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

Most Medicare recipients must pay monthly premiums in addition to various co-payments and deductibles, 42 U.S.C. 1395. States that receive federal Medicaid funds must assist certain low-income Medicare beneficiaries with payment of their out-of-pocket expenses related to the Medicare program. To be eligible for such assistance, a Medicare beneficiary must have income less than or equal to certain percentages of the federal poverty line “for a family of the size involved[.]” In calculating 74-year-old Turner’s family size to determine eligibility for assistance, the Ohio Department of Medicaid did not include Turner’s wife, who lives with him, and denied benefits. Ohio generally does not count a Medicare beneficiary’s spouse as a member of his “family.” The Sixth Circuit held that the Department’s use of an individual-need standard to deny applications and the state’s exclusion spouses in determining the size of a family, was contrary to federal law View "Wheaton v. McCarthy" on Justia Law

The Section 8 low-income housing assistance voucher program, 42 U.S.C. 1437f(o), is administered by public housing agencies such as Cuyahoga Metropolitan Housing Authority (CMHA). Program regulations define “rent to [the] owner” as “[t]he total monthly rent payable to the owner under the lease for the unit. Rent to owner covers payment for any housing services, maintenance and utilities that the owner is required to provide and pay for.” Velez and Hatcher, voucher recipients, entered into one-year leases with K&D. The leases provide: “If Resident(s) shall holdover after the end of the term of this Rental Agreement, said holdover shall be deemed a tenancy of month to month and applicable month to month fees shall apply.” Velez entered into a month-to-month tenancy after her one-year term expired; Hatcher entered into month-to-month tenancies, and, later, a nine-month agreement. K&D charged fees of $35.00 to $100.00 per month. CMHA did not treat these short-term rental fees as rent under the voucher program. Velez and Hatcher were required to pay the fees and filed suit under 42 U.S.C. 1983. The court granted CMHA summary judgment, holding that the fees were not rent. The Sixth Circuit reversed. Recasting the charge as a short-term fee, rather than rent, does not change that it is consideration paid by the tenant for use of the rental unit. View "Velez v. Cuyahoga Metro. Hous. Auth." on Justia Law

From 1977-2009, Kennard worked as a blaster on strip mines, sometimes directly for a coal company and sometimes for contractors. In 2009, Kennard filed for black lung benefits, 30 U.S.C. 901. Kennard has a significant history of smoking, which gave him cancer in his right lung. The lung was removed. He experiences shortness of breath, coughing, and sleep apnea. His treating physician diagnosed Chronic Obstructive Pulmonary Disorder (COPD). His breathing is extremely limited. After the claims examiner initially recommended that his claim, an ALJ concluded that Kennard was entitled to a rebuttable presumption that he had pneumoconiosis and that the disease caused his total disability because he had worked in conditions that were substantially similar to those in an underground mine. The ALJ held that the employer had successfully rebutted the presumption that Kennard had clinical pneumoconiosis, but had failed to rebut the presumption of legal pneumoconiosis or the presumption that Kennardʼs disability was caused by his employment in a coal mine. The employer appealed, arguing that the 15-year presumption should not apply, and, if it did apply, the company had successfully rebutted it. The Sixth Circuit denied a petition for review, finding the award supported by substantial evidence. View "Brandywine Explosives & Supply v. Office of Workers' Comp. Programs" on Justia Law

The Medocks’ company, MAS, transported patients to kidney dialysis for Medicare reimbursement. Reimbursement of non-emergency ambulance transport is allowed only if medically necessary for bedridden patients; both a driver and an EMT must accompany any such passenger. Certification of medical necessity (CMN) must be signed by a doctor. A “run sheet” is reviewed by a Medicare contractor other than the ambulance company, such as AdvanceMed, to reduce fraud. AdvanceMed identified MAS as a high biller in Tennessee for dialysis ambulance transport and audited MAS. MAS’s records were missing some CMNs. Covert surveillance resulted in videotapes of patients walking, riding in the front seat, being double-loaded, being driven by single-staffed ambulances, or being transported by wheelchair. MAS had billed the transports as single-passenger and “stretcher required.” Executing a search warrant at the Medlocks’ home, agents seized CMNs and run tickets; some had been altered or forged. The Sixth Circuit reversed a conviction for aggravated identity theft, 18 U.S.C. 1028A, agreeing that misrepresentations that certain beneficiaries were transported by stretcher did not constitute a “use” of identification, but affirmed health-care fraud convictions, rejecting arguments that the court should have instructed the jury that Medicare, not merely a prudent person, was the relevant decision-maker; that Medicare would have reimbursed MAS without their misrepresentations; and that refusal to sever a defendant was prejudicial. View "United States v. Medlock" on Justia Law

The False Claims Act (FCA) imposes civil liability for fraudulent claims for payment to the United States, 31 U.S.C. 3729(a)(1), and authorizes qui tam suits, in which private parties bring civil actions in the government’s name. A relator must first disclose his claims to the government, which then decides whether to take over the action. Whipple alleged that Erlanger knowingly submitted fraudulent claims to federally funded healthcare programs and that he discovered the fraud while working at Erlanger in 2006, by analyzing past billings, reviewing patient records, and observing operations. He claimed to have direct knowledge of fraudulent practices from supervising patient admissions, planning discharges, and reviewing submission of claims. Unbeknownst to Whipple, the government conducted an audit and investigation; the matter was resolved without a hearing by Erlanger’s 2009 payment of a $477,140.42 refund to the government. Whipple disclosed his qui tam claims to the government in 2010 and filed suit in 2011, and the government declined to intervene. The district court dismissed, finding the claims jurisdictionally barred under the FCA’s public-disclosure bar. The Sixth Circuit reversed. Holding that the government audit was not a “public disclosure” sufficient to trigger the jurisdictional bar, the court did not decide whether the original-source exception to that bar would apply. View "United States v. Chattanooga-Hamilton Cnty. Hosp." on Justia Law

In 1992, Fugate, receiving workers’ compensation, obtained disability benefits from the Social Security Administration. In such cases, SSA reduces payments until the total benefits equal 80 percent of the recipient's “average current earnings.” Using Fugate’s December 1991 pay stub, SSA calculated “one-twelfth of the total of his wages . . . for the calendar year in which he had the highest such wages,” on which FICA taxes are paid. Fugate had 1991 gross earnings of $22,964.41. After subtracting pretax benefits and retirement contributions (not subject to FICA), SSA calculated his covered earnings as $21,693.30. Fugate complained that SSA should have used pay stubs from his three highest months of earnings in 1991. In 2004, after a periodic review, SSA erroneously determined that Fugate’s covered earnings should have been $22,964.41 and paid Fugate an extra $8,875. In 2006, after another periodic review, SSA realized its mistake and asked Fugate to refund the $8,875. Instead of requesting a refund waiver, Fugate sought reconsideration of calculation of benefits for the same reasons he had cited since 1993. An ALJ declined to reconsider the 2004 decision, but erroneously held that Fugate was entitled to a waiver even though he had not requested one. Fugate nonetheless appealed. The Appeals Council vacated. The district court granted the Administration summary judgment. The Eighth Circuit affirmed. View "Fugate v. Comm'r of Social Sec." on Justia Law

Keathley retired from working at strip mines. His health deteriorated. He sought Black Lung Benefits Act benefits, 30 U.S.C. 901. Keathley established eligibility under the 15 -year presumption; he had worked in mines for more than 16 years and was able to show a totally disabling impairment by medical opinion testimony and tests showing poor pulmonary function. His employer rebutted this presumption by offering testimony by Dr. Broudy, who diagnosed Keathley with “a combination of chronic obstructive asthma and pulmonary emphysema and chronic bronchitis” caused by smoking. Conceding that “coal dust may have contributed,” Broudy concluded that “it’s far more likely that the impairment was due to obstructive airways disease from cigarette smoking and some predisposition to asthma or bronchospasm.” On remand, the ALJ awarded benefits; the Benefits Review Board affirmed, rejecting Broudy’s opinion that “bronchitis associated with coal dust exposure usually ceases with cessation of exposure,” as contrary to federal regulations, which state that “pneumoconiosis” may be “latent and progressive” and arise after exposure ceases. The Sixth Circuit denied the employer’s petition for review. The employer did not challenge the evaluation of individual tests, identify any factor the ALJ overlooked, or offer any basis for distinguishing among the tests. View "Sunny Ridge Mining Co., Inc. v. Keathley" on Justia Law

The district court awarded Naegel, counsel for a prevailing social security disability benefits applicant, significantly reduced attorneys’ fees under 42 U.S.C. 406(b). He claimed that the court should have approved his request for $26,049.73, the 25-percent contingency fee accepted by his client and permitted by statute. The Commissioner of Social Security, representing the interests of the claimant whose benefits pay for the fees, opposed that sum as a “windfall” in light of counsel’s 35.5 hours of work. The district court agreed and awarded $12,780. The Sixth Circuit affirmed, noting that: “Within the 25 percent boundary,” prevailing counsel bears the burden of “show[ing] that the fee sought is reasonable for the services rendered.” View "Lasley v. Comm'r of Soc. Sec." on Justia Law

Wallace worked for FedEx for 21 years in a variety of positions. By 2007, she was a senior paralegal, but she had a variety of health problems that required her to take leave from her position. FedEx offered Wallace leave under the Family and Medical Leave Act (FMLA), and its representatives verbally asked her to complete a medical-certification form. FedEx never explained the consequences of not returning a completed form. Wallace failed to provide FedEx with medical certification, and once she was absent for two consecutive days after the form was due, FedEx terminated her employment. Wallace filed suit under the FMLA, alleging that FedEx interfered with her rights under the statute. A jury awarded damages of $173,000, which the judge reduced to $90,788. The Sixth Circuit reversed the remittitur decision and ordered the magistrate judge to enter judgment in favor of Wallace in the amount of $173,000.View "Wallace v. FedEx Corp." on Justia Law

Because of a 2007 car accident, Glenn suffers from degenerative disc disease, a closed head injury and cerebral concussion that cause dizziness and memory loss, left shoulder tendonitis, and post-traumatic headaches. She also suffers major depression, with slow thought processes, mood swings, agitation, poor concentration, anxiousness, feelings of anger and hopelessness, paranoia, auditory hallucinations, and suicidal and homicidal ideation. She has a chronic skin condition that has caused cysts around the vulva that occasionally prevent her from walking and require frequent bathroom breaks. In 2008, Glenn sought social security benefits. Following her hearing, at which Glenn appeared without counsel, the ALJ denied the application at the fifth step of the required analysis: whether, taking into account age, education, and work experience, the claimant can perform other work. The Appeals Council declined review. The district court remanded, based on five errors, but denied attorney’s fees under the Equal Access to Justice Act, finding that the government’s position on appeal was “substantially justified” because the magistrate rejected three of Glenn’s claims of error. The Sixth Circuit reversed the denial of fees. Regardless of what happens on remand, Glenn had to retain counsel to ensure that her claim would be properly adjudicated.View "Glenn v. Comm'r of Soc. Sec." on Justia Law