Mealey's Health Care / ACA

  • January 13, 2021

    Judge: Parity Act Requires More Than Conclusory Statements

    SALT LAKE CITY — A woman’s conclusory statement that her insurer handles mental health claims for residential treatment differently than it does similar services in the medical and surgical setting ia not enough to successfully plead a Parity Act claim, a federal judge in Utah said Jan. 11.

  • January 12, 2021

    Insurer’s Duty Under ERISA In Coverage Denial Notices At Issue In 9th Circuit

    SAN FRANCISCO — Insurers routinely issue generalized denial notices designed to open communication channels with insureds in an effort to balance the needs for quick coverage determinations with the duty under the Employee Retirement Income Security Act to explain the decision, an insurer tells the Ninth Circuit U.S. Court of Appeals in a Dec. 28 appellant brief, urging reversal of a ruling certifying a class of insureds who claim that they were improperly denied coverage for lactation services under the Patient Protection and Affordable Care Act (ACA).

  • January 08, 2021

    Judge: Insured May Plead ERISA Claims In The Alternative, But More Clarity Needed

    FORT LAUDERDALE, Fla. — While a woman may plead both fiduciary duty and benefits claims under the Employee Retirement Income Security Act in a class action alleging an insurer improperly denied coverage for proton beam therapy, they must allege different theories of liability, and any amended action must clearly lay out which allegations apply to which defendant, a federal judge in Florida said Jan. 7.

  • January 07, 2021

    EEOC Wellness Program Rules To Be Published For Review

    WASHINGTON, D.C. — The Equal Employment Opportunity Commission on Jan. 7 announced that it has sent its notices of proposed rulemakings (NPRMs) on wellness programs under the Americans with Disabilities Act (ADA) and the Genetic Information Nondiscrimination Act (GINA) to the Federal Register for publication.

  • January 05, 2021

    Judge: Nothing Arbitrary In Insurer’s Medical Necessity Decision

    SALT LAKE CITY — The arbitrary and capricious standard applies to a decision denying coverage for residential treatments, and because there is no evidence that the insurer did not consider evidence, the record warrants granting summary judgment for the company, a federal judge in Utah said Dec. 30.

  • January 05, 2021

    Judge Won’t Stay Reprocessing Of Residential Treatment Claims In ERISA Action

    SAN FRANCISCO — A federal magistrate judge in California on Dec. 28 declined to stay reprocessing of residential treatment class action claims under the Employee Retirement Income Security Act, saying that the court already rejected many of the arguments raised by the insurer and that a business that recently saw record income is not threatened by the costs.

  • January 04, 2021

    ACA Pricing Rule Survives Hospitals’ Federal Appeals Court Challenge

    WASHINGTON, D.C. — The language and purpose of a rule formulated under the Patient Protection and Affordable Care Act (ACA) supports requiring hospitals provide more robust pricing information, a federal appeals court in the District of Columbia said Dec. 29.

  • December 23, 2020

    9th Circuit Affirms Denial In Out-Of-Network Residential Treatment Case

    SAN FRANCISCO — The evidence shows that an insurer in fact covers residential treatments for eating disorders and that it was an insured’s own insistence on private, out-of-network care that led to denial of his claim, a Ninth Circuit U.S. Court of Appeals panel said Dec. 22 (I.M., et al. v. Kaiser Foundation Health Plan Inc., No. 19-16374, 9th Cir.).

  • December 23, 2020

    Judge Says RICO, ERISA Claims Survive In Outpatient Payment Suit

    LOS ANGELES — Employee Retirement Income Security Act and Racketeer Influenced Corrupt Organizations Act claims involving alleged underpayment for intensive outpatient program services survive a motion to dismiss, a federal judge in California said Dec. 18 (LD, et al. v. United Behavioral Health, et al., No. 20-2254, N.D. Calif., 2020 U.S. Dist. LEXIS 238844).

  • December 22, 2020

    Judge:  ERISA Preempts Health Providers’ California UCL Claims

    LOS ANGELES — A class of health care providers lack standing to pursue Sherman Act and Racketeer Influenced and Corrupt Organizations Act claims against an insurer, and the Employee Retirement Income Security Act preempts their California unfair competition law and other state law claims, a federal judge in California said Dec. 18 (Pacific Recovery Solutions, et al. v. United Behavioral Health, et al., No. 20-2249, N.D. Calif., 2020 U.S. Dist. LEXIS 238854).

  • December 22, 2020

    Judge: Standing Issues Doom Michigan Emergency Physicians’ Underpayment Suit

    ANN ARBOR, Mich. — The Employee Retirement Income Security Act does not preempt emergency room providers’ state law claims seeking the balance of a billed amount, and recent legislation makes clear that the plaintiffs lack standing to pursue those same claims, a federal judge in Michigan said in dismissing the case Dec. 17 (Emergency Department Physicians PC, et al. v. United Healthcare Inc., No. 19-12052, E.D. Mich., 2020 U.S. Dist. LEXIS 237289).

  • December 18, 2020

    Judge: Provision Of Inadequate Interpreter Can’t Support ACA Discrimination Claim

    ATLANTA — A clerk entered judgment on Dec. 15 after a federal judge in Georgia said a medical provider’s procurement of an unlicensed interpreter who was a friend of an employee, resulting in a deaf woman resorting to written notes, gives rise to questions about whether effective communication occurred but that the woman’s Patient Protection and Affordable Care Act (ACA) and other claims fail because she cannot show that the hospital misrepresented the situation, failed in its duties or acted intentionally (Tracy Nix v. Advanced Urology Institute of Georgia PC, No. 18-4656, N.D. Ga.; 2020 U.S. Dist. LEXIS 234855).

  • December 18, 2020

    In Reversal, 9th Circuit Says ERISA Unpaid Benefits Claim Is Plausible

    SAN FRANCISCO — In a Dec. 17 ruling, a panel of the Ninth Circuit U.S. Court of Appeals found that a medical provider sufficiently alleged that an insurer was equitably estopped from raising an anti-assignment provision in an Employee Retirement Income Security Act-governed plan as a reason for denying a claim for benefits (Beverly Oaks Physicians Surgical Center v. Blue Cross Blue Shield of Illinois, No. 19-55820, 9th Cir., 2020 U.S. App. LEXIS 39636).

  • December 16, 2020

    Insurer, Class Battle Over Claim Reprocessing Stay In Mental Health Case

    SAN FRANCISCO — An appeal is unlikely to relieve an insurer from having to reprocess tens of thousands of claims given the number of times its arguments failed already, and any harm is unlikely and minimal, plaintiffs say in opposing a stay of remedies on Dec. 4.  But in a Dec. 11 reply, the insurer tells a federal judge in California that absent a stay, it will likely make payments it can never recover if it prevails on appeal (David Wit, et al. v. United Behavioral Health, No. 14-2346, Gary Alexander, et al. v. United Behavioral Health, No. 14-5337, N.D. Calif.).

  • December 10, 2020

    9th Circuit Revives ACA, Unfair Competition Law Claims In HIV Drug Spat

    SAN FRANCISCO — The Ninth Circuit on Dec. 9 said that while the Patient Protection and Affordable Care Act (ACA) does not create a health care-specific discrimination standard, allegations that an insurer improperly limited HIV drug purchasers’ access to critical care by requiring mail order and pick up services meet the applicable standard and also keeps a California unfair competition law claim alive (John Doe One, et al. v. CVS Pharmacy Inc., et al., No. 19-15074, 9th Cir.).

  • December 09, 2020

    Judge: Health Care Network’s Florida Deceptive Acts Law Claims Survive Dismissal

    MIAMI — A lawsuit alleging that two re-pricing entities deceive providers by prominently displaying a well-known payment system while understating limitations the plan places on compensation satisfies Florida deceptive practices law claims and is not preempted by the Employee Retirement Income Security Act, a federal judge in Florida said Dec. 3 (South Broward Hospital District, et al. v. ELAP Services LLC, et al., No. 20-61007, S.D. Fla., 2020 U.S. Dist. LEXIS 226859).

  • December 09, 2020

    Claims Of Overreliance On Outdated Medical Guidance Save ERISA Case, Judge Says

    ASHEVILLE, N.C. — Allegations that an insurer employed unqualified reviewers who then placed outsized importance on outdated medical criteria information support an Employee Retirement Income Security Act claim, but the balance of the man’s claims are duplicative and fail, a federal judge in North Carolina said Dec. 4 in partially granting a motion to dismiss (Jeffrey Greenwell v. Group Health Plan for Employees of Sensus USA Inc., et al., No. 19-577, W.D. N.C., 2020 U.S. Dist. LEXIS 227618).

  • December 08, 2020

    United Asks For Stay While It Appeals Reprocessing Of 67,000 Claims

    SAN FRANCISCO — An insurer on Nov. 20 asked a federal judge in California to stay a case while it appeals what it says are serious defects in rulings on causation and in the standard applied in the case, arguing that forcing reprocessing of 67,000 claims before the appellate court weighs the challenges threatens it with irreparable harm (David Wit, et al. v. United Behavioral Health, No. 14-2346, Gary Alexander, et al. v. United Behavioral Health, No. 14-5337, N.D. Calif.).

  • December 04, 2020

    Judge: ERISA Permits Cross-Plan Offsetting; Murky Record Precludes Judgment

    NEW ORLEANS — Neither recent case law nor the Employee Retirement Income Security Act precludes cross-plan offsetting of debts an insurer discovered in post hoc audits, a federal judge in Louisiana on Dec. 1 said in a wide-ranging opinion, but he found that the lack of clear record precluded him from granting judgment (Omega Hospital LLC v. United Healthcare Services Inc., et al., No. 16-560, M.D. La., 2020 U.S. Dist. LEXIS 224996).

  • December 03, 2020

    9th Circuit: No Error In Denying Coverage For Residential Treatments

    SAN FRANCISCO — A record’s scant evidence a man posed a risk of harm to himself or others supports a health insurer’s conclusion that residential treatments were not medically necessary, a Ninth Circuit U.S. Court of Appeals panel said Dec. 2 (Brian H., et al. v. Blue Shield of California, et al., No. 19-16775, 9th Cir., 2020 U.S. App. LEXIS 37632).