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

A 66-year -old arrived at petitioner's center with complex ailments, but oriented, able to feed herself and able to speak. During her 18 days at the center, she was sent to the hospital twice with serious medical complications. Upon investigation, the center was found to have failed to maintain substantial compliance with federal regulations for facilities that participate in Medicare and Medicaid (42 U.S.C. § 1395) in its treatment of the resident and appealed the resulting civil money penalty. An administrative law judge, the Departmental Appeals Board, and the Sixth Circuit affirmed. The ALJ acted properly in requiring submission of written testimony, properly weighed the evidence, and found violation of the federal hydration standard, laboratory services requirement, and mandate of a care plan, resulting in "immediate jeopardy."

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.

Plaintiff was in a work-related vehicle accident that injured his back in 1994. He worked on and off until 2000 when back pain prevented him from continuing as a truck driver. A 2001 claim for social security disability benefits was denied. Plaintiff had some relief following surgery in 2001 and was released to work in 2002. When the pain increased he began mental health treatment. In 2004 an ALJ found that plaintiff was not disabled. In 2007, following remand, an ALJ again denied benefits. The appeals council denied jurisdiction. The district court affirmed. The Sixth Circuit reversed and remanded, finding that the decision was not supported by substantial evidence because the ALJ failed to properly apply the treating physician rule and the good reasons rule in disregarding the conclusion of a treating psychiatrist and testimony of a treating counselor. Agency procedural rules require that the ALJ balance factors to determine what weight to give a treating source and to give good reasons for the weight actually assigned.

Petitioner worked as an underground surveyor for a coal company for more than 22 years. He filed an unsuccessful claim for black lung benefits (30 U.S.C. 901) about a year after being laid off. He filed a second claim 10 years later, accompanied by medical opinions and x-ray interpretations. The DOL provided a pulmonary examination for each claim. The first diagnosed shortness of breath of unknown etiology but opined that petitioner suffered no impairment. The second resulted in diagnosis of restrictive lung disease, right mid lung density, bilateral hilar adenopathy and concluded that there was no impairment. An ALJ rejected the second claim. The Benefits Review Board affirmed. The Sixth Circuit vacated for consideration under an amendment to the Act, under which a miner who worked underground for at least 15 years and who demonstrates that he suffers from a total respiratory disability is presumed to be totally disabled due to pneumoconiosis (30 U.S.C. 921(c)(4)). Rebuttal requires an affirmative showing; it is not enough to show that medical evidence does not include a well documented opinion of pneumoconiosis. The ALJ failed to consider all evidence relevant to the issue of disability.

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.

Petitioner was awarded disability insurance benefits for a period beginning in 1983. In 2002 the Social Security Administration produced evidence he had engaged in substantial gainful employment; the Appeals Council accordingly reopened and remanded to an administrative law judge, who determined that petitioner was not entitled to disability benefits. The district court and Sixth Circuit affirmed. Petitioner's subsequent application for supplemental security income benefits was denied; the district court and Sixth Circuit affirmed. The petitioner then sought a writ of mandamus to compel the SSA to reopen his case and reinstate benefits. The Sixth Circuit dismissed for lack of jurisdiction to issue a writ directly to the agency.