Mealey's Health Care / ACA

  • February 20, 2018

    Judge Rejects Indiana’s Challenge To ACA Employer Mandate

    INDIANAPOLIS — Res judicata and U.S. Supreme Court precedent require judgment in favor of the federal government in a state’s and school district’s attack on the Patient Protection and Affordable Care Act (ACA) employer mandate, a federal judge in Indiana held Feb. 14 (Indiana, et al. v. Internal Revenue Service, et al., NO. 13-1612, S.D. Ind., 2018 U.S. Dist. LEXIS 24863).

  • February 20, 2018

    Aetna Says California Investigation Based On ‘Out Of Context’ Comments

    SACRAMENTO, Calif. — Lawyers took deposition comments from a medical claims reviewer out of context to create trial and media leverage, Aetna Inc. says in a Feb. 14 response to an announcement that California would investigate the insurer’s claims processing.

  • February 15, 2018

    Judge Keeps Insurance Spat Alive, Rejects Insurer’s ‘Elastic’ Reading Of Policy

    OKLAHOMA CITY — An insurer’s defense of a decision excluding coverage for applied behavior analysis (ABA) requires a “strained” reading of policy’s exclusions “so elastic” it could cover nearly any illness, while the company’s prior approval of a child’s speech therapy estopped it from later arbitrarily deciding that Oklahoma law did not mandate the coverage, a federal judge in Oklahoma held Feb. 12 (A.B., et al. v. Health Care Service Corp., et al., No. 14-990, W.D. Okla., 2018 U.S. Dist. LEXIS 22537).

  • February 14, 2018

    Oregon Democrats Pass Measure Seeking Constitutional Right To Health Care

    SALEM, Ore. — The Oregon House of Representatives on Feb. 13 approved a measure that would give the state’s voters the ability to amend the state constitution to include health care as a right.

  • February 14, 2018

    Federal Judge Stays Case During Appeal Of ACA Birth-Control Exemption Rules

    HARRISBURG, Pa. — A Pennsylvania federal judge on Feb. 9 stayed the state’s case challenging newly issued Patient Protection and Affordable Care Act (ACA) contraceptive mandate rules while the federal government appeals her issuance of a preliminary injunction (Commonwealth of Pennsylvania, et al. v. Donald J. Trump, et al., No. 17-4540, E.D. Pa.).

  • February 14, 2018

    Reviewer’s Deposition Testimony Sparks California Investigation Into Aetna Claims Process

    SACRAMENTO, Calif. — California launched an investigation into Aetna Inc.’s health insurance claims approval and prior authorization process after learning that one of the company’s medical reviewers testified in a deposition that he was trained not to review medical records but instead rely on what was provided to him by the company’s nurses, the state’s insurance commissioner announced in a Feb. 12 statement.

  • February 13, 2018

    3rd Circuit Vacates ACA Shared Responsibility Judgment, Remands

    PHILADELPHIA — The Patient Protection and Affordable Care Act (ACA)’s shared responsibility payment (SRP) is a penalty, and a couple challenging it used the proper Internal Revenue Service form in their effort to recover the payment, a Third Circuit U.S. Court of Appeals panel held Feb. 9 in vacating a ruling finding a lack of jurisdiction (Robert Cash, et al. v. United States of America, No. 17-1441, 3rd Cir., 2018 U.S. App. LEXIS 3111).

  • February 12, 2018

    6th Circuit Rejects Insurer’s Liquidator’s Reverse-Preemption Argument In Arbitration Suit

    CINCINNATI — In a dispute between an insolvent insurer’s liquidator and an administrative services provider over whether work for the insurer should be arbitrated, the Sixth Circuit U.S. Court of Appeals held Feb. 9 that the McCarran-Ferguson Act does not reverse-preempt the enforcement of a contractual arbitration clause under the Federal Arbitration Act (FAA) (Nancy G. Atkins, liquidator of Kentucky Health Cooperative Inc. v. CGI Technologies and Solutions Inc., No. 17-5506, 6th Cir., 2018 U.S. App. LEXIS 3130).

  • February 9, 2018

    ERISA Health Insurer, Florida Service Provider Ask Court To Dismiss Suit

    TAMPA, Fla. — An insurer and an out-of-network health care provider engaged in a battle over what constitutes the proper reimbursement rate under Florida law and whether those claims implicate ERISA asked a federal court to dismiss the case with prejudice on Feb. 7 (Premier Inpatient Partners LLC, et al. v. Blue Cross and Blue Shield of Florida Inc., Nos. 17-3000, 17-3001, M.D. Fla.).

  • February 9, 2018

    Drug Treatment Providers Say Allegations Support Contract, Health, UCL Claims

    LOS ANGELES — Substance abuse “coverage gaps” require an insurer to pay 100 percent of billed charges under California law, a trio of providers told a federal court in California on Feb. 5 (Casa Bella Recovery International Inc. v. Humana Inc., et al., Nos. 17-1801, 17-1804, 17-1807, C.D. Calif.).

  • February 8, 2018

    Idaho Poised To Allow Non-ACA-Compliant Health Plans

    DES MOINES, Idaho — Idaho insurers already selling Patient Protection and Affordable Care Act (ACA)-compliant plans on the state’s exchange could begin offering plans that do not comply with the law’s provisions governing pre-existing conditions, price caps and lifetime benefits, under a bulletin the state’s insurance industry issued Jan. 24.

  • February 8, 2018

    COMMENTARY: When Strategies Go Awry: Part 4 In A Series On Cognitive Biases And Their Impact

    By Laura A. Frase

  • February 7, 2018

    Judge Takes 2nd Look At ACA Essential Benefits Ruling, Again Denies Judgment

    MILWAUKEE — Congress assigned the job of defining the Patient Protection and Affordable Care Act’s (ACA) “essential health benefit” language to the U.S. Department of Health and Human Services (HHS), and nothing necessitated including dialysis treatments prior to 2014, a federal judge in Wisconsin held in once again denying summary judgment Feb. 5 (Fresenius Medical Care Midwest Dialysis LLC, et al. v. Humana Insurance Co., et al., No. 16-711, E.D. Wis., 2018 U.S. Dist. LEXIS 18409).

  • February 7, 2018

    Spine Center’s ERISA Claims Survive Dismissal, Federal Judge Says

    TRENTON, N.J. — A medical provider has a valid assignment of Employee Retirement Income Security Act benefits, and it is too early in its litigation against an insurer to determine if its claims seek duplicative recovery, a federal judge in New Jersey held Feb. 2 (University Spine Center v. Anthem Blue Cross Life & Health Ins. Co., No. 17-8711, D. N.J., 2018 U.S. Dist. LEXIS 17537).

  • February 6, 2018

    North Dakota ACA Medicaid Audit Opinion Timely, State’s Top Court Says

    BISMARCK, N.D. — The 75-day window imposed on the North Dakota Department of Health and Human Services in a Patient Protection and Affordable Care Act (ACA) audit case is directory, not mandatory, the North Dakota Supreme Court held Feb. 1 (Sanford HealthCare Accessories v. North Dakota Department of Human Services, et al., No. 2018 ND 35, N.D. Sup., 2018 N.D. LEXIS 36).

  • February 5, 2018

    Judge: California Law Bars Discretionary Clause In ERISA Health Insurance Case

    SAN FRANCISCO — De novo review applies to an insurer’s denial of coverage for mental health treatments under the Employee Retirement Income Security Act because the California Insurance Code treats health insurance as a form of disability insurance and bars discretionary clauses, a federal judge in the state held Jan. 31 (Mahlon D., et al. v. Cigna Health and Life Insurance Co., No. 16-7230, N.D. Calif., 2018 U.S. Dist. LEXIS 16332).

  • February 5, 2018

    Judge Vacates Deadlines For ACA Rule-Making In Employee Wellness Program Case

    WASHINGTON, D.C. — A federal judge in the District of Columbia on Jan. 18 vacated portions of a ruling imposing deadlines on a federal agency’s rule-making process related to a Patient Protection and Affordable Care Act (ACA) rule governing employee wellness program disclosures and discounts, but the judge said he would vacate the rules on Jan. 1, 2019 (AARP v. United States Equal Employment Opportunity Commission, No. 16-2113, D. D.C.).

  • February 5, 2018

    Insurer Sitting On 100,000 Unprocessed Claims Worth $100M, Providers Say

    MIAMI — A health insurer’s “dilatory and obstructionist tactics” resulted in 100,000 unprocessed claims worth $100 million to substance abuse centers and their laboratory, the providers tell a federal judge in Florida in a Jan. 18 brief (National Laboratories LLC, et al. v. UnitedHealth Group Inc., et al., No. 17-81178, S.D. Fla.).

  • February 2, 2018

    Judge Finds Vague ERISA Claims Don’t Put Insurer On Notice Of Claims

    ATLANTA — A hospital’s general references to Employee Retirement Income Security Act plans is not sufficiently specific to put a health care insurer on notice of the claims against it, and requiring at least a summary of the number of plans in question would not hamper judicial efficiency, a federal judge in Georgia held Jan. 30 in dismissing the case (Polk Medical Center Inc. v. Blue Cross and Blue Shield of Georgia Inc., et al., No. 17-3692, N.D. Ga., 2018 U.S. Dist. LEXIS 14461).

  • February 2, 2018

    Judge Rejects Defunct ACA Insurer’s Risk-Adjustment Program Challenge

    BOSTON — A now-defunct Patient Protection and Affordable Care Act (ACA) health insurer’s complaints about the law’s risk-adjustment program seek impermissible retroactive rule making or fail to allege that the original rules were arbitrary or capricious, a federal judge in Massachusetts held Jan. 30 (Minuteman Health Inc. v. United States Department of Health and Human Services, et al., No. 16-11570, D. Mass., 2018 U.S. Dist. LEXIS 14727).