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).
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.
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).
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.
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.).
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.
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).
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).
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.).
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.).
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.
By Laura A. Frase
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).
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).
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).
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).
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.).
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.).
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).
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).