Justia Public Benefits Opinion Summaries

Articles Posted in US Court of Appeals for the Sixth Circuit
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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

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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

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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

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In 1983, Rice sought benefits under the Black Lung Benefits Act (BLBA), 30 U.S.C. 901–45. The Department of Labor (DOL) looks to employers that employed the miner for at least one year and are capable of paying benefits. The miner’s most recent employer that meets these requirements is the “responsible operator.” Employers must either qualify as a self-insurer or purchase BLBA insurance. KRCC operated a coal mine where Rice worked in 1982-1983 but he was employed by a separate corporate entity, KRMS, which charged KRCC for the cost of Rice’s labor. The entities' ownership and management overlapped; KRMS had no assets and operated out of KRCC's offices. KRCC obtained BLBA coverage from Bituminous Casualty but only listed 10 employees. The other 150 were employed by KRMS. An ALJ identified KRMS as the responsible operator, then denied Rice’s claim on the merits. Rice appealed; KRCC and Bituminous successfully moved to be dismissed from the case, because the ALJ identified KRMS as the responsible operator.In 2002, Rice filed another BLBA claim. DOL again notified KRCC and Bituminous that KRCC might be the responsible operator. Bituminous claims it “denied coverage based on the fraudulent arrangements” between KRCC and KRMS. DOL refused to dismiss Bituminous.The Sixth Circuit affirmed, rejecting arguments that DOL was collaterally estopped from finding that KRCC was the responsible operator; that Bituminous was entitled to rescind its insurance agreement based on fraud by KRCC; and that delays in DOL administrative proceedings violated its right to due process. View "Karst Robbins Coal Co. v. Director, Office of Workers’ Compensation Programs" on Justia Law

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Hargett, born in 1965, has a high-school education and previously worked as a semi-truck driver, municipal worker, maintenance mechanic, and industrial cleaner. He last worked in March 2015. Hargett applied for disability insurance benefits; he had high blood pressure, type-two diabetes, curvature of the spine, and COPD. Hargett’s primary care physician, Lucardie, referred Hargett to a physical therapist for a functional capacity evaluation (FCE), which indicated that Hargett had a maximum lifting capacity of 35 pounds and maximum carrying capacity of 20 pounds--the “medium strength” category-- but that Hargett could continuously stand for no more than five minutes; could continuously walk for no more than 0.1 miles; could never balance while standing, crouching, or walking; and could never crouch, stoop, or crawl. Lucardie reviewed and signed the FCE.An ALJ denied Hargett’s claim, finding that Hargett retained the residual functional capacity to perform light work. The ALJ gave only “partial weight” to the FCE, discounting its indication that Hargett’s ability to stand or walk did not meet any standard for work activity. The Sixth Circuit vacated. The ALJ should have considered the FCE as a treating-source opinion, which, in 2015, had to be given controlling weight if “well-supported by medically acceptable clinical and laboratory diagnostic techniques” and “not inconsistent with the other substantial evidence.” The error was not harmless. View "Hargett v. Commissioner of Social Security" on Justia Law

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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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Babcock joined the Michigan National Guard in 1970 and became a dual-status technician “a Federal civilian employee” who “is assigned to a civilian position as a technician” while maintaining membership in the National Guard, 10 U.S.C. 10216(a)(1); 32 U.S.C. 709(e). Babcock served as a National Guard pilot, held the appropriate military grade, wore a uniform that displayed his rank while working, and attended weekend drills. In 2004-2005, Babcock was deployed to Iraq on active duty. Babcock received military pay for his active-duty service and his inactive-duty training, including weekend drills. Otherwise, he received civil pay and participated in the Civil Service Retirement System (CSRS), 5 U.S.C. 5301. Babcock paid Social Security taxes on the wages for his active-duty service and his inactive-duty training from 1988 onwards, 42 U.S.C. 410(l)(1). He did not pay Social Security taxes on his wages for inactive-duty training before 1988 or on his civil-service wages.In 2009, Babcock retired and began receiving monthly CSRS payments and separate military retirement pay. For several years after his retirement, Babcock flew medical-evacuation helicopters for hospitals. This private-sector income was subject to Social Security taxes. Babcock fully retired in 2014. The government reduced his Social Security benefits under the Windfall Elimination Provision (WEP) because of his CSRS pension. Babcock cited a WEP exception for payments “based wholly on service as a member of a uniformed service.” While Babcock's case was pending, the Eleventh Circuit rejected the Eighth Circuit’s contrary analysis and held that the uniformed-services exception does not apply to dual-status technicians. The Sixth Circuit subsequently agreed that a federal civil-service pension based on work as a National Guard dual-status technician does not qualify as “a payment based wholly on service as a member of a uniformed service.” View "Babcock v. Commissioner of Social Security" on Justia Law

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Emard, age 33, was injured in a 2010 motorcycle accident. Emard had previously worked as a truck driver, assembler, and packager. He ceased working after the accident. His application for Social Security disability-insurance benefits claimed chronic low-back pain, chronic neck pain, cervical radiculopathy, lumbar radiculopathy, chronic migraine headaches, fatigue, mood swings, anxiety, and Crohn’s disease. An ALJ determined that Emard had not engaged in substantial gainful activity during his insured period; that Emard’s degenerative disc disease, asthma, obstructive sleep apnea, anxiety, and depression were severe impairments, but that his other conditions were mild impairments; that none of Emard’s impairments or any combination thereof met the criteria of any listed impairment; that Emard had the residual functional capacity to perform sedentary work; that Emard’s “subjective complaints exceed the available objective records,” particularly in light of Emard’s conservative course of treatment; that Emard could not perform past relevant work; and that Emard could perform jobs that existed in significant numbers in the national economy.The district court and Sixth Circuit affirmed the denial of benefits. The ALJ made no procedural error by declining to give weight to the opinion of a treating source offered after the claimant’s date last insured that did not relate back to the insured period. The ALJ complied with requirements to view Emard’s impairments in combination and to consider Emard’s ability to work on a sustained basis. View "Emard v. Commissioner of Social Security" 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