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

Tennessee family medicine physicians, mostly in rural areas, received increased Medicaid payments in 2013-2014. In 2015 Tennessee’s Medicaid agency, TennCare, brought an administrative action to “recoup” an average of more than $100,000 per physician, alleging that the physicians had not met the 60-percent requirement of the Final Medicaid Payment Rule. Under 42 U.S.C. 13961(a)(13(C), a state plan for medical assistance must provide payment for primary care services furnished in 2013 and 2014 by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine at a specified rate; “primary specialty designation” was interpreted to mandate that the physician either show board certification in that specialty or that 60 percent of her recent Medicaid billings were for certain primary care services. The Sixth Circuit affirmed summary judgment in favor of the physicians, declaring the Rule invalid. The Centers for Medicare and Medicaid Services interpreted “a physician with a primary specialty designation” to have different meanings in parallel provisions of the Affordable Care Act although the context was the same. There is no 60-percent-of-billings requirement in 42 U.S.C. 1396a(a). The phrase “a physician with a primary specialty designation” means in section 1396a(a) the same thing that the agency said it means in section 1395l(x): a physician who has himself designated, as his primary specialty, one of the specialties recited in those provisions. View "Averett v. United States Department of Health & Human Services" on Justia Law

Brintley is blind. To navigate the internet, she uses a screen reader that scans webpages and narrates their contents. The technology struggles with some material, especially pictures and video. With some effort, companies can make their websites fully screen-reader compatible. The credit unions, established under Michigan law, maintain a limited brick-and-mortar presence; both operate websites. Brintley tried to browse these websites but found her screen reader unable to process some of their content. A “tester” of website compliance with the Americans with Disabilities Act, Brintley sued the credit unions, seeking compensatory and injunctive relief, arguing that the websites were a “service” offered through a “place of public accommodation,” entitling her to the “full and equal enjoyment” of the websites. 42 U.S.C. 12182(a). The district court rejected an argument that Brintley failed to satisfy Article III standing. The Sixth Circuit reversed. To establish standing, Brintley must show that she sustained an injury in fact, that she can trace the injury to the credit unions’ conduct, and that a decision in her favor would redress the injury. Brintley must show an invasion of a “legally protected interest” that is “concrete and particularized” and “actual or imminent” and that affects her in some “personal and individual way.” Brintley lacks eligibility under state law to join either credit union and her complaint does not convey any interest in becoming eligible to do so. View "Brintley v. Belle River Community Credit Union" on Justia Law

A1 learned that government auditors thought that the company had overcharged a federal agency by several million dollars for services provided to Medicare beneficiaries. A1 challenged the auditors’ decisions at two levels of the Medicare appeals process but changed the auditors’ minds only in a few minor ways. The government tried to start collecting the money, as the regulatory regime allows, 42 U.S.C. 1395ff(a)(5), (c)(3)(E). Fearing bankruptcy from the government’s recoupment efforts, A1 obtained a preliminary injunction, barring the government from recouping the money until A1 received a hearing before an administrative law judge. The Sixth Circuit vacated the injunction, first holding that although A1 did not proceed to the third and fourth levels of the administrative appeal, the district court had jurisdiction over A1’s constitutional claims. On the merits, the court identified unanswered questions regarding the statistics concerning the relief likely to be obtained at the third level of administrative review; details about A1’s choice not to take advantage of an option to escalate its claim to the fourth and final level of administrative review; and the parties’ awareness of a recoupment option that might have allowed A1 to obtain an ALJ hearing before making most or even all of its recoupment payments. View "A1 Diabetes & Medical Supply v. Alex Azar II" on Justia Law

Medicare pays for doctors’ home visits if a patient is homebound. Mobile Doctors offered physician services to homebound Medicare beneficiaries, hiring doctors who assigned their Medicare billing rights to the company. Upon receipt of payment, Mobile would pay the physician-employee a percentage of what Mobile received from billing Medicare. Many of Mobile’s patients did not actually qualify as homebound. Some doctors signed certifications for additional unneeded treatment from companies that provided at-home nursing or physical therapy services—companies that had referred the patients to Mobile. Mobile submitted Medicare codes for more serious and more expensive diagnoses or procedures than the provider actually diagnosed or performed. Mobile instructed physicians to list at least three diagnoses in the patient file; if the doctors did not list enough, a staff member added more. Mobile only paid the physicians if they checked at least one of the top two billing codes. Doctors who billed for the higher of the top two codes were paid more. Mobile also paid for “standing orders” for testing, although Medicare prohibits testing done under standing orders. Daneshvar joined Mobile as a physician in 2012. After following Mobile’s policies Daneshvar was convicted of conspiracy to commit healthcare fraud but found not guilty of healthcare fraud; he was sentenced to 24 months' imprisonment. The Sixth Circuit affirmed. Daneshvar’s trial was fair; none of the district court’s rulings during that proceeding should be reversed. There was no reversible error with his sentencing. View "United States v. Daneshvar" on Justia Law

The Commissioner of Social Security imposed an assessment of $51,410 and a civil monetary penalty of $75,000 on Valent after the Social Security Administration found that Valent failed to disclose that she had engaged in paid work activity while receiving Social Security disability benefits. Valent argued that 42 U.S.C. 421(m)(1)(B) prohibits the Administration from considering her work activity in determining whether she continues to be eligible as a disability-benefits recipient and that her failure to disclose her paid work activity was, therefore, not a material omission, and that even if her failure to disclose her paid work activity was a material omission, she did not have actual or constructive knowledge that her omission was material. The Sixth Circuit affirmed, rejecting Valent’s argument that the Administration can consider “substantial gainful activity” but not “work” or “work activity.” The Administration’s interpretation is a permissible construction of the statute and Valent’s construction “would be impossible to implement.” The Administration would be unable to examine a beneficiary’s substantial gainful activity without considering the beneficiary’s work activity that generates profit or pay. Valent had constructive notice that her failure to report her work activity that generated profit or pay was a material omission that misled the Administration. View "Valent v. Commissioner of Social Security" on Justia Law

Murdock, an employee with the Tipton County Board of Education, received an email purporting to be from Dr. Bibb, Director of Tipton County Schools, requesting all 2016 employee W-2s and tax information. Murdock responded with a document containing information from the W-2s of every Board employee, including names, addresses, social security numbers, income information, deductions, exemptions, withholdings, tax payments and taxpayer identifying numbers. Murdock then learned that Bibb had not requested the information. The Tipton County Sheriff notified the U.S. Secret Service and the Internal Revenue Service. The Board notified employees of the information release. Smith, a Board employee, filed suit under 26 U.S.C. 6103 and 7431. Section 6103 of the Internal Revenue Code prohibits “any local agency administering a program listed in [§ 6103](l)(7)(D)” from disclosing “return information.” Smith argues that, because the Board works with the Tennessee State Board of Education to administer the National School Lunch Program, the Board provided a qualifying SNAP benefit. The Sixth Circuit affirmed the dismissal of the suit, finding that the Board does not administer a SNAP benefit in providing lunches to students as part of the National School Lunch Program. View "Smith v. Tipton County Board of Education" on Justia Law

Tramble worked for various Kentucky coal companies from at least May 1963 until June 1985. Tramble’s 1987 claim for benefits under the Black Lung Benefits Act (BLBA), 30 U.S.C. 901–944, indicated that he had stopped working due to a job-related back injury. That claim was denied although the parties stipulated to 17 years of qualifying coal mine employment. The ALJ found that medical evidence established that Tramble suffered from coal workers’ pneumoconiosis but was not totally disabled. After his 2008 death, Tramble’s widow sought survivor’s benefits. Reversing an award by an ALJ, the Department of Labor Benefits Review Board found that the ALJ failed to explain adequately how he calculated the 15.25-years of underground coal mine employment that justified application of the 15-year statutory presumption of entitlement to benefits. On remand, the ALJ again awarded benefits. The Board again reversed. The Sixth Circuit remanded. Further fact-finding is required to ensure that all relevant evidence has been considered. The court rejected Incoal’s argument that, in order to be credited with one year of coal mine employment, a miner must be on the payroll of a mining company for 365 consecutive days and have worked 125 of those days in or around a coal mine . View "Shepherd v. Incoal, Inc." on Justia Law

Wilkerson mined coal for over 25 years. In 1994, he retired from the Island Creek’s Crescent mine, where he had worked most recently as an electrician. In 2012, Wilkers sought benefits under the Black Lung Benefits Act, which provides compensation to miners disabled by pneumoconiosis, 30 U.S.C. 902(b), 922(a)(1). The Sixth Circuit denied a petition for review, upholding the Benefits Review Board’s award of benefits. The defendant forfeited an argument that the ALJ lacked authority to hear the case under the Appointments Clause by failing to raise it in its opening brief. Appointments Clause challenges arise under the U.S. Constitution, but are “not jurisdictional and thus are subject to ordinary principles of waiver and forfeiture.” Substantial evidence supports the award. An ALJ may presume an applicant suffers from the disease if he worked for 15 years at a qualifying coaling mine and suffers “a totally disabling respiratory or pulmonary impairment.” Wilkerson worked for more than 15 years at a qualifying mine, and substantial evidence showed that he suffered total disability due to a respiratory or pulmonary impairment. Faced with the conflicting medical evidence, the ALJ turned to the four doctors who testified, credited testimony from one doctor, discounted the three others for legitimate reasons, and concluded that Wilkerson suffered from a disability. The doctor’s conclusion about Wilkerson’s disability tracked the newest available data. View "Island Creek Coal Co. v. Wilkerson" on Justia Law

In 2006-2008, plaintiffs each applied, unsuccessfully, for Social Security disability benefits, 42 U.S.C. 423(d)(2)(A), 1382c(a)(3)(B). Each plaintiff retained Kentucky attorney Conn to assist with a subsequent hearing. Each plaintiff’s application included medical records from one of four examining doctors. In each case, ALJ Daugherty relied exclusively on the doctor's opinion to conclude, without a hearing, that plaintiffs were disabled and entitled to benefits. Daugherty took bribes from Conn to assign Conn’s cases to himself and issue favorable rulings. Nearly 10 years after the agency learned of the scheme, it initiated “redeterminations” of plaintiffs’ eligibility for benefits and held new hearings, disregarding all medical evidence submitted by the four doctors participating in Conn’s scheme. Plaintiffs had no opportunity to rebut the assertion of fraud as to this evidence. Each plaintiff was deemed ineligible for benefits as of the date of their original applications; their benefits were terminated. Plaintiffs sued, alleging violations of the Due Process Clause and the Social Security Act. The Sixth Circuit held that the plaintiffs are entitled to summary judgment on their due-process claim and the agency is entitled to summary judgment on the Social Security Act claims. The agency must proffer some factual basis for believing that the plaintiffs’ evidence is fraudulent. Plaintiffs must have an opportunity to “rebut the Government’s factual assertions before a neutral decisionmaker.” Congress has already told the agency what to do when redetermination proceedings threaten criminal adjudications; the answer is not to deprive claimants of basic procedural safeguards. View "Griffith v. Commissioner of Social Security" on Justia Law

The Tennessee Hospital Association and three hospitals sued, challenging efforts by the Centers for Medicare and Medicaid Services (CMS) to direct states to recoup certain reimbursements made under the Medicaid program. The hospitals serve a disproportionate share of Medicaid-eligible patients and are thereby entitled to supplemental payments under the Medicaid Act, (DSH payments), 42 U.S.C. 1396a(a)(13)(A)(iv); 1396r-4(b). The Act limits the amount of DSH payments each hospital can receive in a given year. CMS contends that the hospitals miscalculated their DSH payment-adjustments for fiscal year 2012 and received extra payments. Plaintiffs argued, and the district court agreed, that CMS’s approach to calculating DSH payment adjustments is inconsistent with the Act and the regulations that CMS implemented in 2008. The Sixth Circuit affirmed, agreeing that CMS’s policy is inconsistent with its 2008 rule and cannot be enforced unless it is promulgated pursuant to notice-and-comment rulemaking. The court disagreed with the district court’s conclusion that CMS’s policy exceeds the agency’s authority under the Medicaid Act. CMS’s payment-deduction policy is a reasonable interpretation of an ambiguous section of the Act but is not a valid interpretative rule. CMS attempted to exercise its delegated discretion to “determine[]” the “costs incurred” in serving Medicaid-eligible patients—precisely the sort of agency action that requires notice-and-comment rulemaking. View "Tennessee Hospital Association v. Azar" on Justia Law