Mealey's Health Care / ACA

  • October 14, 2019

    5th Circuit Doesn’t Want 2nd Look At Dialysis Provider’s Suit

    NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals denied a motion for rehearing Oct. 10, letting stand a decision finding a health care plan’s anti-assignment provision prevented a health care provider from suing an insurer (Dialysis Newco Inc., et al. v. Community Health Systems Group Health Plan, et al., No. 18-40863, 5th Cir.).

  • October 11, 2019

    New York Risk-Corridor Spat Parties Brief Impact Of U.S. Amicus Brief

    NEW YORK —  The United States’ amicus brief leaves no question about whether New York’s risk-adjustment program violates the Patient Protection and Affordable Care Act (ACA), an insurer tells the Second Circuit U.S. Court of Appeals in a Sept. 23 brief.  But New York says in its own letter brief that the panel should ignore the government’s attempt to recharacterize its earlier position (UnitedHealthcare of New York Inc., et al. v. Linda Lacewell, et al., No. 18-2583, 2nd Cir.).

  • October 09, 2019

    Limited Partnership Action Seeks Labor Department Opinion On Health Care Plan Status

    DALLAS — A limited partnership filed suit in Texas federal court on Oct. 4, seeking to force the U.S. Department of Labor (DOL) to issue an advisory opinion declaring that the self-insured health plan it offers common-law employees and limited partners is not a multiple welfare arrangement (MEWA) under the Employee Retirement Income Security Act (Data Marketing Partnership LP v. United States Department of Labor, et al., No. 19-800, N.D. Texas).

  • October 07, 2019

    HHS Barred Under Colorado Law From Offsetting Insolvent Insurer’s Debt, Court Says

    WASHINGTON, D.C. — Colorado insurance liquidation law precludes the U.S. Department of Health and Human Services (HHS) from using money owed to an insolvent Colorado insurer to pay debts owed under the Patient Protection and Affordable Care Act’s (ACA) reinsurance and risk-adjustment programs, a judge in the U.S. Court of Federal Claims ruled Oct. 3 (Michael Conway v. The United States, No. 18-1623, Fed. Clms., 2019 U.S. Claims LEXIS 1306).

  • October 07, 2019

    Top Court Denies Review In ERISA Health Care Rights-Assignment Spat

    WASHINGTON, D.C. — The U.S. Supreme Court on Oct. 7 denied a health care insurer’s petition for review, leaving stand a Fifth Circuit U.S. Court of Appeals ruling finding that direct payments to a provider waived an Employee Retirement Income Security Act plan’s anti-assignment provision protections (Louisiana Health Service & Indemnity Co. v. Encompass Office Solutions, Inc., No. 19-196, U.S. Sup.).

  • October 07, 2019

    Medicare Recipients: Denied Appeal Rights Of Designation Violates Due Process Clause

    HARTFORD, Conn. — A class of Medicare recipients in a Sept. 19 post-trial brief tell a Connecticut federal court that they have been deprived of a protected property interest by state action without due process of law and that the failure of the secretary of Health and Human Services to allow them to appeal to Medicare the issue of the classification of their hospital services under Medicare rules violates the Fifth Amendment’s due process clause (Christina Alexander, et al. v. Alex M. Azar II, No. 11-1703, D. Conn.).

  • October 02, 2019

    Judge Adopts Report Finding Conflicting Evidence Dooms Mental Health ERISA Claim

    BROOKLYN, N.Y. — Conflicting medical opinions and evidence do not support the conclusion that an insurer acted improperly when it denied coverage for mental health treatments after a suicide attempt, a New York judge held Sept. 30 in adopting a magistrate judge’s report and recommendation (Samuel Halberg, et al. v. United Behavioral Health, et al., No. 16-6622, E.D. N.Y., 2019 U.S. Dist. LEXIS 169679).

  • October 01, 2019

    Plaintiffs Have Standing, But Not Support For Parity Act Case, Judge Says

    SALT LAKE CITY — A man who claims that he spent $340,000 on his daughter’s mental health treatments after an insurer improperly denied coverage has standing but has not adequately alleged a violation of the Mental Health Parity and Addiction Equity Act, a federal judge in Utah said Sept. 27 (Jeff N., et al. v. United Healthcare Insurance Co., No. 18-710, D. Utah, 2019 U.S. Dist. LEXIS 167420).

  • October 01, 2019

    After Paring Claims, Judge Leaves Parity Act Claims In Wilderness Therapy Case

    SALT LAKE CITY — A family’s class action allegations involving the denial of coverage for wilderness treatment under an Employee Retirement Income Security Act health plan are duplicative or fail to state a claim, but their claims involving allegedly disparate treatment in the mental health setting may continue, a federal judge in Utah said Sept. 27 (K.H.B., et al. v. UnitedHealthCare Insurance Co., No. 18-795, D. Utah, 2019 U.S. Dist. LEXIS 167183).

  • September 30, 2019

    Provider Seeks Rehearing After Panel Rules On Assignment, ERISA Preemption

    NEW ORLEANS — A dialysis provider in a Sept. 25 petition asks the Fifth Circuit U.S. Court of Appeals to review a Sept. 11 panel ruling finding that a health care plan precluded assignment of Employee Retirement Income Security Act rights and that ERISA preempted a Tennessee statute making insurers liable to third-party providers (Dialysis Newco Inc., et al. v. Community Health Systems Group Health Plan, et al., No. 18-40863, 5th Cir.).

  • September 26, 2019

    United Wants Judge To Reconsider Facility-Fee Coverage Class Ruling

    NEW YORK — A health insurer in a Sept. 25 memo asks a federal judge in New York to reconsider a Sept. 11 ruling that allegations that the insurer improperly denied coverage for out-of-network facility fees for certain providers supported certification of a class seeking declaratory and injunctive relief, but not classwide benefit awards, contending that determining whether providers properly obtained an assignment of rights under Employee Retirement Income Security Act plans requires claim-by-claim analysis precluding certification (The Medical Society of the State of New York, et al. v. UnitedHealth Group Inc., et al., No. 16-5265, S.D. N.Y.).

  • September 25, 2019

    Dialysis Provider’s Suit Fails On Statutory, Standing Grounds, Judge Says

    CINCINNATI — A health insurance administrator’s decision to make all dialysis companies out-of-network providers does not violate the Medicare Secondary Payor Act (MSPA), and the provider’s assignment is limited to insurance benefits and does not include the right to litigate, a federal judge in Ohio held Sept. 20 (DaVita Inc., et al. v. Marietta Memorial Hospital Employee Health Benefit Plan, et al., No. 18-1739, S.D. Ohio, 2019 U.S. Dist. LEXIS 160793).

  • September 25, 2019

    Judge Says Attorney Fees Warranted In Health Care Spat, But Wants More Evidence

    TRENTON, N.J. — A man’s “completely unsubstantiated” allegations seeking usual and customary medical expenses for which his plan clearly does cover warrant an award of attorney fees, but the plan sponsor must submit more evidence demonstrating that its requested fees constitute reasonable charges, a federal judge in New Jersey held Sept. 24 (Clifford Robinson v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 17-4600, D. N.J., 2019 U.S. Dist. LEXIS 162702).

  • September 24, 2019

    Couple’s ERISA Case For Inpatient Treatment Largely Rejected By Judge

    NEW ORLEANS — A federal judge in Louisiana largely rejected a couple’s Employee Retirement Income Act claims in Sept. 19 and 24 rulings and found that the law’s conflict preemption statute doomed the state law claims (Soileau & Associates LLC, et al. v. Louisiana Health Service & Indemnity Co., Nos. 18-310, 18-7613, E.D. La., 2019 U.S. Dist. LEXIS 159622).

  • September 20, 2019

    Cardiovascular Specialists’ Contract Claim Sole Survivor Of Motion To Dismiss

    NEW YORK — Allegations that health care providers treated individuals in government and church plans outside the reach of the Employee Retirement Income Security Act precludes preemption, and while the breach of contract claim survives, the remaining 10 claims are largely duplicative and must be dismissed, a federal judge in New York held Sept. 17 (Perry A. Frankel, et al. v. U.S. Healthcare Inc., et al., No. 18-6378, S.D. N.Y., 2019 U.S. Dist. LEXIS 159794).

  • September 20, 2019

    Insurer Says Standing, Merits Don’t Require Review Of Medicaid Hearing Challenge

    WASHINGTON, D.C. — The U.S. Supreme Court lacks jurisdiction over a Kentucky top court ruling on standing, and nothing in a ruling precluding a hearing after an insurer denied coverage under Medicaid would warrant review, the insurer tells the court in a Sept. 19 respondent brief (Lettie Sexton, et al. v. Commonwealth of Kentucky, et al., No. 18-1446, U.S. Sup.).

  • September 20, 2019

    Pay Rate Allegations Keep Health Insurance Contract Claims Alive, Judge Says

    SAN JOSE, Calif. — A medical provider’s allegation that an insurer confirmed a 70 percent reimbursement rate supports breach of contract claims because it goes beyond simple coverage verification, a federal judge in California held Sept. 17 (California Spine and Neurosurgery Institute v. United Healthcare Insurance Co., et al., No. 19-2417, N.D. Calif., 2019 U.S. Dist. LEXIS 159286).

  • September 18, 2019

    Judge:  Allegations Support Mental Health Coverage Disparity Case

    SALT LAKE CITY — There is no evidence that plaintiffs seeking to recover Employee Retirement Income Security Act benefits for mental health treatments are part of other class actions, and they successfully allege disparate treatment, a federal judge held Sept. 13 (David S., et al. v. United Healthcare Insurance Co., No. 18-803, D. Utah, 2019 U.S. Dist. LEXIS 157046).

  • September 17, 2019

    Amici Say 5th Circuit Ruling Contravenes Precedent, ERISA

    WASHINGTON, D.C. — Direct payments to health care providers do not waive anti-assignment provisions or transform the provider into the type of party that can sue an insurer under the Employee Retirement Income Security Act, industry groups tell the U.S. Supreme Court in a Sept. 13 amicus curiae brief opposing review (Louisiana Health Service & Indemnity Co. v. Encompass Office Solutions, Inc., No. 19-196, U.S. Sup.).

  • September 17, 2019

    Insurers, Amici Say ACA Payments Still Due, Warn Of Fallout If Not Paid

    WASHINGTON, D.C. — In Sept. 6 amicus briefing and Aug. 30 briefs by the petitioners, the U.S. Supreme Court heard details regarding the harm caused by the government’s failure to follow through on billions of dollars of promised Patient Protection and Affordable Care Act (ACA) risk corridor payments and that later appropriations riders cannot be read as repealing those obligations (Land of Lincoln Mutual Health Insurance Co. v. United States, No. 18-1038, Moda Health Plan Inc., et al. v. United States, No. 18-1028, Maine Community Health Options v. United States, No. 18-1023, U.S. Sup.).

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