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

Tasis and his brother ran a sham medical clinic, recruited homeless Medicare recipients who had tested positive for HIV, hepatitis or asthma, paid the “patients” small sums in exchange for their insurance identification, then billed Medicare for infusion therapies that were never provided. During four months in 2006, the Center billed Medicare $2,855,785 and received $827,000 in return. The scheme lasted 15 months, during which Tasis and his collaborators submitted $9,122,159.35 in Medicare claims. An auditor notified the FBI. After an investigation, prosecutors indicted Tasis on fraud and conspiracy claims. Over Tasis’s objection, co-conspirator Martinez testified that she and Tasis had orchestrated a a similar scam in Florida. The court instructed the jury to consider Martinez’s testimony about the Florida conspiracy only as it related to Tasis’s “intent, plan and knowledge.” The jury found Tasis guilty, and the trial judge sentenced him to 78 months in prison and required him to pay $6,079,445.93 in restitution. The Sixth Circuit affirmed, rejecting various challenges to evidentiary rulings. View "United States v. Tasis" on Justia Law

Adams worked in coal mines for 17 years, leaving A & E Coal in 1988, after 12 years, because he was having difficulty breathing. He has not worked since. Adams also smoked cigarettes for about 25 years, averaging a pack a day before quitting in 1998 or 1999. Adams filed his first claim for benefits under the Black Lung Benefits Act 30 U.S.C. 901 in 1988. His claim was denied: He did not prove that his pneumoconiosis was caused in part by his coal-mine work, or that his pneumoconiosis totally disabled him. In 2007, Adams filed a second claim. Two pulmonologists agreed that he was completely disabled, but disagreed on what lung diseases Adams had, and on what caused them. An Administrative Law Judge awarded benefits, finding that Adams had pneumoconiosis, that the disease was caused by Adams’s exposure to coal dust during his coal-mine employment, and that he was totally disabled because of the disease. The Benefits Review Board and the Third Circuit affirmed. Although the ALJ was not required to look at the preamble to the regulations to assess the doctors’ credibility, he was entitled to do so. View "A & E Coal Co. v. Adams" on Justia Law

Ulman filed her claim for benefits in 2006, alleging that her disability began in 2002. As found by the ALJ, her insured status expired on December 31, 2003. To be eligible for benefits, her disability must have begun on or before that date and continued until she filed her application for benefits. 42 U.S.C. 423(a)(1). Claimant was 47 at the time her insured status expired. She had worked as a waitress, park ranger, and home health aide. In rejecting her claim, the ALJ confused the dates of December 3, 2001 when she fell backwards off a ladder, with the 2006 date of the application, and made an adverse credibility determination. The ALJ recognized that she suffered from physical limitations that prevented her from performing her past work, but found that she could perform other jobs (cashier, parking lot attendant, ticket taker) that existed in the national economy. The Appeals Council and district court affirmed. The Sixth Circuit affirmed, applying harmless error analysis to the credibility determination. With the exception of confusion about the date, the ALJ’s decision carefully parsed the medical records and accorded them fair weight; those records support a finding of no disability.View "Ulman v. Comm'r of Soc. Sec." on Justia Law

Semrau, a Ph.D. in clinical psychology, owned companies that provided psychiatric care to nursing home patients in Tennessee and Mississippi, using contracting psychiatrists who submitted records describing their work. The companies then billed the services to Medicare or Medicaid through private insurance carriers. Services are categorized into five-digit Current Procedural Terminology Codes, published by the American Medical Association. The Centers for Medicare and Medicaid Services sets reimbursement levels for each code as well as “relative value units” corresponding to the amount of work typically required for each service. After audits indicated that the companies had been billing at a higher rate than could be justified by the services actually performed, “upcoding,” Semrau was convicted of healthcare fraud, 18 U.S.C. 1347, and was sentenced to 18 months of imprisonment and ordered to pay $245,435 in restitution. The Sixth Circuit affirmed, rejecting Semrau’s claim that results from a functional magnetic resonance imaging lie detection test should have been admitted to prove the veracity of his denials of wrongdoing. There was ample evidence that Semrau was aware of accepted definitions of the CPT codes; he expressly agreed not to “submit claims with deliberate ignorance or reckless disregard of their truth or falsity.” View "United States v. Semrau" on Justia Law

Watson’s father, Hickle, worked for the Department of Energy, 1954 to 1962. Hickle died of Hodgkin’s disease in 1964. Congress enacted the Energy Employees Occupational Illness Compensation Program Act in 2000 to compensate for illnesses caused by exposure to radiation and other toxic substances while working for the Department of Energy. Covered employees or eligible survivors may receive compensation in a lump sum payment; under specific circumstances, a covered employee’s child is also eligible, 42 U.S.C. 7385s-3(d)(2). When her father died, Watson was 19 years old, not a full-time student; she lived with her parents, worked as a waitress, relied on her parents for support, and was listed as a dependent on their income tax returns. She sought survivor benefits in 2002 and received a lump-sum payment of $150,000. She later claimed further compensation as a “covered child,” under a different section of the Act, arguing that she was “incapable of self-support” at the time of Hickle’s death. The Department of Labor denied her claim. Before the district court, Watson challenged the interpretation of “incapable of self-support,” claiming that the Department impermissibly required a showing of physical or mental incapability. The district court denied her motion for summary judgment. The Sixth Circuit affirmed. View "Watson v. Solis" on Justia Law

Banks worked as a coal miner for 17 years and smoked about one pack of cigarettes per day for 38 years. His employment ended in 1991. After two unsuccessful attempts, in 2003, Banks filed a claim for benefits under the Black Lung Benefits Act, which provides benefits to coal miners who become disabled due to pneumoconiosis, 30 U.S.C. 901. An ALJ found that Banks had shown a change in his condition and that he suffered from legal pneumoconiosis which substantially contributed to his total disability. Banks was awarded benefits and the Benefits Review Board affirmed. The Sixth Circuit affirmed, adopting the regulatory interpretation urged by the Director of the Office of Workers’ Compensation Programs. The ALJ relied on reasoned medical opinions. View "Cumberland River Coal Co. v. Banks" on Justia Law

Cybriwsky served as Turner's attorney to obtain social security disability benefits. The representation agreement relieved Turner of the obligation to pay if they did not win the case, but assigned to Cybriwsky any fees that the court may award under the Equal Access to Justice Act, 42 U.S.C. 2412. After holding a hearing, the Commissioner denied Turner's benefits request. The district court reversed and remanded and Turner sought attorney’s fees under the EAJA. The district court denied this motion, finding that Turner did not “incur” fees as a result of the remand and that the assignment was void under the Anti-Assignment Act, 31 U.S.C. 3727. The Sixth Circuit reversed. A "sentence-four remand," 42 U.S.C. 405(g), like the remand at issue, makes the plaintiff a "prevailing party" under the EAJA. The award is consistent with the purposes of EAJA. Litigants "incur" fees under the EAJA when they have an express or implied legal obligation to pay over such an award to their legal representatives, regardless of whether the court subsequently voids the assignment provision under the AAA.

Hit by a vehicle in 2004, plaintiff had medical bills of $82,036 that were paid in full by Medicare. The owner of the vehicle settled with plaintiff for $125,000. Medicare sought reimbursement of $62,338 under 42 U.S.C. 13955y(b)(2)(B)(i)., which plaintiff paid under protest. An ALJ rejected plaintiff's argument that an unknown motorist was responsible for 90 percent of the damage so that only 10 percent of the settlement was for medical expenses and the rest was for pain and suffering. The Medicare Appeals Council, district court, and Sixth Circuit affirmed, noting that plaintiff presented no evidence of hardship.

Plaintiff suffered a back injury in a work-related vehicle accident in 1994, developed depression, then sought social security disability benefits. The Commissioner of Social Security adjudged him not to be disabled for purposes benefits. The district court affirmed. The Sixth Circuit reversed. The ALJ did not apply the "treating physicians" or "good reasons" rules in rejecting the treating doctor's opinion. That opinion was not patently wrong, so the ALJ's decision was not supported by substantial evidence.

Patient, insured by defendant, diagnosed with end-stage renal disease, and received dialysis at plaintiff's center. Three months after diagnosis, she became entitled to Medicare benefits (42 U.S.C. 426-1). Her plan provided that coverage ceased at that time, because of her entitlement to Medicare, but the insurer continued to pay for two months. Under the 1980 Medicare Secondary Payer Act, a group health plan may not take into account that an individual is entitled to Medicare benefits due to end-stage renal disease during the first 30 months (42 U.S.C. 1395y(b)(1)(C)(i)), but the insurer terminated coverage. Plaintiff continued to treat and bill. The insurer declared that termination was retroactive and attempted to offset "overpayment" against amounts due on other patients' accounts. The outstanding balance after patient's death was $210,000. Medicare paid less than would have been received from the insurer. The center brought an ERISA claim, 29 U.S.C. 1132(a)(1)(B), and a claim for double damages under the 1980 Act. The district court granted plaintiff summary judgment on its ERISA claim but dismissed the other. The Sixth Circuit affirmed on the ERISA claim and reversed dismissal. A healthcare provider need not previously "demonstrate" a private insurer's responsibility to pay before bringing a lawsuit under the 1980 Act's private cause of action.