Justia Health Law Opinion Summaries

Articles Posted in US Court of Appeals for the Sixth Circuit
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General’s clinicians perform services in long-term care facilities. General bills Medicare under 42 U.S.C. 1395. A Centers for Medicare and Medicaid Services (CMS) contractor, AdvanceMed, initiated audits in 2002 after the CMS fraud unit received complaints about General’s billing practices. In 2004 AdvanceMed initiated an audit of General’s physicians without providing any notice to General. AdvanceMed sent records requests to physicians at 12 General facilities, covering 382 claims involving 278 patients in 2002-2004. General was not notified of these requests. AdvanceMed did not request any records from General. AdvanceMed determined that 35 of the 382 claims were allowed as billed; 33 claims were allowed at different levels than billed. The remaining 314 claims were denied: 3 did not meet policy guidelines, 73 had no documentation to support the services, and 238 were medically unnecessary. General learned of this audit when it received a letter in 2007, indicating that General had been overpaid by $16,778.80; the overpayment was extrapolated to a universe of 41,818 claims. The total amount of overpayment demanded was $1,836,646.56. The Appeals Council determined and the Sixth Circuit affirmed that no remedy should be granted because the lack of notice was inconsequential and did not prevent General from ably and thoroughly arguing the principal issues resulting from the audit, the validity of the sampling methodology, and the coverage of the reviewed claims. The addition of more medical records would not have materially impacted its findings. View "General Medicine, P.C. v. Azar" on Justia Law

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Holloway, the qui tam relator, sued Heartland Hospice and related entities under the False Claims Act (FCA), 31 U.S.C. 3729-3733, for orchestrating a corporate-wide scheme to submit false claims for payments from Medicare and Medicaid to cover hospice care. Heartland allegedly enrolled patients in hospice when they were not terminally ill and kept them there, even when employees like Holloway urged their release and allegedly paid bonuses for the recruitment of hospice patients. Heartland argued that Holloway is not a genuine whistleblower, that her claims are drawn from prior allegations against Heartland so that her qui tam action is prohibited by the FCA’s public-disclosure bar. In the alternative, Heartland argued that Holloway has not satisfied the FCA’s heightened pleading standard for allegations of fraud or the limited exception to that standard. The Sixth Circuit affirmed the dismissal of Holloway’s action as barred in light of prior public disclosures. Even if South Carolina complaints, dismissed in 2008, were focused on a single hospice facility, the allegations against Heartland as a whole were sufficiently general and alike to those alleged here such that the government was put on notice of the corporate-wide conduct alleged in this case. Holloway’s claims are barred by the pre-amendment public-disclosure bar. View "Holloway v. Heartland Hospice, Inc." on Justia Law

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When the Sieferts’ child started experiencing suicidal thoughts, they took the teenager to Children’s Hospital near Cincinnati. After about a week, the Sieferts’ insurance company determined that Minor Siefert had no medical problems and denied further coverage. The Sieferts decided to bring their child home but the doctors and social workers resisted. For four weeks, the Sieferts wrangled with the hospital and county about getting their child back. Only after the Sieferts signed a voluntary safety plan did the child leave the facility. The Sieferts sued the county, its employees, the hospital, and its doctors, alleging substantive and procedural due process violations. The district court dismissed the hospital and county defendants. The Sixth Circuit reversed in part. The Sieferts adequately pled procedural due process violations “[e]ven a temporary deprivation of physical custody requires a hearing within a reasonable time.” The issue of their consent was not appropriate for summary judgment. The hospital may be considered a state actor in these circumstances. Children’s and Hamilton County worked together, collaborating and communicating about Minor Siefert’s situation. Rejecting substantive due process claims, the court stated that the defendants’ opting to err on the side of protecting the child at the expense of depriving the parents of their parental rights for a month is not conduct that shocks the conscience. The Sieferts’ claims against the county entities must fail under “Monell.” View "Siefert v. Hamilton County" on Justia Law

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Four men from Miami drove to Louisville to set up chiropractic clinics. Lezcano, the mastermind, decided to file false claims with the patients’ insurers and get paid for treatments that never happened. The others, Chavez, Betancourt, and Diaz joined in. The plan worked due to aggressive marketing. The conspirators recruited and paid patients both to come to the clinics and to recruit others. Many of the patients worked at the Jeffboat shipyard. Jeffboat (through its claim administrator, United Healthcare) paid the clinics more than $1 million for fake injections of a muscle relaxant. The government discovered the scheme and brought criminal charges. Chavez went to trial, claiming he had no idea that Lezcano was cooking the books. Convicted of healthcare fraud, conspiracy to commit healthcare fraud, aggravated identity theft, and conspiracy to commit money laundering for purposes of concealment. Chavez was sentenced to 74 months’ imprisonment. The Sixth Circuit affirmed, rejecting his challenges to the sufficiency of the evidence and a related challenge to the prosecutor’s closing argument; two hearsay arguments; three objections to the jury instructions; and a sentencing argument. View "United States v. Chavez" on Justia Law

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Young, diagnosed with emphysema in 2002, had worked in coal mines for 19 years, retiring from Island Creek Coal in 1999. During and after work, Young would often cough up coal dust. For 35 years, Young smoked at least a pack of cigarettes a day. Young sought benefits under the Black Lung Benefits Act, 30 U.S.C. 902(b). Because Young had worked for at least 15 years as a coal miner and was totally disabled by his lung impairment, he enjoyed a statutory presumption that his disability was due to pneumoconiosis. If Young was entitled to benefits, Island Creek, Young’s last coal-mine employer, would be liable. After reviewing medical reports, the ALJ awarded benefits. The Benefits Review Board affirmed, noting that if there was any error in the ALJ’s recitation of the standard, that error was harmless. The Sixth Circuit denied a petition for review, first rejecting an Appointments Clause challenge as waived. The ALJ did not err by applying an “in part” standard in determining whether Island Creek rebutted the presumption that Young has legal pneumoconiosis. To rebut the “in part” standard, an employer must show that coal-mine exposure had no more than a de minimis impact on a miner’s lung impairment. The ALJ reasonably weighed the medical opinions and provided thorough explanations for his credibility determinations. View "Island Creek Coal Co. v. Young" on Justia Law

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A jury convicted Dr. Chalhoub of defrauding health care benefit programs under 18 U.S.C. 1347. A Kentucky cardiologist, Chalhoub implanted permanent pacemakers in patients who did not need the devices or the tests that he ordered before and after surgery. On appeal, Chalhoub claimed that the district court repeatedly admitted evidence unduly prejudicial to him—and to which he could not effectively respond. The Sixth Circuit affirmed, acknowledging that “some of the government’s tactics here leave something to be desired.” Noting Chaloub’s failure to cross-examine, the court rejected a due process challenge to the admission of testimony by a doctor who claimed to have examined 20 of former Chaloub’s patients but could not name those patients. Chalhoub was not denied a right to be heard and the government did not base its case solely on allegations about those 20 victims. Chalhoub argued that he was severely prejudiced by testimony that he misbilled insurers for other unspecified procedures, but he did not seek clarification or additional information at trial. The court upheld the admission of testimony about Chaloub’s income and expenditures and testimony about his installation of a pacemaker in a former patient. View "United States v. Chalhoub" on Justia Law

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Three out of every five hospitals use Ciox, a medical records provider, which processed 4.3 million pages per day in 2018. Ciox is subject to the 1996 Health Insurance Portability and Accountability Act (HIPAA), 110 Stat. 1936. Department of Health and Human Service fee-limit provisions prohibit Ciox from charging patients more than “reasonable, cost-based fee[s]” for their records. Tennessee’s Medical Records Act (TMRA), prevents hospitals from charging patients more than the “reasonable costs for copying and the actual costs of mailing [their] records.” The named Plaintiffs worked with law firms to request their medical records from Tennessee hospitals. Ciox serviced those requests. Plaintiffs filed a class action, accusing Ciox of charging them more than what HIPAA regulations and TMRA allow. HIPAA does not authorize a private cause of action, so the Plaintiffs cited common-law causes of action: negligence, negligence per se, unjust enrichment, and breach of implied-in-law contract. The district court dismissed the TMRA claim but granted class certification and later granted Ciox summary judgment The Sixth Circuit affirmed. Tennessee's common law is no substitute for the private right of action that Congress refused to create in HIPAA. TMRA’s fee limits unambiguously do not apply to medical-records providers. Plaintiffs cannot prove the existence of any common-law duty or legal contract. Because the court did not send notice to absentee class members, the decision binds only the named Plaintiffs. View "Faber v. Ciox Health, LLC" on Justia Law

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In 2011-2012, Godofsky was a doctor at a “pill mill,” the Central Kentucky Bariatric and Pain Management clinic. The clinic accepted payment by only cash (later by debit card), at $300 for the first visit and $250 per visit thereafter, and did not give change. The clinic had thousands of dollars in cash on hand every day, so the manager was armed with a handgun and patrolled the clinic with a German Shepherd. The clinic scheduled multiple “patients” at the same time, every 15 minutes, and was often open until after 10:00 p.m. The clinic received hundreds of “patients” per day, many of whom had traveled long distances and waited for hours for a few minutes with a doctor who would then provide a prescription for a large amount of opioids, usually oxycodone. The Sixth Circuit affirmed Godofsky’s conviction for prescribing controlled substances, 21 U.S.C. 841(a), and the below-guidelines 60-month prison term and $500,000 fine, upholding the trial court’s refusal to use a jury instruction titled “Good Faith,” which would have instructed the jurors that his “good intentions” were enough for his acquittal or, rather, that the prosecutor had to prove that he had not personally, subjectively, believed that the oxycodone prescriptions would benefit his patients. View "United States v. Godofsky" on Justia Law

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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

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Doe is HIV-positive and takes Genvoya to control his condition. Doe's BlueCross health insurance covers Genvoya. After February 2017, BlueCross required Doe to fill the HIV prescription through mail order or by picking it up at certain brick-and-mortar pharmacies. If Doe used BlueCross's specialty pharmacy network, his co-pay for each monthly batch of Genvoya would be $120. If Doe continued to get the medicine at his local pharmacy, he would have to pay the full cost, thousands of dollars per batch. Doe preferred interacting with his regular pharmacists, who knew his medical history and could spot the effects of harmful drug interactions. He also worried that deliveries to his house might compromise his privacy or risk heat damage to the medicine. Doe filed a putative class action, alleging that BlueCross discriminated against HIV-positive beneficiaries in violation of the Affordable Care Act and the Americans with Disabilities Act (ADA), which breached their insurance contract. The district court dismissed. The Sixth Circuit affirmed. The Affordable Care Act prohibits discrimination against the disabled in the provision of federally supported health programs under section 504 of the Rehabilitation Act. BlueCross did not violate the Rehabilitation Act; it did not exclude Doe from participating in the plan or deny him benefits covered by it. Section 504 does not prohibit disparate-impact discrimination. The ADA claim failed because Doe targets BlueCross’s operation of his health care plan, not its control over his pharmacy (a public accommodation). View "Doe v. BlueCross BlueShield of Tennessee, Inc." on Justia Law