Justia Health Law Opinion Summaries

Articles Posted in US Court of Appeals for the Sixth Circuit
by
A jury convicted Sandra, Calvin, and their son Bryan Bailey of conspiring to commit healthcare fraud and other related crimes (18 U.S.C. 371, 1343, 1347; 42 U.S.C. 1320a-7b). The three, working for medical equipment companies, used fraud, forgery, and bribery to sell power wheelchairs and other equipment that was not medically necessary. The district court sentenced Sandra to 120 months’, Calvin to 45 months, and Bryan to 84 months’ imprisonment.The Sixth Circuit affirmed the convictions and the sentence imposed on Bryan. The court rejected challenges to the sufficiency of the evidence and to various evidentiary rulings and upheld the admission of certain out of court statements made in furtherance of the conspiracy. The district court miscalculated Sandra’s Guidelines-range sentence when it erroneously imposed a two-level increase in her offense level for using “mass marketing” in her scheme and incorrectly calculated the loss amount for which Calvin was responsible—and by extension, his Guidelines-range sentence—by holding him responsible for losses beyond those he agreed to jointly undertake. View "United States v. Bailey" on Justia Law

by
Hepatitis C is a contagious, progressive virus that can lead to cirrhosis of the liver, liver cancer, and ultimately death. There is no vaccine for hepatitis C. Doctors previously treated the virus using interferons; that treatment brought little success and severe side effects. In 2011, the FDA approved new direct-acting antivirals that halt the progress of hepatitis C and eventually cause the virus to disappear. In 2015, the cost of a single course of treatment using direct-acting antivirals was $80,000-$189,000. By the time of trial, those prices was $13,000-$32,000.A 2016 policy specified that the Tennessee Department of Corrections would provide the antivirals only to infected inmates with severe liver scarring. By 2019, approximately 4,740 of Tennessee's 21,000 inmates had hepatitis. Under a 2019 guidance, every new inmate is tested for hepatitis C. Inmates who test positive undergo a baseline evaluation; an advisory committee of healthcare professionals evaluates each infected inmate and determines his course of treatment. The guidance establishes criteria that make antivirals available to “individuals [who] are at higher risk for complications or disease progression," includes a series of procedural steps for local providers, and provides for continuous care and monitoring of infected inmates, regardless of their treatment plan.The Sixth Circuit affirmed the rejection of inmates' claims under 42 U.S.C. 1983, alleging deliberate indifference to their serious medical needs. The 2019 guidance showed reasonable medical judgment to care for the class of infected inmates. While the best course of action might be to treat all infected inmates with antivirals, the defendant could not spend more than was allocated and had repeatedly sought budget increases. View "Atkins v. Parker" on Justia Law

by
Adopted in 2019, Ohio Revised Code 1349.05(B) states: No health care practitioner, with the intent to obtain professional employment for the health care practitioner, shall directly contact in person, by telephone, or by electronic means any party to a motor vehicle accident, any victim of a crime, or any witness to a motor vehicle accident or crime until thirty days after the date of the motor vehicle accident or crime. Any communication to obtain professional employment shall be sent via the United States postal service. Subsection (C) provides the same restrictions but with regard to the agents of health care practitioners. The plaintiffs provide chiropractic services; one plaintiff is a referral service that identifies and contacts prospective patients for health care providers. The plaintiffs claim that they “all rely upon advertising and marketing techniques that permit prompt contact with victims of motor vehicle and pedestrian accidents.” They alleged that the statute violates their constitutional rights to free speech and equal protection. The Sixth Circuit affirmed the district court in denying relief. The plaintiffs failed to show a substantial likelihood of succeeding on the merits of their free speech and equal protection claims; “strong” precedents foreclosed the plaintiffs’ challenges. View "First Choice Chiropractic, LLC v. DeWine" on Justia Law

by
Federal regulations require commercial truck drivers to undergo annual physicals to be “medically certified as physically qualified." A driver is not physically qualified if he has a clinical diagnosis of a respiratory dysfunction likely to interfere with his ability to drive a commercial motor vehicle safely. Respiratory dysfunction includes sleep apnea.Allman was diagnosed with apnea after a sleep study and was instructed to wear a CPAP machine when sleeping in his truck. Allman complained about the device, which was remotely monitored. Allman was suspended twice for noncompliance. Allman independently completed a second sleep study, which showed that Allman did not have sleep apnea. Allman stopped wearing the CPAP and obtained a new DOT certification card without another examination. Walmart instructed Allman to participate in another sleep study because the doctor who performed Allman’s independent study was not board certified. A third study resulted in a second diagnosis of sleep apnea. Allman refused to wear the CPAP machine. Rather than taking the conflicting sleep studies to a DOT medical examiner, Allman resigned and filed suit, asserting discrimination based on perceived disability and retaliation under Ohio law.The Sixth Circuit affirmed the rejection of both claims. Walmart offered a legitimate, nondiscriminatory reason for its CPAP requirement; Allman failed to rebut that reason as pretextual. Walmart’s CPAP requirement was not an unsafe working condition but was a disability accommodation meant to promote public safety and to ensure compliance with federal law. View "Allman v. Walmart, Inc." on Justia Law

by
Darby notified her Childvine supervisor that she had been diagnosed with breast cancer and was scheduled for a double mastectomy. Mayhugh expressed doubt about whether Childvine would allow Darby to remain employed when her surgery date fell within her 90-day probationary period. Darby moved the procedure to the day after her probationary period expired. Darby’s request to use her vacation and sick time to recover from the procedure was approved. When Darby returned to work, with a medical release, she learned that Childvine had sent a letter of termination effective on the last day of her probationary period because of an “unpleasant” attitude, dress code violations, and “being unable to work.” Darby filed suit under the Americans with Disabilities Act (ADA), noting that she was never disciplined for behavior issues. In reviewing Darby’s medical records, Childvine learned that Darby was never diagnosed with cancer; she had a family history of cancer and the BRCA1 “pre-cancerous genetic mutation.” The district court stated that the definition of physical impairment does not include a condition that might lead to cancer, and dismissed the case.The Sixth Circuit reversed. Darby plausibly alleged that her impairment substantially limits her normal cell growth as compared to the general population due to both the BRCA1 gene and a medical diagnosis of abnormal epithelial cell growth serious enough to warrant a double mastectomy. View "Darby v. Childvine, Inc." on Justia Law

by
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

by
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

by
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

by
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

by
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