Justia Public Benefits Opinion SummariesArticles Posted in US Court of Appeals for the Sixth Circuit
Samons v. National Mines Corp.
After working underground in coal mines for three decades, Casey developed pneumoconiosis (black-lung disease). His widow, Mabel, sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901–44. It took the Department of Labor 17 years to deny her claims. During this time, the claims bounced back and forth between an ALJ and the Benefits Review Board. In the last appeal, the Board also rejected one of Mabel’s main arguments, citing “law-of-the-case,” without reaching the merits. The Department of Labor then delayed things further by filing an incomplete and disorganized administrative record in the Sixth Circuit.The Sixth Circuit affirmed. While the government’s actions “perhaps could be described as poor customer service, they do not show any reversible legal error.” The Board could lawfully invoke the discretionary law-of-the-case doctrine to avoid reexamining an issue on which it had affirmed the ALJ years before. The credibility findings concerning the conflicting medical opinions concerning whether Casey was totally disabled or had only “moderate impairment” pass muster under the deferential “substantial evidence” test. View "Samons v. National Mines Corp." on Justia Law
Owsley v. Fazzi Associates., Inc.
Owsley. a nurse for Care Connection, a company providing home healthcare to Medicare patients, alleged that she observed, firsthand, documents showing that her employer had used fraudulent data from Fazzi to submit inflated claims for payment to the federal and Indiana state governments. She sued both companies under the False Claims Act, 31 U.S.C. 3729(a)(1)(A), (B), (C), (G), and an Indiana statute.The Sixth Circuit affirmed the dismissal of the suit. Owsley’s complaint provided few details that would allow the defendants to identify any specific claims—of the hundreds or likely thousands they presumably submitted—that she thinks were fraudulent, and did not meet the requirements of Civil Rule 9(b). While Owsley’s allegations describe, in detail, a fraudulent scheme: Fazzi fraudulently upcoded patient data, which Care then used to submit inflated requests for anticipated Medicare payments, that information does not amount to an allegation of “particular identified claims” submitted pursuant to the fraudulent scheme. View "Owsley v. Fazzi Associates., Inc." on Justia Law
Doucette v. Commissioner of Social Security
Attorney Conn represented Plaintiffs and thousands of other claimants in seeking disability benefits from the Social Security Administration. Conn bribed doctors to certify false applications and bribed an ALJ to approve those applications. After Conn’s scheme was uncovered, the SSA identified over 1,700 applications for redetermination of eligibility. Years of litigation ensued. Both Plaintiffs sought attorney’s fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d)(1)(A). Both courts awarded fees less than the amounts requested.The Sixth Circuit vacated the awards. Courts can award attorney’s fees for work performed during “all phases of successful civil litigation addressed by” the EAJA; one district court erred by holding that the EAJA does not authorize fees for work performed after the judgment becomes final. Both district courts abused their discretions by awarding below-market hourly rates. Plaintiffs’ unrefuted evidence established a market range of $205-500 but the courts concluded that the relative simplicity of the actions justified rates of only $125 and $150, although there is no evidence that any lawyer in the relevant communities would accept these rates for any kind of service. The complexity of the action is relevant to determine where the particular attorney’s representation lies along the spectrum of the market for legal services. It cannot be invoked to justify a rate below the established spectrum. View "Doucette v. Commissioner of Social Security" on Justia Law
Rahimi v. Rite Aid Corp.
Rite Aid’s “Rx Savings Program” provides generic prescription drugs at reduced prices. The program is free and widely available but excludes customers whose prescriptions are paid by publicly funded healthcare programs like Medicare or Medicaid. Federal regulations require pharmacies to dispense prescriptions for beneficiaries of those programs at their “usual and customary charge to the general public” (U&C rate). Rahimi alleged that Rite Aid overbilled the government programs because the amounts it charged did not take into account the lower Rx Savings Program prices. Rahimi claimed Rite Aid's submission of bills for those covered by publicly funded health insurance, representing the price to be the U&C rate, violated the False Claims Act, 31 U.S.C. 3729(a).The Sixth Circuit affirmed the dismissal of Rahimi’s claim. The Act’s public disclosure bar precludes qui tam actions that merely feed off prior public disclosures of fraud. From the beginning, communications about the Rx Savings Program have stated that publicly funded health care programs were ineligible for the discounted prices. Before Rahimi’s disclosures, Connecticut investigated membership discount prices; the Department of Health and Human Services announced that it would review Medicaid claims for generic drugs to determine the extent to which large chain pharmacies are billing Medicaid the usual and customary charges for drugs provided under their retail discount generic programs; and a qui tam action was unsealed in California, describing an identical scheme. View "Rahimi v. Rite Aid Corp." on Justia Law
River City Fraternal Order of Police v. Kentucky Retirement Systems
The plaintiffs retired from the Louisville Metropolitan police department and received free health insurance, administered by Kentucky Retirement Systems. Kentucky initially paid all of their healthcare costs. After the officers turned 65, Medicare became the primary payer, leaving Kentucky to cover secondary expenses. Each officer came out of retirement, joining county agencies different from the ones they served before retiring. They became eligible for healthcare benefits in their new positions. Kentucky notified them that federal law “mandate[d]” that it “cannot offer coverage secondary to Medicare” for retirees “eligible to be on [their] employer’s group health plan” as “active employees.” Some of the officers then paid for insurance through their new employers; others kept their retirement insurance by quitting or going part-time. The officers sued.The district court granted summary judgment to the officers, ordered Kentucky to reinstate their retirement health insurance, and awarded the officers some of the monetary damages requested. The Sixth Circuit affirmed. The officers have a cognizable breach-of-contract claim. Under Kentucky law, the Kentucky Retirement Systems formed an “inviolable contract” with the officers to provide free retirement health insurance and to refrain from reducing their benefits, then breached that contract. The Medicare Secondary Payer Act of 1980 did not bar Kentucky from providing Medicare-eligible police officers with state retirement insurance after they reentered the workforce and became eligible again for employer-based insurance coverage, 42 U.S.C. 1395y. View "River City Fraternal Order of Police v. Kentucky Retirement Systems" on Justia Law
Vitolo v. Guzman
The American Rescue Plan Act of 2021 allocated $29 billion for grants to help restaurant owners. The Small Business Administration (SBA) processed applications and distributed funds on a first-come, first-served basis. During the first 21 days, it gave grants only to priority applicants--restaurants at least 51% owned and controlled by women, veterans, or the “socially and economically disadvantaged,” defined by reference to the Small Business Act, which refers to those who have been “subjected to racial or ethnic prejudice” or “cultural bias” based solely on immutable characteristics, 15 U.S.C. 637(a)(5). A person is considered “economically disadvantaged” if he is socially disadvantaged and he faces “diminished capital and credit opportunities” compared to non-socially disadvantaged people who operate in the same industry. Under a pre-pandemic regulation, the SBA presumes certain applicants are socially disadvantaged including: “Black Americans,” “Hispanic Americans,” “Asian Pacific Americans,” “Native Americans,” and “Subcontinent Asian Americans.” After reviewing evidence, the SBA will consider an applicant a victim of “individual social disadvantage” based on specific findings.Vitolo (white) and his wife (Hispanic) own a restaurant and submitted an application. Vitolo sued, seeking a preliminary injunction to prohibit the government from disbursing grants based on race or sex. The Sixth Circuit ordered the government to fund the plaintiffs’ application, if approved, before all later-filed applications, without regard to processing time or the applicants’ race or sex. The government failed to provide an exceedingly persuasive justification that would allow the classification to stand. The government may continue the preference for veteran-owned restaurants. View "Vitolo v. Guzman" on Justia Law
Wireman v. Commissioner of Social Security
For many years, attorney Conn obtained social security benefits for his clients by submitting fraudulent reports and bribing an Administrative Law Judge. After the government discovered this fraud, the SSA decided to redetermine whether each of Conn’s 1,500 claimants was actually eligible for disability benefits. The SSA held hearings and allowed the claimants to submit evidence but categorically excluded medical reports created by the doctors with whom Conn had conspired because it had “reason to believe” fraud was involved in the creation of the reports (42 U.S.C. 1383(e)(7)(A)(ii))). The claimants were not permitted to challenge that finding. After the denials of their claims, 57 plaintiffs filed suit.The Sixth Circuit held that the exclusion of the reports violated the Due Process Clause and the APA. On remand, the district courts concluded that remand to the SSA was proper because “the Commissioner erred in some respect in reaching the decision to deny benefits.”The Sixth Circuit affirmed the subsequent denial of the plaintiffs’ motions for attorney’s fees under the Equal Access to Justice Act. The government’s position in the litigation was “substantially justified,” in light of the precedent cited by the government, the rationale for the decision, and the fact that district courts across the country have split on this issue. The case involved numerous issues of first impression. Despite the fact that the government’s arguments were rejected, a reasonable person could have believed them to be correct. View "Wireman v. Commissioner of Social Security" on Justia Law
Maur v. Hage-Korban
Dr. Korban and his medical practice Delta, practice diagnostic and interventional cardiology. In 2007, Dr. Deming filed a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729(a)(1)(A)–(C), (G) against Korban, Jackson Regional Hospital, and other Tennessee hospitals, alleging “blatant overutilization of cardiac medical services.” The United States intervened and settled the case for cardiac procedures performed in 2004-2012. Korban entered into an Integrity Agreement with the Office of Inspector General, effective 2013-2016 that was publicly available and required an Independent Review Organization. The U.S. Department of Justice issued a press release that detailed the exposed fraudulent scheme and outlined the terms of Korban’s settlement. In 2015, Jackson Regional agreed to a $510,000 settlement. The Justice Department and Jackson both issued press releases.In 2017, Dr. Maur, a cardiologist who began working for Delta in 2016, alleged that Korban was again performing “unnecessary angioplasty and stenting” and “unnecessary cardiology testing,” paid for in part by Medicare. In addition to Korban and Jackson, Maur sued Jackson’s corporate parent, Tennova, Dyersburg Medical Center, and Tennova’s corporate parent, Community Health Systems. The United States declined to intervene. The district court dismissed, citing the FCA’s public-disclosure bar, 31 U.S.C. 3730(e)(4). The Sixth Circuit affirmed. Maur’s allegations are “substantially the same” as those exposed in a prior qui tam action and Maur is not an “original source” as defined in the FCA. View "Maur v. Hage-Korban" on Justia Law
Waskul v. Washtenaw County Community Mental Health
Community Mental Health modified the methodology through which it allocated funding to individuals with disabilities receiving community living support services under a Medicaid waiver received by Michigan. Individuals receiving those services, together Advocacy, challenged that methodology as violating the Medicaid Act, 42 U.S.C. 1396a(a)(8), (a)(10)(A), (a)(10)(B), 1396n(c)(2)(A) and (C); Title II of the Americans with Disabilities Act (ADA), 42 U.S.C. 12132; section 504 of the Rehabilitation Act, 29 U.S.C. 794; the Michigan Mental Health Code; and the terms of Michigan’s Medicaid Habilitation Supports Waiver and the contracts implementing it. The district court dismissed the claims in full.The Sixth Circuit reversed, first holding that the plaintiffs have standing, that the defendants are not entitled to Eleventh Amendment immunity, that the plaintiffs were not required to exhaust their administrative remedies provided by the state under the Medicaid Act, and that the plaintiffs have a private right of action under sections 1396a(a)(8) and (a)(10). The plaintiffs’ allegations suffice to state plausible claims that they are being denied sufficient necessary medical services; that feasible alternatives that provide them a meaningful choice between institutionalized and at-home or community-based care exist and are not being ensured; and that they face a serious risk of institutionalization. View "Waskul v. Washtenaw County Community Mental Health" on Justia Law
Flack v. Commissioner of Social Security
The plaintiffs sought Social Security disability and/or supplemental security income benefits. In each case, the application was denied, and an ALJ upheld the denial. The Appeals Council denied relief. The plaintiffs sought judicial review. While the appeals were pending, the plaintiffs moved to raise an issue they had not raised during administrative hearings--a challenge to the ALJs’ appointments, citing the Supreme Court’s 2018 "Lucia" decision that SEC ALJs had not been appointed in a constitutionally legitimate manner and that remand for a de novo hearing before a different ALJ was required. The district courts agreed that the Appointments Clause challenges were forfeited and affirmed the denials of benefits.The Sixth Circuit vacated and remanded for new hearings before constitutionally appointed ALJs other than the ALJs who presided over the first hearings. There is no question that Social Security ALJs are inferior officers who were required to be, but were not, appointed consistently with the Appointments Clause. There are no statutory or regulatory exhaustion requirements governing Social Security proceedings and, while a court may still impose an implied exhaustion rule, such a requirement is inappropriate because the regulations provide no notice to claimants that their failure to raise an Appointments Clause challenge at the ALJ level will preclude them from later seeking a judicial decision on the issue. View "Flack v. Commissioner of Social Security" on Justia Law