Mealey's Health Care / ACA

  • May 18, 2022

    Unmet Deductible Dooms Parity Act Challenge To Drug Treatment Denials

    INDIANAPOLIS — Because outpatient and urine analysis claims all fall short of the plan’s deductible there is no injury on which to base claims, a federal judge in Indiana said in dismissing the lack of jurisdiction and denying class certification on May 13.

  • May 17, 2022

    Inspector General Flags Medicare Advantage Preapproval Rejection Rate

    WASHINGTON, D.C. — Some Medicare Advantage organizations denied coverage for preauthorized services that appear to meet the Medicare standard at a rate — up to 13% — that raises concerns about enrollees’ ability to obtain medically necessary care, according to an April 28 report from the Department of Health and Human Services’ Office of the Inspector General (OIG).

  • May 17, 2022

    Couple Can’t Secure Stay, Discovery In Speech Therapy Coverage Case

    MADISON, Wis. — Plaintiffs’ claim that they need discovery into why an insurer denied coverage for speech therapy is “confusing and unconvincing,” and they never truly grapple with the insurer’s Parity Act arguments, a federal magistrate judge in Wisconsin said May 6 in declining to defer consideration of a motion for summary judgment and discovery.

  • May 16, 2022

    Magistrate Judge Says Medical Record Discrimination Settlement Should Be Enforced

    GREENSBORO, N.C. — A medical provider’s attempt to add payment of liens and Medicare reporting requirements to a settlement resolving discrimination claims would introduce material terms to the deal and likely prejudice plaintiffs, a federal magistrate judge in North Carolina said May 6 in recommending that the court order compliance with the settlement.

  • May 16, 2022

    Mother’s ACA Gender Dysphoria Discrimination Claim Survives Dismissal

    ST. LOUIS — A woman’s action alleging that her insurer violated the Patient Protection and Affordable Care Act (ACA) by denying coverage for her son’s gender dysphoria treatments may proceed, but her civil rights claim fails based on the statute’s more narrow definition of sex, a federal judge in Missouri said in partially granting a motion to dismiss on April 25.

  • May 12, 2022

    Insurer Subclass Seeks Stipulated Judgment Attorney Fees In Risk-Corridor Dispute

    WASHINGTON, D.C — An attorney representing insolvent insurers’ subclass on May 9 moved the U.S. Court of Claims for attorney fees of 5% of the $13,714,723 net recovery related to the settlement of risk-corridor claims after the court two weeks earlier granted partial judgment in a suit seeking a declaratory judgment that the U.S. government owes the insurers millions of dollars under the Patient Protection and Affordable Care Act (ACA) risk-corridor program.

  • May 09, 2022

    Magistrate Judge: Power Of Attorney Gives Standing; Air Transport Suit Lacking

    TAMPA, Fla. — A power of attorney and allegations that an insured remains liable for the $237,770 balance an insurer did not pay an air ambulance company give an attorney standing to pursue the insurer but not the air ambulance company he represents, but because the plaintiffs point to no plan provision authorizing payment for transporting a woman from the Dominican Republic, the claims should be dismissed without prejudice, a federal magistrate judge in Florida said in an April 26 report and recommendation.

  • May 09, 2022

    Commercial Insurance Market Per-Person Spending Doubles Inflation, CBO Says

    WASHINGTON, D.C. — Spending per person in commercial insurance plans rose at twice the rate of the gross domestic price index over the five-year period ending 2018, with the price for physician services varying widely by state while per-person spending on prescription drugs purchased from pharmacies leveled off after a sharp increase caused by the introduction of a new class of hepatitis C drug, according to an April 27 Congressional Budget Office (CBO) report.

  • May 06, 2022

    Class Warns 9th Circuit Of Impact From ERISA Coverage Ruling

    SAN FRANCISCO — A Ninth Circuit U.S. Court of Appeals panel ruling allows an insurer to deny coverage based on guidelines inconsistent with the Employee Retirement Income Security Act plan’s own clear language mandating it follow the medical community’s generally accepted standards of care and which were formulated by the insurer’s finance department in a clear conflict of interest, a class argues in a May 5 petition seeking rehearing in a case it termed “an inflection point and a bellwether.”

  • May 04, 2022

    Judge Certifies Class Of 25 Lipedema Sufferers Denied Insurance Coverage

    SAN FRANCISCO — Allegations that an insurer denied coverage for tumescent liposuction in essentially all instances satisfy the commonality standard even where the insurer sometimes approved treatment, and while smaller than typical, a class of 25 is likely the best way to handle the claims given the nationwide insurance coverage and the class’s diverse geographic nature, a federal judge in California said April 25 in certifying the class.

  • May 04, 2022

    5th Circuit Stays Appeal In No Surprises Act Case

    NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals on May 3 granted an unopposed motion to stay an appeal of a ruling enjoining part of the No Surprises Act while the government formulates and releases a final rule governing the law’s dispute resolution procedure.

  • April 29, 2022

    5th Circuit Withdraws Opinion, Dismisses ACA Risk-Adjustment Opinion

    NEW ORLEANS — A district court’s remand of a procedural due process claim in an insolvent insurer’s case challenging the Patient Protection and Affordable Care Act’s risk-adjustment program leaves no final appealable order and strips a court of jurisdiction, a Fifth Circuit U.S. Court of Appeals panel said April 20 in withdrawing a previous opinion.

  • April 29, 2022

    Judge: Binary Sex Usage Means ACA Sexual Orientation Discrimination Case Proceeds

    AMARILLO, Texas — Physicians face a real threat of injury from the government’s inclusion of sexual orientation in the Patient Protection and Affordable Care Act’s (ACA) prohibition on discrimination, a federal judge in Texas said April 26 while finding that federal law appears to use the word “sex” as a binary term and allowing a suit challenging the ruling to proceed.

  • April 28, 2022

    Emergency Care Laws Lack Private Right Of Action, Insurer Tells Texas Top Court

    HOUSTON — The lack of clear statement from the Legislature creating a private right of action in the state’s emergency care statutes and the fact that the state’s insurance department already includes a comprehensive compliance scheme weigh heavily in favor of rejecting hospitals’ suits seeking compensation, an insurer tells the Texas Supreme Court in an April 27 brief.

  • April 28, 2022

    Federal Health Emergency Supports Georgia Contract Injunction, Providers Say

    ATLANTA — Medical providers told the Georgia Supreme Court on March 28 that a Georgia statute barring insurers from terminating provider contracts during a public health crisis does not require the governor to declare an emergency to become effective and that they submitted adequate evidence of the harm they would suffer if an insurer terminated its contract with them.

  • April 28, 2022

    Supreme Court: No Emotional Distress Damages In ACA Discrimination Case

    WASHINGTON, D.C. — Contract law traditionally excludes emotional distress damages, and once it is clear that federal funding recipients are unlikely to expect such damages, it is a “straightforward” conclusion that they are unavailable under the Patient Protection and Affordable Care Act (ACA) and a related anti-discrimination statute, a divided U.S. Supreme Court said April 28.

  • April 28, 2022

    Insurer:  Texas Insurance Department Proper Venue For Hospital Care Payment Case

    AUSTIN, Texas — If hospitals believe they are entitled to additional compensation under Texas emergency care laws, their exclusive remedy lies with the insurance department, and they lack standing to bring a tort action, Molina Healthcare of Texas Inc. tells the Texas Supreme Court in an April 25 response.

  • April 27, 2022

    Host Of Issues, Statutes At Issue In Insurer, Drug Treatment Provider Battle

    LOS ANGELES — An insurer and providers of substance abuse treatments filed dueling April 22 oppositions to motions for summary judgment involving California unfair competition law (UCL) standing, whether the insurer enjoyed discretionary power, whether its payment decisions were arbitrary or capricious and whether its per diem payment rate denied coverage for essential health services mandated by the Patient Protection and Affordable Care Act.

  • April 27, 2022

    Judge Tosses Most Claims In Surgery Benefits Row But Allows Amended Complaint

    NEWARK, N.J. — Ruling in part that an anti-assignment provision bars claims asserted by one plaintiff and that the complaint does not adequately allege that five entities are proper defendants, a New Jersey federal judge on April 25 granted dismissal of most claims in a suit over allegations that health insurers improperly and “systematically deny benefits for post-mastectomy breast reconstruction when performed by assistant surgeons or co-surgeons” but granted leave to file an amended complaint within 30 days.

  • April 26, 2022

    Insurer Prevails On Appeal Of Contract, ACA Out-Of-Pocket Cap Rulings

    NEW YORK — The shortness of an insurance communication and the fact that it repeatedly referred to other plan documents placed an insured on notice that the contract included other terms and nothing in the Patient Protection and Affordable Care Act (ACA) required the insurer to apply the individual out-of-pocket cap to prescription drug purchases rather than the family cap, a panel of the Second Circuit U.S. Court of Appeals said in affirming a trio of district court rulings on April 22.