Justia Health Law Opinion Summaries

A dialysis provider created a wholly-owned subsidiary, RCGSC, which supplied dialysis equipment for home use, to take advantage of the Medicare reimbursement scheme and increase profits. In 2005 former employees filed a qui tam action under the False Claims Act, 31 U.S.C. 3729-33, alleging that RCGSC was not a legitimate and independent durable medical equipment supply company, but a “billing conduit” used to unlawfully inflate Medicare reimbursements. The United States intervened and the relators’ claim was voluntarily dismissed. The government alleged that defendants submitted claims, knowing that RCGSC was a sham corporation created solely for increasing Medicare reimbursements; knowing that RCGSC was not in compliance with Medicare rules and regulations; knowing that RCGSC was misleading patients over their right to choose between Method I and Method II reimbursements; and for facility support charges for services rendered to home dialysis patients who had selected Method II reimbursements. The government also brought common law theories of payment by mistake and unjust enrichment. The district court granted summary judgment in favor of the United States. The Sixth Circuit reversed on all counts and remanded some. Defendants did not act with reckless disregard of the alleged falsity of their submissions to Medicare.View "United States v. Renal Care Grp., Inc." on Justia Law

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

In 2004, Ohio passed a law criminalizing the distribution of mifepristone, also known as RU-486, unless the distribution complied with protocols and gestational time limits identified by the FDA when mifepristone was first approved in 2000. Ohio Rev. Code 2919.123. Mifepristone, in combination with misoprostol, was the only form of medical abortion offered by Planned Parenthood in Ohio. Planned Parenthood’s Ohio regional clinics and two of its doctors challenged the Ohio Act. The district court entered a preliminary injunction to cover the Act’s failure to make an exception for circumstances involving the health and life of the mother, but the Act has otherwise been in force since February 2011. Following resolution of certified questions by the Ohio Supreme Court, the district court entered summary judgment that: the Act was no longer unconstitutionally vague; did not violate a woman’s right to bodily integrity under the Fourteenth Amendment; and did not impose an undue burden on a woman’s Fourteenth Amendment right to choose abortion. Whether the Act unduly burdens a woman’s right to health and life under the Fourteenth Amendment was held for trial. The Sixth Circuit affirmed summary judgment on the vagueness and bodily-integrity claims. View "Planned Parenthood SW OH Region v. DeWine" on Justia Law

In 2008, Michigan passed the MMMA, Comp. Laws 333.26421, to protect medical marijuana. Any “qualifying patient” who possesses a registry identification card is not “subject to arrest, prosecution, or penalty of any manner, or denied any right or privilege, including but not limited to civil penalty or disciplinary action by a business.” Plaintiff was employed by Wal-Mart for five years before he was terminated after testing positive for marijuana, in violation of the company’s drug use policy. The test was administered on the day after Plaintiff injured his knee at work. Plaintiff was diagnosed with sinus cancer and an inoperable brain tumor at age 17; he experiences constant pain and side effects of medications. In 2008, Plaintiff’s oncologist recommended marijuana; Plaintiff obtained a registry card and maintains that he followed state laws, never used marijuana at work, nor did he work under the influence. Plaintiff sued in state court for wrongful discharge and MMMA violation; defendants removed to federal court based on diversity. The district court denied remand and dismissed. The court held that the store manager, a Michigan resident, was fraudulently joined and that the MMMA does not regulate private employment. The Sixth Circuit affirmed, noting that the manager had no potential liability. View "Casias v. Wal-Mart Stores, Inc." on Justia Law

A collective bargaining agreement governs the relationship between Acument and its retired employees. Prior to 2008, the company paid healthcare and life-insurance benefits to qualified retirees. When Acument ended these benefits in 2008, a class of 64 retirees claimed that the company had violated the CBA in violation of the Employee Retirement Income Security Act and the Labor Management Relations Act. The district court granted Acument summary judgment. The Sixth Circuit affirmed, characterizing the issue as “a matter of contract.” The relevant language states that the company “reserves the right to amend, modify, suspend, or terminate the Plan,” consisting of: retiree medical coverage; retirement income; disability income; and life insurance. View "Witmer v. Acument Global Tech., Inc." on Justia Law

In a 2009 opinion, the Sixth Circuit held that, in a 1998 collective bargaining agreement, CNH agreed to provide health-care benefits to retirees and their spouses for life, but rejected the suggestion that the scope of this commitment in the context of healthcare benefits, as opposed to pension benefits, meant that CNH could make no changes to the healthcare benefits provided to retirees. The court remanded for a determination of reasonableness with respect to CNH’s proposed changes to its retiree healthcare benefits, under which retirees, previously able to choose any doctor without suffering a financial penalty, would be put into a managed-care plan. The court listed three considerations: Does the modified plan provide benefits “reasonably commensurate” with the old plan? Are the proposed changes “reasonable in light of changes in health care”? And are the benefits “roughly consistent with the kinds of benefits provided to current employees”? On remand, the district court granted CNH summary judgment without reaching the reasonableness question or creating a factual record from which the determination could be made on appeal. The Sixth Circuit again remanded.View "Reese v. CNH America LLC" 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

Genentech manufactured and sold the psoriasis medication Raptiva, approved by the FDA in 2003. Raptiva works by suppressing T-cells ; because T-cells help fight infections, suppression has the potential to cause potentially life-threatening side effects. Following reports of adverse health effects, including a rare brain infection, Genentech voluntarily removed Raptiva from the market in 2009. Marsh began using Raptiva in 2004 and subsequently suffered viral meningitis and a collapsed lung. She sued in 2011, alleging strict products liability under design-defect and failure-to-warn theories, negligence, breach of warranty, and fraud. She claimed that, before and after FDA approval, Genentech knew of dangerous side effects that it concealed and did not include in the drug’s label. The district court dismissed, holding that Genentech was immune from suit because neither statutory exception to immunity for drug manufacturers applied. Marsh argued that immunity does not apply because failure to submit updated information rendered Raptiva noncompliant with FDA approval when it left Genentech’s control and that her claim was not preempted because it was premised on non-compliance rather than fraud or bribery. The Sixth Circuit affirmed. Allegations underlying Marsh’s argument that immunity does not apply are essentially the type of claim that is preempted.View "Marsh v. Genetech Inc." on Justia Law