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

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

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

While working at a Ford Motor plant, Rudisill was hit in the face by a piece of equipment, was knocked against a wall, fell to the floor, and rolled forward through the floor opening into the hot pit below. He lay there unconscious, being burned, until coworkers pulled him out of the pit. Rudisill had gained consciousness by this time and was screaming in pain. Rudisill sustained a head injury that required several staples to close. He was also burned on his arms and legs, abdomen, and left hand. Rudisill continues to experience pain, dizzy spells, ringing in the ears, and memory problems. He has had numerous surgeries and has undergone physical and occupational therapy. After a safety review immediately following the incident, Ford decided to modify the process so that employees slide metal grates over the pit before removing the guard rails. After receiving workers’ compensation benefits, Rudisill sued Ford, alleging intentional tort; his wife asserted a derivative claim of loss of consortium. The district court granted summary judgment for Ford. The Sixth Circuit affirmed, finding insufficient evidence that Ford acted with deliberate intent to injure Rudisill, as required by Ohio statute. View "Rudisill v. Ford Motor Co." on Justia Law

Since enacting a program for black-lung benefits in 1969, known as the Black Lung Benefits Act,83 Stat. 742, Congress has repeatedly amended the claim-filing process, sometimes making it harder for miners and survivors to obtain benefits, sometimes making it easier. The most recent adjustment, part of the 2010 Patient Protection and Affordable Care Act, reinstated a presumption that deceased workers who had worked for at least 15 years in underground coal mines and had developed a totally disabling respiratory or pulmonary impairment were presumed to be totally disabled by pneumoconiosis and to have died from it. The presumption is rebuttable. The Act also reinstated automatic benefits to any survivor of a miner who had been awarded benefits on a claim filed during his lifetime, 124 Stat. at 260. Groves, a miner for 29 years, filed a claim for benefits in 2006 and died four months later. An ALJ denied his widow benefits. The law changed while her appeal was pending. The Benefits Review Board concluded that the new law covered this claim. The Sixth Circuit affirmed. View "Vision Processing, LLC v. Groves" on Justia Law

Sexton, a smoker, spent 25 years working in coal mines. He first applied for Black Lung Act (30 U.S.C. 901) benefits in 1973. The application was unsuccessful as were two other claims. In 2001, two years after the denial became final, Sexton filed a subsequent claim. The district director recommended an award of benefits. Buck Creek Coal requested a formal hearing. While his claim was pending Sexton died. His widow filed her own claim and the district director issued a proposed order awarding benefits in the survivor claim. Buck Creek requested a hearing. The administrative law judge considered four medical opinions, and based on that new evidence, determined that Sexton suffered a total disability from clinical and legal pneumoconiosis and that Sexton established a change in an applicable condition of entitlement pursuant to 20 C.F.R. 725.309 and awarded benefits. The Benefits Review Board affirmed with respect to Sexton’s claim and affirmed in part and vacated in part with respect to the survivor claim. The Sixth Circuit affirmed, holding that 20 C.F.R. 725.309 is valid and was correctly applied and that the Board’s decision did not violate principles of finality or res judicata. View "Buck Creek Coal Co. v. Sexton" on Justia Law

Plaintiff is the surviving spouse of a 39-year AK employee, who died in 2008, then receiving a monthly pension benefit of $1,386. Plaintiff applied for the surviving spouse benefit and was advised that she was entitled to$693 (50%), reduced by 50% of her social security widow’s benefit (not yet determined), but not less than $140 per month. SSA first advised AK that plaintiff’s monthly benefit would be $458. Weeks later, SSA indicated that the widow’s benefit would be $1469. AK calculated the $140 benefit. Plaintiff received a statement from SSA indicating her widow’s benefit amount was $485 and plaintiff’s own earnings benefit was $973: a total monthly payment of $1,458. Plaintiff calculated that 50% of the $485 widow’s benefit, subtracted from $693, yielded a monthly benefit of $450.50 under the AK Plan. According to AK, $458 represented only the remainder of the entire widow’s benefit, $1,469, after offset for plaintiff’s own old-age retirement benefit, $1,011. In an action under ERISA, 29 U.S.C. 1001, the district court awarded judgment to plaintiff. The Sixth Circuit reversed, holding that AK’s proposed interpretation of the plan language to be truer to its plain meaning when read with reference to the law it expressly refers to. View "Lipker v. AK Steel Corp." on Justia Law