Mealey's Health Care / ACA

  • June 17, 2024

    Renal Care Provider, Insurers Debate Proper Standard In Health Care Payment Spat

    ATLANTA — Two insurers defended summary judgment in their favor, saying in a pair of appellee briefs filed in a Georgia appellate court that coverage verification calls and explanation of benefits forms cannot form the basis of misrepresentation claims.

  • June 14, 2024

    California Court Finds Provider’s Calls To Insurer Didn’t Create Contract

    LOS ANGELES — Verification calls and forms produced in conjunction with the contacts between an insurer and medical provider did not create an oral contract to pay rates outside the health plan’s provisions, a California appeals court affirmed in an unpublished opinion.

  • June 11, 2024

    9th Circuit Affirms ERISA Medical Necessity Ruling In Residential Treatment Row

    SAN FRANCISCO — Affirming summary judgment for an insured in a $182,410.14 dispute with a health insurer over reimbursement for a minor’s stay at a residential treatment facility, a Ninth Circuit U.S. Court of Appeals panel said in an unpublished memorandum disposition that the lower court didn’t abuse its discretion in considering two sets of guidelines and ruling the stay medically necessary.

  • June 11, 2024

    Texas Court: AI Surgery Tool Maker Need Not Submit To Presuit Deposition

    FORT WORTH, Texas — Even assuming counsel’s arguments during a hearing constitute evidence in a dispute involving an artificial intelligence-assisted surgery tool manufacturer, the company need not produce a corporate representative because the statements fall short of the requirements for a presuit deposition under Texas law, an appeals court in the state said, granting mandamus relief and vacating a ruling to the contrary.

  • June 11, 2024

    Battling Class, Humana Says Medicare Plaintiffs Lack Jurisdiction In AI Suit

    LOUISVILLE, Ky. — A class action claiming that health insurer Humana Inc. improperly denies Medicare claims through the use of artificial intelligence improperly stitches together state law claims while ignoring administrative exhaustion and federal rules, the company tells a federal judge in Kentucky in a motion to dismiss.

  • June 07, 2024

    Judge Denies Dismissal Of Emergency Appendectomy ERISA Claims

    LOS ANGELES — A California federal judge has denied dismissal of two core Employee Retirement Income Security Act claims by an insured who says United Healthcare Insurance Co. failed to pay for her emergency appendectomy at a network rate as provided in the summary plan description (SPD).

  • June 07, 2024

    Judge: Denial Of Wilderness Therapy Coverage Was Arbitrary, Capricious

    SALT LAKE CITY — A Utah federal judge has found that Anthem Blue Cross Life & Health Insurance Co. and a self-funded employer health plan it administers arbitrarily and capriciously denied coverage for wilderness therapy for a minor child and in lieu of a court award of benefits remanded the issue to the insurer for further consideration consistent with the judge’s decision.

  • June 06, 2024

    New York Court: Provider Entitled To Summary Judgment On Insurance Counterclaim

    BROOKLYN, N.Y. — Because language in a contract between a weight-loss surgery provider and a preferred provider network administrator is ambiguous as to what reimbursement would be for contracted services, a trial court improperly granted the administrator’s motion for summary judgment on its counterclaim, a New York appeals court said June 5 in modifying a lower court ruling.

  • June 06, 2024

    2nd Circuit Affirms That ERISA Expressly Preempts Claims In Reimbursement Row

    NEW YORK — Rejecting a medical provider’s argument that its causes of action arose from a legal duty based in presurgery phone calls with a claims administrator, a Second Circuit U.S. Court of Appeals panel issued a summary order affirming dismissal of state law claims the panel ruled are “expressly preempted” by the Employee Retirement Income Security Act.

  • June 05, 2024

    9th Circuit: ERISA Preempts State Law Claims In Case Over Alleged Fee-Forgiving

    SAN FRANCISCO — Issuing separate rulings regarding Employee Retirement Income Security Act preemption and recovery of plan benefits, a Ninth Circuit U.S. Court of Appeals panel upheld summary judgment for defendants in a health insurance dispute reportedly involving more than $8.6 million in unreimbursed claims from a substance abuse treatment center and alleged fee-forgiving.

  • May 31, 2024

    Judge Dismisses Wilderness-Outdoor Therapy Claims Under ERISA, Parity Act

    SALT LAKE CITY — A Utah federal judge has dismissed claims that a health insurance claims administrator and two employer health plans violated the Employee Retirement Income Security Act and the Parity Act by denying coverage for wilderness or outdoor therapies.

  • May 31, 2024

    Health Insurer Gets Summary Judgment Against Non-Network Autism Treatment Provider

    TOMS RIVER, N.J. — A New Jersey state court judge has granted summary judgment for a health insurer after finding that an out-of-network autism treatment provider failed to demonstrate that the insurer breached an implied contract to pay for treatment.

  • May 30, 2024

    Judge Awards $1.4M In Fees In Libby, Mont., Asbestos Claims Fraud Case

    MISSOULA, Mont. — A railway that obtained some of the relief it sought in a suit claiming that an asbestos-disease scanner in Libby, Mont., submitted false claims under a special program involving the Patient Protection and Affordable Care Act (ACA) may recover attorney fees, but the award must be reduced by 25% because its submission never ties the hours worked and associated rates to specific tasks, a federal judge in Montana said in awarding $1,423,936.58.

  • May 29, 2024

    No Gender Dysphoria Standards Exist; Ruling Creates Uncertainty, Amici Say

    PASADENA, Calif. — Amici curiae warned the Ninth Circuit U.S. Court of Appeals that there was no consensus on the proper standard of care for gender dysphoria and that a ruling below holding a third-party administrator who denied coverage liable for violating the Patient Protection and Affordable Care Act (ACA)’s discrimination provision threated to create a “problematic” situation full of uncertainty for self-insured Employee Retirement Income Security Act plans.

  • May 28, 2024

    Federal Judge Won’t Remand Hawaii’s Drug Cost Suit Against 3 Benefit Managers

    HONOLULU — A Hawaii federal judge has denied, at least for now, the state’s motion to remand its consumer prescription drug pricing lawsuit against three major pharmacy benefit managers (PBMs) on the basis of contracts the PBMs have with the federal government.

  • May 24, 2024

    D.C. Circuit Affirms Rejection Of Section 340B Enforcement Letters

    WASHINGTON, D.C. — Two drug manufacturers’ restrictions on the number of pharmacies they will service under the Section 340B drug price program of the Public Health Service Act do not run afoul of the program’s requirement that manufacturers offer drugs at or below the program’s price ceiling, a panel of the District of Columbia Circuit U.S. Court of Appeals said.

  • May 24, 2024

    No Surprises Act Permits Arbitration Suits, Air Ambulance Companies Say

    ATLANTA — The No Suprises Act (NSA) authorizes suits against arbitrators when one of the parties prevails based on misrepresentations or fraud, which occurred when an insurer produced a rigged qualified payment amount to make its offer more palatable and refused to explain how it arrived at that amount, two air ambulance providers say in an opening brief in the 11th Circuit U.S. Court of Appeals.

  • May 21, 2024

    Multiplan Is Using AI To Drive Down Out-Of-Network Reimbursements, Hospitals Say

    CHICAGO — Multiplan Inc., a company purportedly dedicated to lowering health care costs, and insurers conspire and violate the Sherman Act through the use of artificial intelligence and related tools to drive down the price of out-of-network medical care, two hospitals allege in a class action filed in Illinois federal court.

  • May 17, 2024

    Attorneys Get 25% Of $169M Exaction Class Settlement In ACA Reinsurance Row

    WASHINGTON, D.C. — A U.S. Court of Federal Claims judge on May 16 granted final approval of a class settlement under which the government will pay $169,022,397.28 to resolve part of a long-running lawsuit over the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA), also awarding 25% of that sum, net of expenses, for attorney fees.

  • May 15, 2024

    On Appeal, Parties Argue Property Interest In ACA Reinsurance Takings Case

    WASHINGTON, D.C. — Arguing primarily that the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA) “did not implicate a cognizable property interest,” the government filed an appellee brief urging the Federal Circuit U.S. Court of Appeals to affirm rulings against two self-insured group health plan trusts.

  • May 14, 2024

    AI Health Company Seeks Dismissal Of Counterclaims In Sci-Fi-Based Trademark Case

    NEW YORK — An artificial intelligence health care company named in honor of a word created by science fiction author Robert A. Heinlein asked a federal judge in New York to dismiss counterclaims against it, saying courts lack jurisdiction over trademark applications and that the lone exception to the rule does not apply.

  • May 06, 2024

    Under ERISA, Dermatologist Loses Yet Another 11th Circuit Appeal Over Assignments

    ATLANTA — In the latest of many similar Employee Retirement Income Security Act rulings concerning patients’ purported assignment of benefits, an 11th Circuit U.S. Court of Appeals panel said in an unpublished per curiam opinion that a pro se dermatologist lacks statutory standing to bring a claim for purported failure to provide insurance documents.

  • May 06, 2024

    Express Scripts Must Turn Over Some Financial Records In Blue Cross Contract Row

    DETROIT — Partly granting an insurance company’s motion to compel financial documents from its pharmacy benefit manager (PBM), a Michigan federal magistrate judge found that many of them were relevant to determining the PBM’s understanding of a 2019 agreement between the parties, including disputed rebates for medical supplies to which the insurer claims it was entitled.

  • May 03, 2024

    Amended Complaint Planned In Fiduciary Breach Case Against Health Plans’ Sponsor

    CAMDEN, N.J. — In a granted joint stipulation, parties in a high-profile putative class Employee Retirement Income Security Act fiduciary duty case over alleged “mismanagement of prescription-drug benefits” told a New Jersey federal court they agree that a pending dismissal motion will be mooted by a forthcoming amended complaint.

  • May 03, 2024

    Judge Lifts Limited Stay In Employment Group’s Suit After ACA Rule Reveal

    FARGO, N.D. — A federal judge in North Dakota lifted a limited stay after federal defendants in a lawsuit over Patient Protection and Affordable Care Act (ACA) Section 1557 filed notice that they issued a final rule governing the handling of the law’s provision prohibiting discrimination in health care.