

Circle C contracted to construct buildings at the Fort Campbell military base. The agreement included determinations of hourly wages for electrical workers. Circle C has had government contracts for 20 years; its co-owner and a bookkeeper attended training on the prevailing wage requirement for federal government contracts. PT was Circle C’s subcontractor on 98 percent of the electrical work, but did not have a written contract. Circle C provided PT with the wage determination excerpts from its contract, but did not explain the Davis-Bacon Act (40 U.S.C. 3142) prevailing wage requirements nor verify whether PT submitted its own payroll certifications, nor monitor PT’s eight employees’ work on the project, nor take measures to ensure payment of proper wages. One of the PT electricians claimed violation of the federal False Claims Act, 31 U.S.C. 3729(a)(2). The Department of Labor found inaccurate or false payroll certifications. The district court awarded treble damages: $1,661,423.13. The Sixth Circuit affirmed summary judgment in favor of plaintiffs, but remanded for recalculation of the damages. Circle C, an experienced contractor, made false statements, acted in reckless disregard of the truth or falsity of the information, and the false statements were “material” to the government’s decision to make payment.View "Wall v. Circle C Constr., L.L.C." on Justia Law

Semrau, a Ph.D. in clinical psychology, owned companies that provided psychiatric care to nursing home patients in Tennessee and Mississippi, using contracting psychiatrists who submitted records describing their work. The companies then billed the services to Medicare or Medicaid through private insurance carriers. Services are categorized into five-digit Current Procedural Terminology Codes, published by the American Medical Association. The Centers for Medicare and Medicaid Services sets reimbursement levels for each code as well as “relative value units” corresponding to the amount of work typically required for each service. After audits indicated that the companies had been billing at a higher rate than could be justified by the services actually performed, “upcoding,” Semrau was convicted of healthcare fraud, 18 U.S.C. 1347, and was sentenced to 18 months of imprisonment and ordered to pay $245,435 in restitution. The Sixth Circuit affirmed, rejecting Semrau’s claim that results from a functional magnetic resonance imaging lie detection test should have been admitted to prove the veracity of his denials of wrongdoing. There was ample evidence that Semrau was aware of accepted definitions of the CPT codes; he expressly agreed not to “submit claims with deliberate ignorance or reckless disregard of their truth or falsity.” View "United States v. Semrau" on Justia Law