NEWARK, N.J. — Anti-assignment provisions largely free two of three insurers from providers’ suit seeking compensation, and the providers have failed to state a claim for all but the church-plan-based claims, a federal judge in New Jersey found April 27 (Somerset Orthopedic Associates, et al. v. Horizon Healthcare Services Inc., et al., No. 19-8783, D. N.J.).
WASHINGTON, D.C. — An insolvent insurer’s demand for payment under the Patient Protection and Affordable Care Act’s (ACA) reinsurance program fails because it had already been paid based on an offset of the amount owed by the insurer under the ACA’s risk adjustment program, the U.S. government argues in its April 27 opening brief to the Federal Circuit U.S. Court of Appeals (Michael Conway v. The United States, No. 20-1292, Fed. Cir.).
NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals on March 24 denied a petition for en banc rehearing without poll, leaving stand a panel ruling that the Patient Protection and Affordable Care Act (ACA) is spending clause legislation that acts as a contract and cannot support emotional distress damages (Jane Cummings v. Premier Rehab Keller PLLC, et al., No. 19-10169, 5th Cir.).
WASHINGTON, D.C. — The Patient Protection and Affordable Care Act (ACA) risk-corridor program mandated payments that subsequent appropriations riders did not eliminate, and an insolvent insurer and its fellow petitioners may pursue the billions of dollars in lost payments in federal court, a majority of the U.S. Supreme Court said April 27 (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.).
BATON ROUGE, La. — A judge found an expert qualified to testify on hospital policies, but her opinion is unreliable because it is based on a site visit she performed in a different case in an entirely different context, a hospital told a federal judge in Louisiana April 17 (Katrina Rivers LaBouliere, et al. v. Our Lady of the Lake Hospital Inc., No. 16-785, M.D. La.).
BALTIMORE — A district court erroneously established medical providers’ ethical concerns about a Title X rule as the governing law and ignored the proper standard of review and existing precedent in concluding that abortion rules violated the Patient Protection and Affordable Care Act (ACA), federal defendants and various states tells the Fourth Circuit U.S. Court of Appeals in April 17 supplemental briefing before the en banc court (Mayor and City Council of Baltimore v. Alex M. Azar II, et al., Nos. 19-1614, 20-1215, 4th Cir.).
SALT LAKE CITY — Allegations that an insurer imposed acute level criteria on subacute care in the mental health setting but not in other medical and surgical settings successfully allege a Parity Act violation, and the claim is not duplicative of the Employee Retirement Income Security Act claim seeking benefits, a federal judge in Utah said April 7 (M.S., et al. v. Premera Blue Cross, et al., No. 19-199, D. Utah).
WASHINGTON, D.C. — The U.S. Supreme Court on April 20 granted a request by the solicitor general for divided arguments in a pair of cases involving whether the Patient Protection and Affordable Care Act (ACA) and Religious Freedom Restoration Act (RFRA) permit expanded religious and moral exemptions to the contraceptive mandate. Originally scheduled for late April, oral arguments were postponed due to the coronavirus, and the cases are now set for telephonic arguments on May 6 (Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania, et al., Donald J. Trump, et al. v. Pennsylvania, Nos. 19-431, 19-454, U.S. Sup.).
GREENSBORO, N.C. — An insurer on April 15 appealed a decision by a federal judge in North Carolina finding that the Employee Retirement Income Security Act did not preempt a dispute over reimbursement because neither party enjoyed standing under the law and that a private contract with the provider did not give rise to federal officer removal simply because some beneficiaries were federal employees or covered by Medicare (LifeBrite Hospital Group of Stokes LLC v. Blue Cross and Blue Shield of North Carolina, No. 18-293, M.D. N.C.).
CHICAGO — Medical providers misconstrue insurers’ arguments in seeking reconsideration of an order finding derivative standing under the Employee Retirement Income Security Act (ERISA) and have not shown that Texas law would provide them with damages, a federal judge in Illinois said April 6 (Emerus Hospital, et al. v. Health Care Service Corp., et al., No. 13-8906, N.D. Ill., 2020 U.S. Dist. LEXIS 60269).
SACRAMENTO, Calif. — The Patient Protection and Affordable Care Act (ACA) does not preempt California’s charity care regulation requiring a hospital to provide a certain amount of indigent care or donate the equivalent amount of that care to entities that do, a Ninth Circuit U.S. Court of Appeals panel held April 2 (Deanco Healthcare LLC, et al. v. Xavier Becerra, et al., No. 19-55155, 9th Cir., 2020 U.S. App. LEXIS 10407).
SAN FRANCISCO — Mental health treatments planned well in advance of hospitalization were not emergency services covered by an Employee Retirement Income Security Act health plan, and because the insureds never sought preauthorization from their insurer, the out-of-network coverage provision does not apply, a Ninth Circuit U.S. Court of Appeals panel held April 6 (Carol Meyers v. Kaiser Foundation Health Plan Inc., No. 19-15051, 9th Cir., 2020 U.S. App. LEXIS 10704).
DENVER — An insurer did not act in an arbitrary or capricious way when it credited certain medical opinions over those of treating physicians or when it denied coverage for residential mental health treatment, a 10th Circuit U.S. Court of Appeals panel held April 3 (Tracy O., et al. v. Anthem Blue Cross Life and Health Insurance, et al., No. 17-4135, 10th Cir.).
GREENSBORO, N.C. — The Patient Protection and Affordable Care Act (ACA) and other federal statutes preventing discrimination apply to gender dysphoria exclusion claims against North Carolina universities and related entities, a federal judge said March 11 in denying motions to dismiss (Maxwell Kadel, et al. v. Dale Folwell, et al., No. 19-272, M.D. N.C., 2020 U.S. Dist. LEXIS 42586).
BOSTON — A family adequately alleges that an insurer’s denial of coverage for mental health care violates the Parity Act and the Employee Retirement Income Security Act, a federal judge in Massachusetts said March 30 (Steve C., et al. v. Blue Cross and Blue Shield of Massachusetts Inc., et al., No. 18-12278, D. Mass., 2020 U.S. Dist. LEXIS 54857).
SALT LAKE CITY — A family adequately alleges that a health insurance plan’s blanket exclusion on wilderness treatments sufficiently deviates from how it covers similar treatments in the medical or surgical setting to keep the claim alive, and there is no reason at this stage to believe that the Parity Act claim is duplicative of the claim seeking benefits, a federal judge in Utah said March 26 (Candace B., et al. v. Blue Cross and Blue Shield of Rhode Island, No. 19-39, D. Utah, 2020 U.S. Dist. LEXIS 52850).
NEW ORLEANS — An out-of-network surgery provider’s breach of contract and detrimental reliance claims are adequately pleaded and avoid Employee Retirement Income Security Act (ERISA) preemption, but the remainder of the case fails, a federal judge in Louisiana held March 30 while denying a blanket request for an “attorneys’ eyes only” provision (Crescent City Surgical Centre v. Cigna Health and Life Insurance Co., et al., No. 18-11385, E.D. La., 2020 U.S. Dist. LEXIS 54556).
NEW YORK — A medical billing expert is qualified to testify, and medical providers’ benefits recovery and injunctive relief claims largely survive in a case alleging that an insurer ignored plan language and instead issued automatic denials of coverage for office-based practices’ facility fees, a federal judge in New York said March 26 (The Medical Society of the State of New York, et al. v. UnitedHealth Group Inc., et al., No. 16-5265, S.D. N.Y., 2020 U.S. Dist. LEXIS 53262).
BOSTON — A woman’s Employee Retirement Income Security Act class action seeking disgorgement and an injunction barring an insurer from denying proton beam therapy claims simply repackages a denial of benefits claim and must be dismissed without prejudice, a federal judge in Massachusetts said March 25 (Kate Weissman v. United Healthcare Insurance Co., et al., No. 19-10580, D. Mass., 2020 U.S. Dist. LEXIS 51568).
HARTFORD, Conn. — The portion of a class of Medicare beneficiaries placed on observation status after being admitted the hospital as inpatients and now suing the federal government for depriving them of their property interest in Part A coverage have shown that the U.S. secretary of Health and Human Services (HHS) violated the due process clause of the Fifth Amendment to the U.S. Constitution, a federal judge in Connecticut ruled March 24, ordering that those members should be permitted to appeal the denial of their coverage (Christina Alexander, et al. v. Alex M. Azar II, No. 11-1703, D. Conn., 2020 U.S. Dist. LEXIS 50636).