Justia U.S. 7th Circuit Court of Appeals Opinion Summaries

Carrie Musselman, a chiropractor in Illinois, expanded her practice to include non-chiropractic medical services and subsequently engaged in fraudulent billing practices targeting Medicare. She directed staff to bill services performed by nurse practitioners and physician assistants under physicians’ names, circumventing Medicare’s “Incident To” requirements, which resulted in higher reimbursements. Additionally, she billed a non-surgically implanted pain-relief device using a code for surgically implanted devices and billed sublingual allergy drops under a code intended for injectable allergy treatments. Despite repeated internal and external warnings about these improper practices, Musselman persisted, primarily seeking advice from sources with vested financial interests.A federal grand jury indicted Musselman on charges of healthcare fraud, wire fraud, and obstruction of a federal audit. Following a 13-day trial in the United States District Court for the Central District of Illinois, a jury found her guilty of healthcare fraud and five counts of wire fraud, acquitting her on other charges. Post-verdict, the district court discovered that the jury foreperson had created a deliberation guide based on online articles, which included references to non-unanimous verdicts. Musselman moved for a new trial on this basis and challenged the court’s use of an “ostrich” instruction regarding deliberate ignorance. The district court denied both motions, reasoning that the outside research was harmless and the ostrich instruction was justified by the evidence.On appeal, the United States Court of Appeals for the Seventh Circuit affirmed. The court held that the district court properly found no reasonable possibility that the jury’s verdict was affected by the foreperson’s outside research and that Musselman had waived a further evidentiary hearing. The appellate court also concluded that the evidence supported the ostrich instruction, given Musselman’s repeated disregard of obvious red flags and her heightened duty to inquire about her practice’s billing practices. View "USA v. Musselman" on Justia Law

A pretrial detainee housed in the Milwaukee County Jail alleged that, during a medical emergency involving COVID-19 symptoms, two correctional officers failed to provide adequate medical attention. He claimed that despite using his in-cell intercom to request help for chest pain and shortness of breath, the officers did not respond. Later, a nurse administered a COVID-19 test, but the detainee was never informed of the results, and his condition worsened until he eventually passed out and was hospitalized.After recovering, the detainee followed the jail’s grievance procedure by submitting a grievance through the electronic kiosk, updating it as his symptoms persisted, and eventually receiving a response from jail staff that closed the grievance. He did not appeal the grievance. The detainee later filed a lawsuit under 42 U.S.C. § 1983 in the United States District Court for the Eastern District of Wisconsin, alleging violations of his Fourteenth Amendment rights. Before discovery, the defendants moved for summary judgment, arguing that the detainee failed to exhaust his administrative remedies as required by the Prison Litigation Reform Act (PLRA). The district court granted summary judgment for the defendants, concluding that the detainee did not appeal his grievance and that the remedies were available to him, dismissing his assertion that the process was unavailable.Reviewing the appeal, the United States Court of Appeals for the Seventh Circuit held that a genuine dispute of material fact existed as to whether the jail’s grievance appeals process was actually available to the plaintiff. The Seventh Circuit vacated the district court’s summary judgment, finding that the detainee’s sworn declaration provided sufficient evidence to require further fact-finding, either through an evidentiary hearing or a jury trial if the exhaustion issue is intertwined with the merits. The case was remanded for further proceedings. View "Burns v Polk" on Justia Law

Heritage Operations Group operates long-term care facilities in Illinois, with Green Tree Pharmacy providing pharmacy services to these facilities. Both companies are family-owned and operated. A. Samuel Enloe, who has extensive experience in the long-term care pharmacy industry, alleged that Heritage and Green Tree dispensed Schedule II controlled substances to residents without valid prescriptions, particularly during emergencies when the pharmacy was closed. Enloe claimed that this practice violated the Controlled Substances Act (CSA) and that subsequent claims for Medicare reimbursement were fraudulent under the False Claims Act (FCA).The United States District Court for the Northern District of Illinois, Eastern Division, dismissed Enloe’s second amended complaint. The court concluded that Enloe failed to plead his FCA claims with the particularity required by Federal Rule of Civil Procedure 9(b), specifically not identifying the “who, what, when, where, and how” of the alleged fraud. It also found that the CSA does not provide a private cause of action and, as a result, dismissed the related unjust enrichment claim. Enloe appealed, challenging only the dismissal of his FCA claims.The United States Court of Appeals for the Seventh Circuit reviewed the district court’s dismissal de novo. The appellate court held that Enloe’s allegations were speculative and lacked the concrete factual detail required under Rule 9(b). The court found that Enloe did not sufficiently allege either a clear violation of the CSA or that any misrepresentation was material to the government’s payment decision. Thus, the Seventh Circuit concluded that Enloe failed to state a claim under the FCA and affirmed the district court’s judgment dismissing his complaint. View "Enloe v Heritage Operations Group, LLC" on Justia Law

The defendant, a physician specializing in obstetrics and gynecology in Illinois, owned and operated a medical practice where she engaged in fraudulent billing to health care benefit programs, including Medicaid and Tricare, from February 2018 to April 2022. She submitted claims for procedures and services that were either not provided or not medically necessary, including telemedicine visits, office visits, and tests. Some of these fraudulent claims were for endometrial ablations, a procedure with significant consequences for patients’ reproductive health.Facing a thirteen-count indictment for health care fraud, the defendant pleaded guilty to two counts pursuant to a plea agreement. These counts specifically alleged the submission of fraudulent claims to Tricare for a telemedicine visit and lab testing. The United States District Court for the Northern District of Illinois, Eastern Division, held a sentencing hearing, during which it considered testimony from patients, expert witnesses, and victim impact statements. The court found that the defendant performed medically unnecessary procedures without informed consent, and that her statements during the plea hearing and subsequent professional regulation proceedings indicated a failure to accept responsibility.On appeal, the United States Court of Appeals for the Seventh Circuit reviewed three main issues: the district court’s denial of a reduction for acceptance of responsibility, application of a sentencing enhancement for reckless risk of serious bodily injury, and the substantive reasonableness of the 120-month sentence. The Seventh Circuit held that the district court did not clearly err in its factual findings, properly applied the sentence enhancement, and did not abuse its discretion in weighing aggravating and mitigating factors. The court affirmed the judgment of the district court, upholding the defendant’s sentence. View "USA v Ghosh" on Justia Law

Four individuals who were Medicaid beneficiaries in Illinois were admitted to long-term care facilities between 2018 and 2023. The facilities submitted required electronic admission packets to the Illinois Department of Healthcare and Family Services so that the cost of care could be reimbursed by Medicaid. In each case, the Department either rejected or mishandled these admission packets, resulting in the facilities not being reimbursed for all or part of the care provided. Despite regulations prohibiting providers from billing Medicaid beneficiaries for unreimbursed care, the facilities sent bills to the plaintiffs. The plaintiffs, however, did not pay these bills, nor did they suffer any loss of benefits or interruption in care.The plaintiffs filed a proposed class action in the United States District Court for the Northern District of Illinois against state officials responsible for Medicaid administration. They alleged violations of due process and the Medicaid Act, and requested only injunctive relief to require systemic changes in the admission packet review process. The defendants moved to dismiss, arguing both lack of standing and failure to state a claim. The district court found that the plaintiffs had standing because they received bills, but it dismissed the case for failure to state a claim, reasoning that the plaintiffs were not denied benefits or services and no statutory or constitutional rights were violated.On appeal, the United States Court of Appeals for the Seventh Circuit reviewed only standing. The appellate court held that the plaintiffs lacked standing for injunctive relief because they did not allege a real and immediate threat of repeated injury. The prior receipt of bills did not amount to legal harm, as the plaintiffs had no obligation to pay. The court modified the district court’s judgment to reflect a jurisdictional dismissal for lack of standing and affirmed the judgment as modified. View "Arcidiacono v Whitehorn" on Justia Law

Indiana amended its laws in 2022 to prohibit and criminalize the use of telehealth and telemedicine for abortions, requiring that abortion-inducing drugs be dispensed and consumed in person by a physician in a hospital or qualified surgical center. The Satanic Temple, a Massachusetts-based religious nonprofit, operates a telehealth abortion clinic serving only patients in New Mexico but seeks to extend these services to its Indiana members. It does not run, nor intends to operate, an in-person abortion clinic in Indiana or maintain ties to Indiana hospitals or surgical centers. The Temple filed suit against the Indiana Attorney General and Marion County Prosecutor, seeking to enjoin enforcement of the criminal statute (§ 16-34-2-7(a)) and to obtain declaratory relief under Indiana’s Religious Freedom Restoration Act.The United States District Court for the Southern District of Indiana reviewed the case and granted the defendants’ motion to dismiss for lack of standing. The court found that the Satanic Temple failed to identify any specific member who suffered an injury from the challenged law, thus lacking associational standing. It also held that the Temple itself lacked standing, as it could not show an injury in fact and could not demonstrate that favorable relief would redress its alleged harms due to other Indiana laws independently barring its intended conduct.On appeal, the United States Court of Appeals for the Seventh Circuit affirmed the district court’s dismissal. The Seventh Circuit held that the Satanic Temple lacked both associational and individual standing. The Temple failed to identify a specific injured member and relied only on statistical probabilities and generalized claims of stigmatic injury, which were insufficient. Additionally, the Temple did not present concrete plans to violate the law, and even if § 16-34-2-7(a) were enjoined, other statutes would independently prevent its telehealth abortion services in Indiana. Thus, the Seventh Circuit affirmed the dismissal for lack of subject matter jurisdiction. View "Satanic Temple, Inc. v Rokita" on Justia Law

A pharmaceutical company participated in a federal program that required it to report the average price it received for drugs sold to wholesalers, which in turn affected the rebates it owed the government under Medicaid. From 2005 to 2017, the company sold drugs to wholesalers at an initial price, but if it raised the price before the wholesaler resold the drugs to pharmacies, it required the wholesaler to pay the difference. The company reported only the initial price as the average manufacturer price (AMP), excluding the subsequent price increases, which resulted in lower reported AMPs and thus lower rebate payments to the government. The company justified this exclusion by categorizing the price increases as part of a bona fide service fee to wholesalers, even though the increased value was ultimately paid by pharmacies.The United States District Court for the Northern District of Illinois reviewed the case after a qui tam action was filed by a relator, who alleged that the company’s AMP calculations were false and violated the False Claims Act (FCA). The district court granted summary judgment to the relator on the issue of falsity, finding the AMP calculations and related certifications were factually and legally false. The issues of scienter (knowledge) and materiality were tried before a jury, which found in favor of the relator and awarded substantial damages. The company appealed, challenging the findings on falsity, scienter, and materiality, while the relator cross-appealed on the calculation of the number of FCA violations.The United States Court of Appeals for the Seventh Circuit affirmed the district court’s judgment. The court held that the company’s exclusion of price increase values from AMP was unreasonable and contradicted the plain language and purpose of the relevant statutes, regulations, and agreements. The court also held that the jury reasonably found the company acted knowingly and that the false AMPs were material to the government’s payment decisions. The court rejected the cross-appeal on damages, finding the issue was not properly preserved for appeal. View "Streck v Eli Lilly and Company" on Justia Law

A former sales representative for a pharmaceutical company alleged that the company engaged in an aggressive campaign to market one of its drugs, Vraylar, for uses not approved by the Food and Drug Administration (FDA), specifically for substance abuse and major depressive disorder (MDD). The representative, who was responsible for promoting the drug to medical providers, claimed that the company trained its sales force to encourage off-label prescriptions and incentivized providers to prescribe Vraylar for these unapproved uses. He further asserted that he faced adverse employment actions, such as loss of promotion and increased workload, after raising concerns internally about the legality and compliance of these marketing practices.After the representative filed a qui tam action under the False Claims Act (FCA) in the United States District Court for the Northern District of Indiana, the government declined to intervene. The plaintiff then amended his complaint, dropping his direct fraud claim and proceeding solely on a theory of retaliation under 31 U.S.C. §3730(h). The district court dismissed the complaint with prejudice, finding that the plaintiff’s internal complaints to the company focused on regulatory noncompliance rather than fraud against the government, and thus did not put the employer on notice of protected activity under the FCA.The United States Court of Appeals for the Seventh Circuit reviewed the case de novo. The court held that, to state a claim for FCA retaliation, an employee must plausibly allege that the employer was on notice that the employee was attempting to prevent fraud against the government, not merely regulatory violations. Because the plaintiff’s communications only referenced regulatory and policy concerns, and did not suggest government fraud, the court found the notice requirement unmet. The Seventh Circuit affirmed the district court’s dismissal and found no abuse of discretion in denying leave to amend. View "Lewis v AbbVie Inc." on Justia Law

Lauren Richwine, through her business Death Done Differently, provides services as a “death doula,” assisting clients and their families with end-of-life planning, emotional support, and guidance on funeral arrangements. Richwine is not a licensed funeral director, and her website notes that her services are performed under the supervision of a licensed funeral director. In 2021, a complaint was filed with the Indiana Public Licensing Agency alleging that Richwine was practicing funeral services without a license. Following an investigation, the Indiana Attorney General sought a cease-and-desist order from the State Board of Funeral and Cemetery Service, which was approved. The order prohibited Richwine and her company from advertising or providing certain services related to funeral planning, community death care, and support with funeral homes.After the cease-and-desist order was issued, Richwine and Death Done Differently filed suit in the United States District Court for the Northern District of Indiana, Fort Wayne Division, arguing that enforcement of the Indiana statute against them would violate their First Amendment rights. The district court granted a preliminary injunction, enjoining enforcement of the statute against the plaintiffs. The defendants appealed, arguing that the plaintiffs had waived their rights by signing the cease-and-desist agreement and that federal abstention doctrine barred the suit. The district court rejected these arguments, finding no clear and unmistakable waiver of federal rights and no ongoing state proceeding that would justify abstention.The United States Court of Appeals for the Seventh Circuit reviewed the district court’s decision. The Seventh Circuit held that the Indiana statute, as applied to Richwine and Death Done Differently, burdens substantially more speech than necessary to further the state’s interests in public health, safety, and consumer protection. The court found that the statute’s restrictions on the plaintiffs’ speech and advertising likely violate the First Amendment. The Seventh Circuit affirmed the district court’s preliminary injunction and remanded for further proceedings. View "Richwine v. Matuszak" on Justia Law

Cordell Sanders, an inmate at Pontiac Correctional Center, suffered from serious mental health issues and spent over eight years in segregation housing due to multiple disciplinary infractions. He received mental health services from various providers employed by Wexford Health Sources, the prison’s contracted healthcare provider. Sanders alleged that these providers were deliberately indifferent to his mental health needs, offering inadequate treatment and failing to advocate for him during disciplinary proceedings. He also claimed that Wexford maintained a widespread practice of denying mental health care until inmates were in crisis and failed to implement policies guiding provider participation in disciplinary hearings.The United States District Court for the Central District of Illinois granted summary judgment in favor of all defendants. The court found that Sanders had not presented sufficient evidence to support his claims of deliberate indifference or to establish a Monell claim against Wexford. Sanders appealed this decision, arguing that the providers’ treatment was ineffective and that Wexford’s practices and lack of policy amounted to constitutional violations.The United States Court of Appeals for the Seventh Circuit reviewed the district court’s summary judgment order de novo. The appellate court held that Sanders failed to provide evidence from which a reasonable jury could find that the providers’ conduct constituted deliberate indifference under the Eighth Amendment. The court emphasized the lack of expert testimony regarding the effectiveness of Sanders’s treatment and found no substantial departure from professional standards. Regarding Wexford, the court concluded that Sanders did not demonstrate a widespread practice of denying care or that the absence of a more detailed policy caused constitutional harm. The Seventh Circuit affirmed the district court’s grant of summary judgment for all defendants. View "Sanders v. Moss" on Justia Law