Mealey's Health Care / ACA : Mealey's : Legal News & Analysis

Mealey's Health Care / ACA

January 30, 2023
Timeliness, Record Issues Doom Residential Treatment Case, Judge Says

SEATTLE — An insurer’s explanation that an insured’s symptoms were not acute enough to qualify for residential treatments meets the standard adequately explaining the grounds for its decision, and nothing else in the record was ignored or misrepresented, a federal judge in Washington said.
January 30, 2023
Insurer: Provider’s Suit An Attempt At Avoiding Health Care Cost Laws

LOS ANGELES — A medical provider’s efforts at additional reimbursement for post-stabilization care are simply an effort to avoid precedent and government regulations capping the price for such care in government-funded health care systems, a California Medi-Cal insurer tells a California appeals court.
January 30, 2023
Provider Derides Insurer’s ‘Hide The Ball Scheme’ As Breach Of Contract

SAN DIEGO — A substance abuse treatment provider tells a California appeals court it provided life-saving treatments on an insurer’s promise of compensation, only to be told after the treatments that the insurer believed that it had no contractual obligation to make payments, a “hide the ball scheme” that would be unacceptable in any other setting and permits breach of contract and California unfair competition law (UCL) claims.
January 27, 2023
Texas Court Denies Petition After Emergency Care Law Ruling

AUSTIN, Texas — In the wake of its ruling finding no private right of action in the state’s emergency care laws, the Texas Supreme Court on Jan. 27 denied a petition in a third and related case brought by hospitals, according to the court’s docket.
January 26, 2023
Managed Care Group Urges Review Of Medicaid Private Right Of Action Ruling

WASHINGTON, D.C. — A divided Seventh Circuit U.S. Court of Appeals turned what should have been a routine compensation dispute between health care providers and Medicaid managed care payers on its head by creating a “novel and unjustified private right of action” within federal law, a trade organization argues in support of a petition for review before the U.S. Supreme Court.
January 25, 2023
Bad Faith Claim Survives, But Oklahoma Insurance Law Can’t Gird Negligence Claim

OKLAHOMA CITY — Allegations that an insurer provided shifting explanations for denying coverage for proton beam therapy (PBT) keep a bad faith claim alive, but an Oklahoma law precluding insurers from heightening the standard for such treatment cannot form the basis for a negligence per se claim, a federal judge in Oklahoma said in partly granting a motion to dismiss.
January 25, 2023
Judge Finds Errors And Contradictions In Wilderness Treatment Coverage Case

SEATTLE — An insurer’s and plan’s erroneous assessments of which state agency enjoyed proper licensing powers and their denial of coverage for wilderness treatment in direct contradiction of plan language providing for coverage at licensed treatment facilities constitutes an abuse of discretion, a federal judge in Washington said in granting plaintiffs’ motion for summary judgment and ordering the insurer and plan to cover the cost of the treatments.
January 20, 2023
Ghost Rates Among Surprise Billing Rule Flaws, Providers Say

DALLAS — “Ghost rates” and the use of potentially enormous geographic regions to determine contracted rates haunt an agency rule and combined with delayed payment determinations are directly contradictory to the clear language of the No Surprises Act (NSA), which puts providers on unequal footing and renders the rule both unfair and unlawful, a group of medical providers tell a Texas federal judge.
January 19, 2023
Insurer Escapes Claims It Underpaid For Care In Network Savings Program

MIAMI — A medical provider’s contract is with a network savings program, not a participating insurer, and calls verifying insurance coverage do not evidence an agreement to make specific payments for five surgeries, a federal judge in Florida said.
January 19, 2023
Judge Slices Claims From Out-Of-Network Provider’s Compensation Case

NEW YORK — Claims against an insurer stemming from the alleged failure to pay an out-of-network provider’s contracted rates all fail, but breach of contract claims against a preferred provider organization for allegedly failing to enforce its agreement may proceed, a federal judge in New York said in ruling on motions to dismiss.
January 18, 2023
Hearing Scheduled For Remaining Defendants In Insolvent Health Plan Dispute

CHICAGO — An Illinois federal magistrate judge issued a minute docket entry scheduling an in-person status hearing for the remaining parties in a breach of duty of care suit filed by an independent fiduciary against insurance brokers in connection with the sale of an insolvent health plan.
January 17, 2023
Texas High Court: No Private Right Of Action In Emergency Care Statutes

AUSTIN, Texas — The high bar for implied rights of action and the regulatory power of the insurance department mean that Texas emergency care statutes lack a private right of action, dooming providers’ suits alleging that insurers undercompensated them, the Texas Supreme Court said Jan. 13.
January 17, 2023
Medical Provider Objects To Discovery In Insurance Pay Dispute

CLEVELAND — A special master ordered discovery production “wholly irrelevant” to the question of whether an insurer reasonably compensated a provider for emergency services, a plaintiff argues in a federal court in Ohio.
January 13, 2023
ERISA, ACA Discrimination Claims Fail In Clinical Coverage Case

MIAMI — An insurer’s belated decision to cover a clinical trial treatment moots Employee Retirement Income Security Act claims, and the insured has not shown discrimination based solely on disability as required for her Patient Protection and Affordable Care Act (ACA) Section 1557 claim, a federal judge in Florida said Jan. 12.
January 13, 2023
Some Of Surgery Provider’s Claims In Insurance Payment Dispute Dismissed

NEW YORK — Inclusion of a discount plan’s logo on insurance cards and other marketing material are not evidence of a promise to pay and do not form a contract, nor does evidence that insurers made payment at certain rates in other instances, a federal judge in New York said in dismissing some claims without leave to amend.
January 11, 2023
4th Circuit Dismisses Disability Claimant’s Appeal Based On Parties’ Agreement

RICHMOND, Va. — The Fourth Circuit U.S. Court of Appeal dismissed a disability claimant’s appeal of a district court’s ruling in favor of a disability insurer after the claimant notified the appeals court that the parties reached an agreement over the termination of her long-term disability (LTD) benefits claim.
January 10, 2023
ACA Preventive Mandate Objectors Lay Out Remedy Options

DALLAS — Entities that are unable to purchase health insurance to their liking as a result of the Affordable Care Act’s contraceptive mandate are injured, and a universal remedy of vacatur of preventive care decisions is appropriate even if that relief was not specifically requested, plaintiffs tell a Texas federal judge in supplemental summary judgment briefing on remedies and standing.
January 10, 2023
Catholic-Operated Hospital, Parent Company Both Liable In ACA Case, Judge Says

BALTIMORE — A Catholic-operated hospital and its owner can both be liable in a transgender man’s Patient Protection and Affordable Care Act (ACA) discrimination case regardless of which party received federal funding and, having successfully argued that they are state actors immune to suit, cannot now contend to be private businesses entitled to a Religious Freedom Restoration Act (RFRA) defense, a federal judge in Maryland said in granting summary judgment to the patient on a discrimination claim.
January 05, 2023
Provider: Court Erred In Reinstating Out-Of-Network Arbitration Award

FORT WORTH, Texas — An appeals court ignored that the Legislature took pains to exclude Medicare rates from the out-of-network care arbitration rate in reinstating an award despite a lack of necessary evidence, a medical provider told the Texas Supreme Court in a petition for review.
January 05, 2023
Insurer: Individualized Issues Precluded Class In ACA Transgender Case

TACOMA, Wash. — Determining whether gender-affirming care was medically necessary under specific plans requires individualized inquiry, amounts to an attempt at individual monetary reward and would not provide complete relief to the class, precluding certification, an insurer argues in a reply in support of a petition for permission to appeal.
January 03, 2023
4th Circuit Finds Deliberate Indifference, Revives ACA, RA Claims

RICHMOND, Va. — A deaf man who repeatedly requested an in-person interpreter and was provided with only faulty remote interpreter equipment during a three-day hospital stay successfully demonstrated deliberate indifference, a Fourth Circuit U.S. Court of Appeals panel said in reviving Rehabilitation Act and Patient Protection and Affordable Care Act discrimination claims.
January 03, 2023
Judge: ACA ‘Adult Child’ Coverage Doesn’t Impose Liability On Policyholder

FREEHOLD, N.J. — The Patient Protection and Affordable Care Act’s extension of insurance policies to adult children did not create liability on the part of the policyholder for unreimbursed medical care, a New Jersey superior court judge said in denying summary judgment on what he said he believed were two issues of first impression.
December 22, 2022
No Evidence Provider, Insurer Agreed To Compensation, Judge Says

TRENTON, N.J. — A medical provider fails to introduce any evidence that insurance authorization calls included the types of specific payment terms required for contract and promissory estoppel claims, a federal judge in New Jersey said.
December 22, 2022
Summary Judgment Granted On Exaction Claim In ACA Transitional Reinsurance Row

WASHINGTON, D.C. — A U.S. Federal Claims Court judge on Dec. 21 granted an opt-in class summary judgment on a claim that the government illegally exacted certain contributions from self-administered, self-insured employee health and welfare benefit plans under the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA).
December 22, 2022
Fee-Forgiveness Plan Warranted Insurer’s Denial Of Claims, Judge Says

SANTA ANA, Calif. — An insurer did not abuse its discretion when it stopped making payments to a substance abuse treatment center after an investigation produced evidence that it was engaged in fee forgiveness, a federal judge in California said in granting summary judgment after remand from the Ninth Circuit U.S. Court of Appeals.