Mealey's Health Care / ACA

  • October 02, 2023

    Big TPA Seeks Dismissal Of Backward-Looking Claims In DOL’s ERISA Case

    MADISON, Wis. — Arguing in part that Acting U.S. Department of Labor Secretary Julie A. Su “invokes two inapposite causes of action,” the third-party administrator (TPA) of hundreds of self-funded employee welfare benefit plans in a Sept. 29 motion asked a Wisconsin federal court to dismiss backward-looking claims in the suit over hospital emergency services claims and urinary drug screening claims.

  • October 02, 2023

    Judge Vacates Notice Allowing Copayment Accumulator Drug Program

    WASHINGTON, D.C. — A federal judge in the District of Columbia on Sept. 29 vacated a notice allowing insurers to exclude manufacturers’ copay assistance programs from deductible and out-of-pocket calculations, finding that the notice conflicted with the Patient Protection and Affordable Care Act’s (ACA) definition of cost sharing and that remand was necessary to correct the defects.

  • October 02, 2023

    Supreme Court Won’t Review Ruling Equating Health Care ‘Benefit’ With Bill

    NEW ORLEANS — The U.S. Supreme Cout on Oct. 2 denied a petition for certiorari in which a woman claimed that by defining health care “benefits” as requiring an unpaid bill the court below improperly doomed her case seeking coverage for medically necessary proton beam therapy (PBT) and ignored that many insureds who are denied coverage lack the resources required to pay out of pocket.

  • October 02, 2023

    Rehearing Opposed In ERISA Case Where 10th Circuit Ordered Claim Reprocessing

    DENVER —Contending in part that an “extreme argument” against remand for claim reprocessing was raised too late to be considered and “has no legal or logical basis,” United Health Insurance Co. and related entities urge the 10th Circuit U.S. Court of Appeals not to rehear a case involving residential treatment claims for mental health and substance use.

  • September 29, 2023

    Judge: Vague Health Plan References Can’t Save Bariatric Surgery Case

    LOS ANGELES — Allegations that bariatric surgery providers obtained assignment of rights suffice for standing under the Employee Retirement Income Security Act, but the failure to identify the plans or terms in question require dismissal, a federal judge in California said while granting leave to amend.

  • September 28, 2023

    Parties Stipulate To Dismissal Of ERISA Drug Prices Suit Against Insurer

    NEW HAVEN, Conn. — Parties in an Employee Retirement Income Security Act suit over allegations that Cigna Health and Life Insurance Co. “had no right under its prescription drug plans to charge ‘spread’ and then ‘claw back’ the member copayment or deductible ‘overpayments’” have filed a joint stipulation in Connecticut federal court to dismissal with prejudice.

  • September 27, 2023

    Provider Urges Review In Connecticut Surprise Billing Certified Questions Case

    HARTFORD, Conn. — A medical provider told the Connecticut Supreme Court that certified questions ask the court only to resolve an area of unsettled law involving the interplay of the state’s Surprise Billing Law and insurance statutes and do not seek an advisory opinion or ask the justice to act as a trial court.

  • September 27, 2023

    Air Ambulance:  Insurer Must Make No Surprises Act Arbitration Payments

    PHOENIX — An insurer refuses to make payments on 21 claims for which it is liable under the No Surprises Act independent dispute resolution process, even where the arbitrator selected the insurer’s own submission, an air ambulance company alleges in a complaint filed in an Arizona federal court.

  • September 27, 2023

    Provider’s Distinct Injuries Permit 2nd Suit Against Insurer, Court Says

    LOS ANGELES — Because a medical provider’s second lawsuit seeking compensation from an insurer involves different claims and injuries arising from distinct time periods, it does not constitute impermissible claim splitting, and a trial court erred in imposing sanctions for filing it, a California appeals court said Sept. 26 in reviving California unfair competition law (UCL) and other causes of action.

  • September 26, 2023

    California Court Won’t Publish Opinion Reviving Provider’s Suit Against School

    FRESNO, Calif. — A California appeals court on Sept. 25 declined to publish an opinion finding that questions about whether a school health plan is its own legal entity or a public one keep alive claims that it underpaid for emergency air transport and that the school district’s argument about its discretionary power ignores that the contract is with its insured and not the third-party provider.

  • September 25, 2023

    Mental Health Insurer Never Meaningfully Engaged With Insureds, Judge Says

    SALT LAKE CITY — An insurer’s apparent failure to recognize that the program for which it originally approved treatment included both residential and transitional levels, its “cryptic denials” and its dismissal of the opinions of treating physicians evidence a failure to participate in meaningful dialogue with the insureds, a federal judge in Utah said in granting summary judgment on both Employee Retirement Income Security Act (ERISA) and Parity Act claims.

  • September 25, 2023

    AI Company:  Health Care Startup Stole Sci-Fi-Based Trademark

    NEW YORK — A startup health care company that uses artificial intelligence to tailor treatments skipped the hard part of earning its own reputation and instead simply stole an existing and completely unique name and established trademark in an effort to confuse consumers, an artificial intelligence technology company tells a New York federal court.

  • September 22, 2023

    COVID-19 Test Provider Denied Reimbursement From Insurer Requests Rehearing En Banc

    SAN FRANCISCO — A COVID-19 test provider petitioned the Ninth Circuit U.S. Court of Appeals for rehearing en banc after a panel of the court affirmed the judgment of a California federal court dismissing five complaints brought by the provider seeking reimbursement from an insurer for COVID testing services, asserting that the panel erred in determining that the Coronavirus Aid, Relief and Economic Security (CARES) Act does not provide an implied private right of action to diagnostic testing providers.

  • September 22, 2023

    AI Health Care Company Seeks To Defend Common-Law Trademark

    SAN FRANCISCO — A company’s registration of an already-in-use trademark and its intention to use the mark going forward sow confusion and tie the name’s existing goodwill to a disreputable entrepreneur in violation of the California unfair competition law (UCL), among others, a company hoping to use artificial intelligence in the medical education space says in a complaint.

  • September 21, 2023

    Amici Praise Pricing, Economics Behind Drug Price Negotiation Law

    WASHINGTON, D.C. — A law allowing federal health programs to negotiate drug prices represents a step toward affordability in a market otherwise clouded by complicated pricing signals, two AARP entities and a group of scholars and economists told a federal judge in the District of Columbia in amicus briefs.

  • September 21, 2023

    Full 4th Circuit Hears Arguments On Plan’s Gender Surgery Exclusion

    RICHMOND, Va. — The en banc Fourth Circuit U.S. Court of Appeals heard oral argument Sept. 21 over whether North Carolina’s health plan’s exclusion on gender transition procedures necessarily discriminates on the basis of sex of the patient or simply imposes an exclusion on certain treatments like any other designed to save it and the state money.

  • September 20, 2023

    Some Claims Proceed In Health Care Repricing Scheme Case Against UnitedHealth

    NEW YORK — Claims that various UnitedHealth Group Inc. entities collected billions of dollars in fees under a repricing scheme providing Employee Retirement Income Security Act plans with largely illusory savings suffice to overcome a motion to dismiss, a federal judge in New York said Sept. 19 in partly denying the motion.

  • September 18, 2023

    No Cure For Defective ACA Preventive Care Mandate, 5th Circuit Challengers Say

    NEW ORLEANS — The government cannot cure defects in an independent governmental body’s actions by simply by reappointing its group’s members, Patient Protection and Affordable Care Act (ACA) preventive care mandate challengers told the Fifth Circuit U.S. Court of Appeals while seven days later, a pair of amicus briefs warned about the potential risks of an unaccountable regulatory state.

  • September 18, 2023

    Government Urges High Court To Uphold ‘Bedrock Principle’ Of Chevron Deference

    WASHINGTON, D.C. — The U.S. secretary of Commerce, two National Oceanic and Atmospheric Administration (NOAA) officials and the National Marine Fisheries Service (NMFS) (collectively, the government) urge the U.S. Supreme Court in a Sept. 15 brief to not overrule the doctrine of Chevron deference in a challenge to fishery regulations that were upheld by the District of Columbia Circuit U.S. Court of Appeals, writing that doing so could “cause disruption” to complex federal regulatory schemes.

  • September 18, 2023

    Insurer Isn’t Honoring No Surprises Act Arbitration Payment Duty, Provider Says

    OAKLAND, N.J. — Despite a No Surprises Act (NSA) arbitration award against it, a 30-day payment mandate and repeated attempts to collect on that debt, an insurer has yet to make any payment, a provider says in a complaint filed in New Jersey federal court.

  • September 15, 2023

    California High Court Won’t Review UCL Mental Health Coverage Ruling

    SACRAMENTO, Calif. — The California Supreme Court denied a petition for review after a lower court published its opinion finding that two insureds adequately alleged standing under the California unfair competition law (UCL) and that the way the insurer handles mental health care results in shortages of that care.

  • September 15, 2023

    Texas HMO Wants Rehearing Over Question On Immunity From Provider’s Suit

    HOUSTON — An appellate ruling finding that a statutorily created hospital district’s nonprofit health maintenance organization was not a unit of local government and therefore not entitled to statutory immunity glosses over complicated issues and ignores Texas Supreme Court precedent and the very purpose for such organizations, an insurer told a Texas appeals court in seeking rehearing and rehearing en banc on Sept. 14.

  • September 15, 2023

    Certified Class: Insurer Used Single Experimental Treatment For Blanket Denials

    UTICA, N.Y. — A federal judge in New York on Sept. 14 certified a class of insureds who claim that United Behavioral Health violated the Employee Retirement Income Security Act by issuing blanket denials for residential treatments when it considered even a single aspect of the facility’s treatment experimental.

  • September 14, 2023

    Enforceability Of ACA, Parity Act Argued Before Washington High Court

    TACOMA, Wash. — A family denied coverage for their daughter’s residential treatments told the Washington Supreme Court during Sept. 14 oral arguments that a health plan explicitly incorporated federal and state parity law and that the Patient Protection and Affordable Care Act (ACA) can form a breach of contract claim; but in response, the insurer told the court that regulatory agencies are the proper venue to correct insurer behavior and that not every claim denial is an act of bad faith.

  • September 14, 2023

    Parties In ERISA Case With Large Class Denied Permission For Interlocutory Appeal

    RICHMOND, Va. — Bids by a health insurer and subcontractor for permission to file interlocutory appeals to the Fourth Circuit U.S. Court of Appeals over a class certification order in a suit concerning an alleged cost-shifting scheme were denied without explanation in a Sept. 13 order.

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