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

During her second grade year and after three years of disagreement between school officials and her parents over requests for certain disability accommodations for A.C., a minor with Type 1 diabetes,the principal made reports to Tennessee’s Department of Children’s Services alleging that the parents were medically abusing A.C. The parents filed suit, claiming that the principal’s reports were made in retaliation to their disability accommodation requests and violated the Rehabilitation Act and the Americans with Disabilities Act, 2 U.S.C. 12203 and 29 U.S.C. 794(a). The district court found that the parents did not prove a prima facie element of their case and could not prove that the reasons given for making the child-abuse reports were a pretext for retaliation. The Sixth Circuit reversed, stating that the district court prematurely placed on the parents the burden of rebutting the school’s stated reasons for its actions. Evidence of falsity in the reports of abuse coupled with the temporal proximity of those reports to requests for accommodations is sufficient to permit an inference of causation. View "A.C.v. Shelby Cnty. Bd. of Educ." 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 1979, Plaintiffs sued under 42 U.S.C. 1983, on behalf of present and future recipients, alleging that Tennessee’s Medicaid program violated federal requirements, 42 U.S.C. 1396, and the Due Process Clause. The decades that followed involved intervenors, consent orders, revisions, and creation of a subclass. In 1994, Tennessee converted to a managed care program, TennCare. In 1995, five class members filed motions alleging that TennCare was being administered inconsistent with a 1992 decree and federal law. In 2009, the district court awarded plaintiffs more than$2.57 million for fees and expenses leading up to a 2005 Revised Consent Decree. Plaintiffs had originally requested a lodestar amount of $3,313,458.00, but the court reduced the award by 20 percent on account of plaintiffs’ “limited” success relative to the breadth of defendants’ requests and the scope of the litigation. The court noted that there was “no dispute that Plaintiffs in this case are the prevailing party, and thus entitled to attorneys’ fees under 42 U.S.C. 1988.” The Sixth Circuit vacated parts of the award, noting that section 1988 “is not for the purpose of aiding lawyers and that the original petition for fees included requests for dry cleaning bills, mini blinds, and health insurance. View "Binta B. v. Gordon" on Justia Law

Tennessee participates in Medicaid through “TennCare,” Tenn. Code 71-5-102. The Medicaid Act requires that TennCare administer an Early and Periodic Screening, Diagnosis, and Treatment program for all enrollees under age 21, 42 U.S.C. 1396a(a)(43), 1396d(r) and must provide outreach to educate its enrollees about these services. In 1998 plaintiffs filed a putative class action under 42 U.S.C. 1983, alleging that TennCare had failed to fulfill these obligations. The district court entered a consent decree that explained in detail the requirements that TennCare had to meet to “achieve and maintain compliance” with the Medicaid Act, based on the assumption that the Act created rights enforceable under section 1983. Eight years later, the Sixth Circuit held that one part of the Medicaid Act was unenforceable under section 1983. Following a remand, the district court vacated paragraphs of the decree that were based on parts of the Act that are not privately enforceable. After a thorough review of TennCare’s efforts, the court then vacated the entire decree, finding that TennCare had fulfilled the terms of the decree’s sunset clause by reaching a screening percentage greater than 80% and by achieving current, substantial compliance with the rest of the decree. The Sixth Circuit affirmed. View "John B. v.Emkes" on Justia Law

Fulgenzi was prescribed the generic drug metoclopramide (FDA approved in 1980), sold originally under the brand name Reglan, a drug approved for short-term treatment of patients suffering from gastroesophageal reflux disease. In her suit, claiming failure to adequately warn of risks, she alleged that taking the drug caused her to develop tardive dyskinesia, an often-irreversible neurological disorder that causes involuntary movements, especially of the lower face. In 2009, the Supreme Court held that with respect to branded drug manufacturers, state failure-to-warn suits were not preempted by the federal Food Drug and Cosmetic Act , 21 U.S.C. 301. In 2011 the Court held that such suits could not go forward against generic drug manufacturers, as it is impossible to comply simultaneously with their state duty to adequately warn and their federal duty of sameness (federal law requires generic drug labels to be the same as their branded counterpart). The district court dismissed. The Sixth Circuit reversed, noting that after the branded-drug manufacturer of metoclopramide strengthened warnings on its label, the generic manufacturer failed to update its label as required by federal law, rendering compliance with both federal and state duties no longer impossible. View "Fulgenzi v. PLIVA, Inc." on Justia Law

Gayheart applied for Social Security disability insurance benefits in 2005 due to manifestations of anxiety, panic disorder, bipolar disorder, and depression. After an initial denial and three separate hearings, an administrative law judge (ALJ) found that the limitations caused by Gayheart’s impairments did not preclude him from performing a significant number of jobs available in the national economy and denied Gayheart’s application. Gayheart’s request for an administrative appeal was denied. The Report and Recommendation issued by the federal court’s assigned magistrate judge concluded that the ALJ’s decision was not supported by substantial evidence and that Gayheart should be awarded benefits. But the district court sustained the Commissioner’s objections and affirmed the ALJ’s decision. The Sixth Circuit reversed and remanded, holding that the ALJ failed to weigh the medical opinions according to 20 C.F.R. 404.1527. View "Gayheart v. Comm'r of Soc. Sec." on Justia Law

Plaintiff, a teacher since 1976, was diagnosed with Type 2 diabetes. By 1999, she required insulin injections. Until 2008, plaintiff was never disciplined. In 2008, plaintiff was summoned to address allegations that she had been sleeping during class. Plaintiff claimed that she was not sleeping but rather exhibiting symptoms of diabetes. She was formally reprimanded and requested accommodations: training in recognizing symptoms of diabetes; assistance if she appeared asleep; and breaks for insulin injections. The superintendent allowed her to keep snacks in her classroom, to use the nurse’s office if she first obtained classroom coverage, and to disseminate diabetes information to students and staff. Plaintiff was subsequently suspended for missing classes, sleeping in class, and referring to Playgirl Magazine in class discussion. The Board decided to terminate her contract. Plaintiff was 71 years old. A referee upheld the termination. Instead of appealing, plaintiff filed suit, alleging age discrimination under Ohio law; failure to make reasonable accommodations (ADA, 42 U.S.C. 12112, and state law); retaliation for engaging in protected activity (ADA and state law); and intentional infliction of emotional distress. The district court granted summary judgment to defendants. The Sixth Circuit affirmed with respect to age discrimination, but reversed on other claims. View "Smith v. Perkins Bd. of Educ." on Justia Law

Quigley was 23 years old, with no known life-threatening physical conditions when he was transferred from one Michigan Department of Corrections (MDOC) facility to an MDOC guidance center, where he was under the care of CMS, a service provider with which MDOC contracted. CMS employees Dr. Thai and physician’s assistant Garver treated Quigley for moderate depression and prescribed medications. After about a month, Quigley was found dead in his cell. The medication chart confirmed that Quigley had been administered both Amitriptyline and Trazodone the previous three days. The autopsy report concluded that Quigley died of an epileptic seizure disorder. Quigley’s estate obtained affidavits from a forensic pathologist, who concluded that Quigley likely died from a fatal drug interaction between the tricyclic Amitriptyline and tetracyclic Trazodone and from a psychiatrist, who similarly concluded that the fatal drug interaction likely killed Quigley. Thai provided three medical-expert affidavits, all concluding that the best explanation for Quigley’s death is epileptic seizure. Quigley’s estate sued Thai, Garver, and CMS under 42 U.S.C. 1983. The district court denied a motion asserting qualified immunity. The Sixth Circuit affirmed, finding that there were unresolved material questions of fact concerning the cause of death. View "Quigley v. Thai" on Justia Law