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

Ramage, born in 1933, worked for Island Creek for 28 years, five years underground and 23 years on the surface. In 2007 he sought black lung benefits. While the claim was pending, Congress revived a statutory rebuttable presumption that a coal miner who worked in an underground coal mine for 15 years and suffers from a total respiratory or pulmonary disability is presumed to be totally disabled due to pneumoconiosis, 30 U.S.C. 921(c)(4), applicable to pending claims filed after January 1, 2005. The ALJ noted that x-rays did not show pneumoconiosis, that Ramage could not complete a pulmonary function test due to a tracheostomy, and that arterial blood-gas studies were qualifying under the federal standards. The ALJ summarized the medical opinions of five doctors, including one who emphasized that it was impossible to distinguish between the damage due to coal dust as opposed to the damage due to smoking. The ALJ awarded benefits and the Benefits Review Board affirmed. The Sixth Circuit denied a petition for review, holding that the ALJ’s determinations were reasoned and reasonable and that the legislative provisions creating the presumption are self-executing.View "Island Creek KY Mining v. Ramage" on Justia Law

A nursing home resident and her community spouse (husband) were penalized based on husband’s purchase of an annuity for himself using funds from his IRA. The district court granted summary judgment in favor of the director of the Ohio Department of Job and Family Services, holding that 42 U.S.C. 1396r-5(f)(1) precluded the transfer of assets because it exceeded husband’s community spouse resource allowance. Section 1396p(c) requires a state to impose a transfer penalty (a period of restricted coverage) if either spouse disposed of assets for less than fair market value during the look-back period. The Sixth Circuit reversed, reasoning that the transfer occurred before the Ohio agency determined that wife was eligible for Medicaid coverage and section 1396p(c)(2)(B)(i) permits an unlimited transfer of assets “to another for the sole benefit of the individual’s spouse.” View "Hughes v. Colbert" on Justia Law

Williams had worked at Marathon’s Ashland, Kentucky, facility for 25 years, most recently as a senior barge welder. Williams alleged that he sustained a long thoracic nerve injury to his right shoulder while replacing parts of a barge in 2003. His injury was likely the result of the cumulative effect of his heavy lifting. Williams has not returned to work and has been seen by several physicians, but they do not agree on a common diagnosis. Following a remand the Benefits Review Board of the U.S. Department of Labor affirmed an administrative law judge’s award of permanent and total disability benefits under the Longshore and Harbor Workers’ Compensation Act, 33 U.S.C. 901. On a second appeal, the Sixth Circuit affirmed, finding that Williams is permanently and totally disabled and is unable to perform the alternative employment identified by Marathon’s vocational expert. The court granted Williams leave to seek attorney fees under 33 U.S.C. 928(a). View "Marathon Ashland Petroleum v. Williams" on Justia Law

Southern Rehabilitation Group and its medical director sued the Secretary of Health and Human Services and past and present Medicare contractors, seeking review of the Secretary’s final decision on 6,200 claims for Medicare reimbursement. The district court remanded so that the Secretary could pay the disputed amount. After payment, the case returned to the district court, which concluded that the claims for payment were moot and dismissed remaining constitutional and statutory claims as barred by jurisdictional provisions of the Medicare Act. The court also held that plaintiffs did not show that they were eligible to collect interest on their claims and that it did not have jurisdiction over 8,900 other claims that plaintiffs alleged were still in the administrative process. The Sixth Circuit affirmed summary judgment to defendants on plaintiffs’ federal and state law claims and on the 8,900 claims still in the administrative process, but reversed summary judgment on plaintiffs’ claims for interest. The Secretary could not rely on her unreasonable interpretation of the “clean-claims” statute as a basis for summary judgment concerning interest. View "S. Rehab. Grp. v. Sec'y of Health & Human Servs." on Justia Law

Plaintiffs, employees of Coca-Cola, suffered work-related injuries and applied for workers’ compensation benefits through Sedgwick, Coca-Cola’s third-party benefit claims administrator. Sedgwick disputed the claims. Plaintiffs claim that Coca-Cola and Sedgwick “engaged in a fraudulent scheme involving the mail . . . to avoid paying benefits to injured employees,” and filed suit under the civil remedies provision of the Racketeer Influenced and Corrupt Organizations Act (RICO), 18 U.S.C. 1962(c). The district court dismissed. On rehearing, en banc, the Sixth Circuit affirmed, holding that the plaintiffs did not plead an injury to their “business or property” that is compensable under RICO. The RICO theory advanced in this case would throw the viability of workers’ compensation schemes into doubt; RICO “does not purport to afford remedies for all torts committed by or against persons engaged in interstate commerce.” The Michigan workers’ compensation scheme provides ample mechanisms by which the employee can contest denials. View "Jackson. Segwick Claims Mgmt. Servs." on Justia Law

Brigance worked as a coal miner for 20 years, until he stopped working in 1994 because of shortness of breath, which prevented him from obtaining other employment. Brigance obtained Kentucky state black lung benefits, which expired after about eight years. Brigance sought federal benefits under the Black Lung Benefits Act. An administrative law judge held that the claim was not barred by the Act’s three-year statute of limitations, 30 U.S.C. 932(f). The Benefits Review Board affirmed an award of benefits. The Sixth Circuit reversed. Brigance admitted that he had a medical determination of total disability (pneumoconiosis) seven years before filing his claim. View "Peabody Coal Co. v. Dir., Office of Workers' Comp." on Justia Law

Dotson died in August 1998. An administrative law judge determined that his wife was entitled to survivor’s benefits under the 2010 Black Lung Amendments, Pub. Law 111-148, 1556(a)–(c). The Sixth Circuit denied the company’s petition for review of the Benefits Review Board decision. The company filed a petition for rehearing, arguing that its case involved an additional issue: whether an award of benefits should commence the month the miner died. The Sixth Circuit denied the petition. The regulation says: “Benefits are payable to a survivor who is entitled beginning with the month of the miner’s death, or January 1, 1974, whichever is later.” 20 C.F.R. 725.503(c). This language was clear before Congress enacted the Amendments, and, by its terms, the widow is entitled to benefits beginning with the month of the miner’s death: August 1998. Rejecting an argument concerning retroactive application, the court stated that “imposition of liability for the effects of disabilities bred in the past is justified as a rational measure to spread the costs of the employees’ disabilities to those who have profited from the fruits of their labor—the operators and the coal consumers.” View "McCoy Elkhorn Coal Corp. v. Dotson" on Justia Law

Kentucky provided medical care to its poorest citizens through Medicaid (42 U.S.C. 1396-1) using a traditional fee-for-service model until 2011, when it transitioned to a managed-care program and awarded Coventry a contract to administer Medicaid services in southeastern Kentucky. Coventry entered into a temporary agreement with Appalachian, the dominant hospital care provider in that area, to provide members in-network hospital care and other services. Coventry soon realized it was losing money, partly because its network included Appalachian, whose patients, on average, were sicker and more expensive to treat. Coventry learned that its competitors were not required to contract with Appalachian and unsuccessfully sought an increase in payment rates. Coventry then noticed termination of Appalachian’s contract, which would have made thousands of Medicaid recipients unable to access healthcare providers at Appalachian’s facilities without first paying fees. Appalachian sued Coventry and state defendants. The district court required Coventry to keep Appalachian in its network for four months longer than the contract specified (until November 1, 2012) and denied Coventry’s motion to require Appalachian to post a security bond. The Sixth Circuit affirmed with respect to the bond and otherwise dismissed an appeal as moot because no recognized exception permits review of an expired injunction. View "Appalachian Reg'l Healthcare, Inc. v. Coventry Health & Life Ins. Co." on Justia Law

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