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

Doctors filed suit, alleging violations of the False Claims Act, 31 U.S.C. 3279 and the Michigan Medicaid False Claim Act, as qui tam relators on behalf of the United States/ The claimed that the business defrauded the government by submitting Medicare and Medicaid billings for defective radiology studies, and that the billings were also fraudulent because the business was an invalid corporation. The federal government declined to intervene. The district court dismissed. Sixth Circuit affirmed. The doctors failed to identify any specific fraudulent claim submitted to the government, as is required to plead an FCA violation with the particularity mandated by the FRCP. A relator cannot merely allege that a defendant violated a standard (in this case, with respect to radiology studies), but must allege that compliance with the standard was required to obtain payment. The doctors had no personal knowledge that claims for nondiagnostic tests were presented to the government, nor do they allege facts that strongly support an inference that such billings were submitted.

The Medicare program pays teaching hospitals to cover "direct" and "indirect costs of medical education," 42 U.S.C. 1395ww(d)(5)(B), (h). Direct costs include expenses such as residents' salaries. Indirect costs are incurred due to "general inefficiencies" and "extra demands placed on other staff." Congress created a formula for calculating indirect expenses based on full-time equivalency interns; an HHS regulation referred to time residents spend in the "portion of the hospital subject to the prospective payment system or in the outpatient department of the hospital." In reimbursing plaintiff, HHS excluded from the FTE count time residents spent on pure research, unrelated to treatment of a patient. While appeal of a decision favoring the hospital was pending, Congress enacted the Patient Protection and Affordable Care Act, 124 Stat. 119, 660–61. For the years at issue, HHS must include in FTE: "all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary." HHS promulgated a regulation specifying that eligible non-patient care activities do not include time residents spend conducting pure research. The Sixth Circuit upheld the regulation as within the Secretary's authority and applicable to the years at issue.

In 2006 the claimant sought disability benefits, alleging injury in a construction accident. An ALJ denied the claim and the appeals council denied review. The district court upheld the denial. The Sixth Circuit vacated. The ALJ's decision was incomplete and improperly gave greatest weight to the opinion of a non-treating state agency physician, rather than to the opinion of a treating physician. The ALJ mischaracterized the treating physician's treatment notes.

Plaintiff filed several suits against healthcare groups on behalf of the United States, claiming violation of the Medicare Secondary Payer Act, 42 U.S.C. 1395y(b). No court has ever found that the MSP is a qui tam statute, permitting private attorneys general to sue on behalf of the United States. The Sixth Circuit found plaintiff was on notice of the frivolous nature of his filings from their inception in the Tennessee district courts and remanded for a show-cause hearing on why sanctions should not issue. The district court awarded sanctions to two defendants in amounts of $131,158.50 and $145,431.19. The Sixth Circuit affirmed, but denied an award for the appeal.

After being fired from his position as operations manager for a regional passenger airline, plaintiff sued, alleging "association discrimination" under the Americans with Disabilities Act, 42 U.S.C. 12112(b)(4). Plaintiff is not disabled; his wife suffers from Polyarteritis Nodosa, a rare and debilitating autoimmune disorder. The district court entered summary judgment in favor of the employer. The Sixth Circuit affirmed. While his wife's condition may have precipitated plaintiff's poor performance, plaintiff did not present evidence that he was fired because of her condition, rather than his performance.

The district court upheld the constitutionality of the Patient Protection and Affordable Care Act, 26 U.S.C. 5000 A, which, among other things, the minimum coverage provision of the Act requires all applicable individuals to maintain minimum essential health insurance coverage or to pay a penalty. The Sixth Circuit affirmed, first holding that the plaintiffs had standing, that the case was not barred by the Anti-Injunction Act, 26 U.S.C. 7421(a), and that the matter was ripe for judicial review. The provision is a valid exercise of the legislative power under the Commerce Clause; it regulates economic activity with a substantial impact on interstate commerce. The court rejected an argument that it regulates inactivity.

A podiatrist, primarily serving elderly patients, was convicted of healthcare fraud counts that resulted in a loss of $120. The podiatrist was sentenced to 18 months in prison followed by three years of supervision and ordered to pay more than $244,000, based on acquittal counts. The Sixth Circuit affirmed the conviction, but vacated and remanded the sentence. There was sufficient evidence that the podiatrist mailed bills for patients who were not actually treated and for work done by staff no longer employed at the office. Sentencing based on acquittal counts is not unconstitutional if those counts have been established by a preponderance of evidence, but the sentence was unreasonable. Although a court need only make a reasonable estimate of loss, the court relied solely on statistical evidence about loss from up-coding without a sound representative sample. The acquittal counts were part of a broad scheme to defraud and an award of restitution, based on those counts, was proper.