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

Kevin Clay and his associate founded a pharmaceutical sales company that marketed compounded prescriptions directly to patients, promising them a share of the insurance reimbursements for each prescription filled. The company partnered with a pharmacy willing to pay a portion of the insurance proceeds and recruited employees from a local business whose health plan covered these prescriptions. Patients were directed to a doctor who readily prescribed the creams, resulting in millions of dollars in reimbursements over two years. Clay established a public charity to reduce his tax burden but used its funds for personal expenses and failed to comply with nonprofit requirements.The United States District Court for the Northern District of Ohio oversaw Clay’s trial. A jury convicted him of conspiracy to commit healthcare fraud, healthcare fraud, and making a false statement to the IRS, but acquitted him of a separate tax charge. The court sentenced Clay to 51 months’ imprisonment and ordered restitution totaling nearly $7 million to both Fiat Chrysler and the IRS. Clay appealed his convictions, sentence, and restitution orders.The United States Court of Appeals for the Sixth Circuit reviewed the case. The court affirmed Clay’s convictions and rejected his challenges to the jury instructions and evidentiary rulings. However, it found error in the district court’s restitution orders and the application of a sentencing enhancement. Specifically, the Sixth Circuit held that restitution should not include payments for medically necessary prescriptions and that the apportionment of restitution must consider each defendant’s contribution and economic circumstances. The court also determined the restitution order to the IRS was not properly substantiated and included acquitted conduct. Finally, the case was remanded for further proceedings on restitution and for clarification or reconsideration of the leadership sentencing enhancement. View "United States v. Clay" on Justia Law

Troy Williams pleaded guilty to various federal offenses, including drug trafficking, firearm possession by a felon, and money laundering, and was sentenced to 198 months in prison, which was below the applicable sentencing guideline range. Williams has a history of serious medical conditions—thrombophilia and recurrent deep vein thrombosis—that require ongoing management, including regular blood testing and medication. Nearly ten years into his sentence, Williams sought compassionate release, asserting that inadequate medical care at his current facility placed him at risk of severe health complications or death.After Williams filed his pro se motion for compassionate release in the United States District Court for the Northern District of Ohio, counsel was appointed to supplement his arguments. Williams claimed the Bureau of Prisons was not providing sufficient medical care, particularly after his transfer to FCI Coleman, where he alleged infrequent blood testing and interruptions in medication. He also argued the sentencing factors under 18 U.S.C. § 3553(a) favored his release. The district court reviewed his medical records and expert testimony from the prison’s clinical director, ultimately finding that Williams’s care was not so deficient as to amount to extraordinary and compelling circumstances. The district court further concluded that, even if such circumstances were present, the sentencing factors did not support early release. Williams timely appealed.The United States Court of Appeals for the Sixth Circuit reviewed the district court’s denial for abuse of discretion, considering legal questions de novo and factual findings for clear error. The Sixth Circuit held that the district court did not clearly err in finding that Williams’s medical care was adequate and that his situation did not present extraordinary and compelling circumstances under the relevant Sentencing Commission policy statement. Accordingly, the Sixth Circuit affirmed the denial of Williams’s motion for compassionate release. View "United States v. Williams" on Justia Law

Two healthcare professionals operated a clinic specializing in pain management in Kentucky. One owned and managed the clinic, while the other served as its medical director. Together, they implemented a scheme to maximize profits by routinely ordering and billing insurers for both basic and more expensive, specialized urine drug tests for patients, regardless of actual medical need. The clinic eventually acquired in-house testing equipment to further increase billing. Staff raised concerns about the medical necessity of the tests and the reliability of the equipment, but the practice continued. The clinic also billed for tests conducted on malfunctioning equipment and for tests whose results could not be used for patient care due to processing delays.A grand jury indicted both individuals for conspiracy to commit health care fraud, substantive health care fraud, and (for one defendant) unlawful distribution of controlled substances. Both defendants went to trial in the United States District Court for the Eastern District of Kentucky. The jury convicted one defendant of health care fraud, and the other of both health care fraud and conspiracy to commit health care fraud. After denying post-trial motions for acquittal and new trial, the district court sentenced both to below-Guidelines imprisonment terms, after calculating loss amounts based on insurer payments for unnecessary testing, with a discount for tests likely to have been medically necessary.The United States Court of Appeals for the Sixth Circuit reviewed the convictions and sentences. The court held there was sufficient evidence to support both defendants’ convictions, upheld the district court’s evidentiary rulings (including admission of propensity and patient death evidence with limiting instructions), found no variance between the indictment and proof at trial, and determined that one defendant’s conflict-of-interest waiver was valid. The court also affirmed the district court’s methodology for estimating loss amounts for sentencing and restitution. The Sixth Circuit affirmed all convictions and sentences. View "United States v. Siefert" on Justia Law

Eskender Getachew, a medical doctor in Columbus, Ohio, operated a clinic treating patients with opioid addiction. The government alleged that Dr. Getachew unlawfully prescribed controlled substances, particularly Subutex, at rates far exceeding medical norms, often without verifying patients’ claimed allergies to naloxone. Evidence at trial included testimony from an undercover officer, clinic staff, and an expert who identified repeated deviations from accepted medical practice, such as prescribing drugs without documented need and ignoring signs of drug diversion. The jury found Dr. Getachew guilty on eleven counts of unlawful distribution of controlled substances and not guilty on four counts.The United States District Court for the Southern District of Ohio presided over the trial. After conviction, Dr. Getachew was sentenced to concurrent six-month terms and three years of supervised release. He moved for a new trial, arguing ineffective assistance of counsel during plea negotiations and requested an evidentiary hearing, which the district court denied. Dr. Getachew appealed, challenging the sufficiency of the evidence, the deliberate-ignorance jury instruction, the content of that instruction, his absence at the return of the verdict, and the denial of an evidentiary hearing.The United States Court of Appeals for the Sixth Circuit reviewed the case. The court held that the evidence was sufficient to support the jury’s finding that Dr. Getachew knowingly issued unauthorized prescriptions. It found no plain error in the deliberate-ignorance instruction or its content. The court determined that Dr. Getachew’s absence at the verdict’s return did not affect his substantial rights and that the district court did not abuse its discretion in denying an evidentiary hearing on the new trial motion. The Sixth Circuit affirmed the district court’s judgment. View "United States v. Getachew" on Justia Law

A physician who worked at several cancer centers in Kentucky brought a lawsuit under the False Claims Act, alleging that his former employers fraudulently billed Medicare and other federal programs. He claimed that the centers submitted claims falsely representing that radiation and chemotherapy services were either supervised or performed by qualified physicians, when in fact, they were not. The allegations included both radiation services and chemotherapy services, with the core assertion being that the centers either lacked proper physician supervision or used unqualified personnel, and that this resulted in improper billing to federal programs.The United States District Court for the Eastern District of Kentucky initially dismissed some of the physician’s claims and, after discovery, granted summary judgment to the defendants on the remaining claims. The court found that the plaintiff failed to show that Medicare required the specific type of physician supervision he alleged for radiation services, and that he did not provide sufficient evidence of any specific fraudulent chemotherapy claims. The court also determined that the plaintiff’s analysis of schedules and staffing was unreliable and speculative, and that he could not identify a single false claim actually submitted to the government. The court dismissed the radiation-services claims for failure to state a claim and granted summary judgment on the chemotherapy claims due to lack of evidence.On appeal, the United States Court of Appeals for the Sixth Circuit reviewed the district court’s decisions de novo. The appellate court held that the plaintiff failed to establish that the alleged physician supervision requirements were material preconditions for Medicare payment, and that he did not present evidence of any specific false claims for chemotherapy services. The court also found that the conspiracy claim failed because there was no underlying FCA violation. Accordingly, the Sixth Circuit affirmed the district court’s dismissal and grant of summary judgment in favor of the defendants. View "United States ex rel. O'Laughlin v. Radiation Therapy Services" on Justia Law

Several chambers of commerce, including regional and national organizations, brought a lawsuit on behalf of their pharmaceutical-manufacturer members challenging the constitutionality of the Drug Price Negotiation Program established by the Inflation Reduction Act of 2022. This federal program authorizes the Secretary of Health and Human Services to negotiate prices for certain high-expenditure drugs sold to Medicare and Medicaid. Among the plaintiffs’ members were AbbVie Inc. and its subsidiary Pharmacyclics LLC, manufacturers of a drug selected for the first round of negotiations. Notably, Pharmacyclics joined the Dayton and Ohio Chambers only after the litigation began, while AbbVie had longstanding membership in several chambers.The United States District Court for the Southern District of Ohio reviewed the case after the government moved to dismiss, arguing that the Dayton Chamber lacked associational standing and that venue was therefore improper. The district court allowed limited discovery and permitted the plaintiffs to amend their complaint. Ultimately, the district court dismissed the case, holding that the regional chambers’ purposes were not sufficiently related to the interests at stake in the lawsuit, and thus they lacked associational standing. The court also found that, without standing for the Dayton and Ohio Chambers, venue in the Southern District of Ohio was improper and declined to transfer the case.The United States Court of Appeals for the Sixth Circuit affirmed the district court’s judgment. The Sixth Circuit held that the interests asserted in the lawsuit were not germane to the purposes of the Dayton, Ohio, or Michigan Chambers, as their regional missions were too remote from the national pharmaceutical issues at stake. The court further concluded that, with no plaintiff residing in the district, venue was improper. The judgment of dismissal for improper venue was therefore affirmed. View "Dayton Area Chamber of Commerce v. Kennedy" on Justia Law

The case concerns a defendant who, after being excluded from Medicare and Medicaid as part of a civil False Claims Act settlement, purchased a Medicare-participating home healthcare company using an alias and forged documents. The company then submitted hundreds of fraudulent claims to Medicare, resulting in over $2.7 million in payments for services that were never provided. The defendant transferred the proceeds to India, where they remain unrecovered. During the criminal investigation, the defendant also attempted to prevent a former employee from testifying by impersonating another person and making false reports to U.S. authorities, which led to the employee’s visa being denied.A grand jury in the United States District Court for the Eastern District of Michigan indicted the defendant on charges including health care fraud, money laundering, conspiracy, aggravated identity theft, and witness tampering. The trial was delayed, and shortly before it began, the defendant’s counsel experienced internal conflict, leading to motions to withdraw and requests for a mistrial, all of which the district court denied. During trial, the defense sought to call a surprise witness, an unindicted co-conspirator, on the last day. The district court excluded this witness, citing a violation of a discovery order and concerns about delay, prejudice, and the likelihood the witness would invoke the Fifth Amendment.On appeal, the United States Court of Appeals for the Sixth Circuit reviewed whether the district court violated the defendant’s constitutional rights by excluding the witness, denying counsel’s motion to withdraw, and excluding the defendant from an in-chambers conference. The Sixth Circuit held that the exclusion of the witness did not violate the Sixth Amendment, as the district court reasonably balanced the defendant’s right to present a defense against countervailing interests, and the defendant failed to show what exculpatory evidence the witness would have provided. The court also found no abuse of discretion in denying the motion to withdraw and no reversible error in excluding the defendant from the conference. The Sixth Circuit affirmed the district court’s judgment. View "United States v. Pancholi" on Justia Law

The Grand Traverse Band of Ottawa and Chippewa Indians and its employee welfare plan (the Plan) alleged that Blue Cross Blue Shield of Michigan (Blue Cross) breached fiduciary duties under ERISA and related duties under Michigan state law. The Tribe claimed that Blue Cross submitted false claims, causing the Tribe to overpay for hospital services. The Tribe also alleged violations of the Michigan Health Care False Claims Act (HCFCA) and sought to amend its complaint to include additional facts.The United States District Court for the Eastern District of Michigan dismissed the Tribe’s ERISA and common-law fiduciary duty claims as time-barred, granted summary judgment to Blue Cross on the HCFCA claim, and denied the Tribe’s motion for leave to amend its complaint a second time. The court found that the Tribe had actual knowledge in 2009 that it was not receiving Medicare-Like Rates (MLR) and thus the claims were time-barred. The court also concluded that Blue Cross was not directly governed by the MLR regulations, and therefore, the Tribe could not prove a violation of the HCFCA based on Blue Cross’s failure to apply MLR.The United States Court of Appeals for the Sixth Circuit affirmed the district court’s decisions. The appellate court agreed that the Tribe’s fiduciary duty claims were time-barred because the Tribe knew in 2009 that it was not receiving MLR. The court also upheld the summary judgment on the HCFCA claim, finding that the MLR regulations did not apply to Blue Cross. Additionally, the court found no error in the district court’s denial of the Tribe’s motion for leave to amend its complaint, as the proposed amendments would not have cured the deficiencies in the ERISA claim. View "Grand Traverse Band of Ottawa & Chippewa Indians v. Blue Cross Blue Shield of Michigan" on Justia Law

Two hospitals in Tennessee, Saint Francis Hospital and Saint Francis Hospital-Bartlett, sued Cigna Health and Life Insurance Company, claiming that Cigna routinely underpaid them for emergency services provided to Cigna members. The hospitals, which are out-of-network providers for Cigna, argued that Cigna had a quasi-contractual obligation to pay the reasonable value of their services based on federal and state laws requiring hospitals to treat emergency patients and insurers to cover emergency care.The United States District Court for the Western District of Tennessee dismissed the hospitals' claims. The court found that the hospitals' complaint did not meet the pleading standards of Rule 8, that Tennessee common law did not support their claims, and that the Employee Retirement Income Security Act (ERISA) preempted their claims.The United States Court of Appeals for the Sixth Circuit reviewed the case and affirmed the district court's dismissal. The Sixth Circuit held that neither federal law (specifically the Affordable Care Act) nor Tennessee law imposed a duty on Cigna to pay the full value of out-of-network emergency services. The court noted that the ACA's requirement for insurers to provide "coverage" for emergency services did not mean that insurers had to pay the full cost. The court also found that Tennessee common law did not support the hospitals' claims for quantum meruit and unjust enrichment, as there was no contractual or statutory duty for Cigna to pay the full value of the services.The Sixth Circuit concluded that the hospitals' claims failed because they could not establish that Cigna had a legal obligation to pay more than what was stipulated in its contracts with its members. The court did not address the ERISA preemption issue, as the dismissal was affirmed on other grounds. View "AMISUB (SFH), Inc. v. Cigna Health & Life Ins. Co." on Justia Law

Randy Wiertella died in the Lake County Adult Detention Facility on December 10, 2018. Dennis Wiertella, as the Administrator of Randy's estate, filed a lawsuit claiming that Randy's constitutional rights under the Eighth and Fourteenth Amendments were violated by Jail staff Diane Snow, RN, and Christina Watson, LPN. Randy had been booked into the Jail without his essential medications for heart disease, diabetes, high blood pressure, and a psychiatric disorder. Despite multiple requests, he did not receive all necessary medications, leading to his death from hypertensive cardiovascular disease.The United States District Court for the Northern District of Ohio denied Snow and Watson's motion for summary judgment, which sought dismissal based on qualified immunity. The court found that there were genuine disputes of material fact regarding whether Snow and Watson were aware of the substantial risk to Randy's health and whether they failed to respond reasonably.The United States Court of Appeals for the Sixth Circuit reviewed the case. The court held that Snow and Watson were not entitled to qualified immunity. The court found that both nurses were aware of Randy's serious medical conditions and the need for continuous medication. Despite this knowledge, they failed to ensure that Randy received his essential medications in a timely manner. The court concluded that their actions were unreasonable and violated Randy's constitutional rights. The court affirmed the district court's decision and remanded the case for further proceedings on the Estate's § 1983 claim. View "Wiertella v. Lake County" on Justia Law