Articles Posted in U.S. Court of Appeals for the Sixth Circuit

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In 2006, Congress amended 42 U.S.C. 1396p(c)(1)(F)(i), which permits individuals and married couples to dispose of their assets (to qualify for Medicaid) by purchasing an annuity, under which the state is named as the remainder beneficiary in the first position for the amount of medical assistance paid. The federal law initially contained a drafting error. It was subsequently amended. A corresponding Kentucky regulation, promulgated four months later, mistakenly included the pre-amendment language, stating that the state had to be the beneficiary for the amount of assistance paid on behalf of the annuitant, rather than the institutionalized spouse. The state agency enforced the corrected federal statute. The Singletons sought Medicaid benefits to support Claude’s full-time nursing home care; in purchasing an annuity, Mary wanted to name the state as a beneficiary for the value of care provided to her, rather than Claude, as the Kentucky regulation seemed to permit. Claude obtained Medicaid eligibility after the purchase of an annuity that complied with the federal regulation. The government paid $98,729.01 in medical expenses before Claude's death. Mary later died, leaving $118,238.41 in the annuity. In compliance with the federal rule, the government’s claim left $19,509.40 for the secondary beneficiaries. The Singleton children sued. The Sixth Circuit rejected their argument that the Medicaid statute gave the state discretion to be more generous concerning annuities and the general spend-down rules. The Kentucky regulation departed from the Medicaid statute’s clear instructions and was preempted. View "Singleton v. Commonwealth of Kentucky" on Justia Law

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During 2012-2013, three undercover DEA agents posed as patients during an investigation into Dr. Zaidi’s controlled substances prescription practices. As a result, the DEA Deputy Administrator suspended Zaidi’s controlled substances prescription privileges, finding that his continued registration posed an imminent danger to the public health and safety, 21 U.S.C. 824(d). DEA agents also seized controlled substances from Zaidi’s offices. Following a hearing, an ALJ recommended that the suspension and seizure be affirmed and that Zaidi's registration be revoked. The Administrator affirmed the suspension and seizure, but found the registration issue was moot due to the expiration of Zaidi’s registration and his decision not to seek renewal. The Sixth Circuit affirmed, rejecting arguments that the ALJ arbitrarily and capriciously denied Zaidi the opportunity to present testimony from an expert, employees, and former patients; there was insufficient evidence to support the suspension; the government failed to make a prima facie showing that Zaidi’s continued registration was inconsistent with the public interest; Zaidi’ prescriptions to the three undercover officers were not outside the usual course of professional practice and did not lack a legitimate medical purpose; Zaidi did not falsify medical records; and the sanction imposed was disproportionately harsh. View "Akhtar-Zaidi v. Drug Enforcement Administration" on Justia Law

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Brookdale Senior Living hired Prather to review documentation related to thousands of Brookdale residents who had received home-health services from Brookdale. Medicare claims regarding those patients were on hold and Brookdale faced possible recoupment of payments it had received if it did not review and submit final Medicare claims. Prather noticed that the required certifications stating that the doctor had decided that the patient needed home-health services, established a plan of care, and met with the patient, were signed long after care was provided. Prather repeatedly raised this issue, but was rebuffed. Brookdale, facing financial disaster, began paying doctors to complete the paperwork months after treatment was provided. Prather thought that Brookdale was not just asking treating physicians to complete forgotten paperwork, but had provided the services without physician involvement and then found doctors willing to validate the care after-the-fact. Prather's suit under the False Claims Act, 31 U.S.C. 3729, was dismissed. The Sixth Circuit reversed as to unlawful retention of payments. Completing certifications months after the fact was not “as soon as possible” after the plan was established, as required by regulations. Prather provided a detailed description of the alleged fraudulent scheme and her personal knowledge. Affirming dismissal of her false-records claim, the court concluded that Prather failed to plead with particularity the use of government forms to certify falsely that care had been provided under a doctor’s orders, or that unnecessary care had been provided. View "Prather v. Brookdale Senior Living Communities, Inc." on Justia Law

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Means, 18 weeks pregnant, went into labor. She went to Mercy Health, the only hospital within 30 minutes of her residence. Doctors diagnosed preterm premature rupture of the membrane, which usually results in a stillbirth or the baby's death. Means’s unborn baby still had a heartbeat. Mercy sent her home with pain medication without telling Means that the baby would likely not survive or that continuing her pregnancy could endanger her health. The next morning, Means returned with a fever, excruciating pain, and bleeding. Mercy did not give her additional treatment or options, although Means’s physician suspected she had a serious bacterial infection. Mercy sent her home. Means returned that night with contractions. The baby was delivered and died. The pathology report confirmed that Means had acute bacterial infections. Two years later, a public health educator discovered and inquired into Means’s case. Mercy explained that its Directives (ethical guidelines dictated by Catholic doctrine) prohibited inducing labor or similar action. The limitations period had run out on medical malpractice claims. Means sued the Conference of Catholic Bishops, alleging negligence for promulgating and enforcing the Directives. The Sixth Circuit affirmed dismissal. The only link to the Eastern District, where the case was filed, was the decision of Catholic Health Ministries to adopt the Directives. Each individual defendant lives out of state. Means lives in and Mercy is located in the Western District. Means did not allege that the defendants, by adopting the Directives, caused her any cognizable injury.. View "Means v. United States Conference of Catholic Bishops" on Justia Law

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The amount of additional Medicare reimbursements that a hospital is entitled to receive for serving a disproportionate share of low-income patients depends, in part, on the number of days that the hospital served patients who were “eligible for medical assistance under a State plan approved under [the Medicaid statute].” 42 U.S.C. 1395ww(d)(5)(F)(vi)(II). Kentucky hospitals contend that because Kentucky has chosen in its Medicaid plan to award additional Medicaid funds to hospitals based on how many days they treat patients who are eligible for the Kentucky Hospital Care Program (KHCP), a state program that provides medical coverage to low-income individuals who do not qualify for Medicaid, KHCP patient days should be counted in the calculation of the additional Medicare reimbursements. The Sixth Circuit affirmed rejection of the state’s argument on summary judgment, stating that the statutory term “eligible for medical assistance under a State plan approved under [the Medicaid statute]” is synonymous with “eligible for Medicaid” and KHCP patients are, by definition, not eligible for Medicaid. View "Owensboro Health, Inc. v. United States Dept. of Health & Human Servs." on Justia Law

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Blue Cross controls more than 60% of the Michigan commercial health insurance market; its patients are more profitable for hospitals than are patients insured by Medicare or Medicaid. BC enjoys “extraordinary market power.” The Justice Department (DOJ) claimed that BC used that power to require MFN agreements: BC would raise its reimbursement rates for services, if a hospital agreed to charge other commercial insurers rates at least as high as charged to BC. BC obtained MFN agreements with 40 hospitals and MFN-plus agreements with 22 hospital systems. Under MFN-plus, the greater the spread between BC's rates and the minimum rates for other insurers, the higher the rates that BC would pay. Class actions, (consolidated) followed the government’s complaint, alleging damages of more than $13.7 billion, and seeking treble damages under the Sherman Act, 15 U.S.C 15. In 2013, Michigan banned MFN clauses; DOJ dismissed its suit. During discovery in the private actions, plaintiffs hired an antitrust expert, Leitzinger. BC moved to exclude Leitzinger’s report and testimony. Materials relating to that motion and to class certification were filed under seal, although the report does not discuss patient information. BC agreed to pay $30 million, about one-quarter of Leitzinger's estimate, into a settlement fund and not to oppose requests for fees, costs, and named-plaintiff “incentive awards,” within specified limits. After these deductions, $14,661,560 would be allocated among three-to-seven-million class members. Class members who sought to examine the court record or the bases for the settlement found that most key documents were heavily redacted or sealed. The court approved the settlement and denied the objecting class members’ motion to intervene. The Seventh Circuit vacated, stating that the court compounded its error in sealing the documents when it approved the settlement without meaningful scrutiny of its fairness to unnamed class members . View "Shane Group, Inc. v. Blue Cross Blue Shield of Mich." on Justia Law

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A class of Tennessee residents who applied for Medicaid sought declaratory and injunctive relief, alleging that the delays they have experienced in receiving eligibility determinations on their applications violate 42 U.S.C. 1396a(a)(8) of the Medicaid statute, and that the state’s failure to provide a fair hearing on their delayed applications violates that statute and the Due Process Clause. Regulations implementing the statute provide that “the determination of eligibility for any applicant may not exceed” 90 days for those “who apply for Medicaid on the basis of disability” and 45 days for all other applicants. The district court certified a class and granted a preliminary injunction, which requires the state to grant a fair hearing on delayed applications to class members who request one. The Sixth Circuit affirmed the preliminary injunction, holding that the matter is not moot and that the federal government is not a required party. The court noted that the federal government submitted an amicus brief, supporting plaintiffs’ position. Despite the passage of the Affordable Care Act, states remain ultimately responsible for ensuring their Medicaid programs comply with federal law. View "Wilson v.Gordon" on Justia Law

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Plaintiff is a 26-bed, for-profit, physician-owned hospital that specializes in acute-care surgical services. Its Dayton-area competitors include the defendant hospitals (Premier Group), which have joint operating agreement for negotiating managed care insurance contracts and sharing revenues and losses through an agreed-upon formula, while maintaining separate asset ownership and filing separate tax returns and other corporate forms. Plaintiff sued, alleging violation of the Sherman Act, claiming that Premier was not a single entity, but a group of hospitals capable of concerted action to keep plaintiff from competing in the market. The court dismissed, concluding that Premier was a single entity. The Sixth Circuit reversed, citing the Supreme Court’s multi-factored test for determining whether a joint venture constitutes a “combination” under 15 U.S.C. 1: the condition of the business before and after the restraint is imposed; the nature of the restraint and its effect, actual or probable; the reason for adopting the particular remedy, and the purpose or end sought to be attained. The summary judgment record indicated that the purpose of Premier was to prevent plaintiff from entering the Dayton market; there was evidence of coercive conduct, threatening physicians and insurance companies with financial loss if they did business with plaintiff. There was also evidence of continued competition among the defendants, creating a genuine issue of material fact. View "Med. Ctr. at Elizabeth Place, LLC v. Atrium Health Sys." on Justia Law

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Relator brought a qui tam action (False Claims Act, 31 U.S.C. 3730(b)), alleging KHN (network of hospitals, physicians, and healthcare facilities) falsely certified its compliance with the Health Information Technology for Economic and Clinical Health Act (HITECH), 123 Stat. 226 (2009), to receive “meaningful use” incentive payments. HITECH was designed to encourage the adoption of sophisticated electronic health record technology and creates incentive payments for “meaningful use” of certified technology, 42 U.S.C. 1395. To receive incentive payments, providers must meet meaningful-use objectives and accompanying compliance measures. Stage 1 of Act implementation required a security risk analysis in accordance with 45 C.F.R. 164.308(a)(1); implementation of need security updates; and correction of identified security deficiencies. During Stage 2, providers are required to address[] the encryption/security of data stored in Certified EHR Technology in accordance with 45 C.F.R. 164.312(a)(2)(iv) and 164.306(d)(3). To receive incentive payments, providers must attest to meeting these standards. The Sixth Circuit affirmed dismissal, finding that Relator failed to plausibly allege that KHN’s attestation of HITECH compliance was false and failed to plead a specific claim for payment; and that Relator’s claims were precluded by a prior Ohio state judgment in a case involving similar claims filed by Relator against KHN. View "United States v. Kettering Health Network" on Justia Law

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From 1983-2005, Moen entered into collective bargaining agreements (CBAs) with the union. Employees who retired 1983-1996 and their dependents received hospitalization, surgical and medical coverage without cost. If the retirees (or spouses) were over age 65, Moen also reimbursed the full cost of Medicare Part B premiums. After 1996, retirees and dependents received hospitalization, surgical, and medical coverage upon payment of a co-premium frozen at the time of retirement. If over 65, they received Part B premium reimbursements at specified rates. In 2008, Moen shut down its Elyria operations. A “Closure Effects Agreement” provided that health-care coverage “shall continue” for retirees and spouses “under the [final] Collective Bargaining Agreement.” In 2013, Moen decreased benefits in response to “recent Medicare improvements” and the imposition of an excise tax on “Cadillac plans” through the Patient Protection and Affordable Care Act, 26 U.S.C. 4980I. Medicare-eligible retirees no longer receive coverage or Part B premium reimbursements; Moen shifted non-Medicare-eligible retirees to a plan that requires higher out-of-pocket payments. The court certified a class of about 200 individuals who had retired from the plant and were not covered by an earlier settlement agreement, then granted the plaintiffs summary judgment in reliance on Sixth Circuit precedent that was subsequently repudiated by the Supreme Court. The Sixth Circuit reversed, based on that 2015 decision. View "Gallo v. Moen Inc." on Justia Law