Mealey's Health Care / ACA

  • April 22, 2022

    Relying On Review Lacking Records Was Abuse Of Discretion, Panel Agrees

    RICHMOND, Va. — Ruling that trustees of a health plan governed by the Employee Retirement Income Security Act abused their discretion in part by relying on an independent medical review (IMR) for which the plan had not provided relevant medical records, a Fourth Circuit U.S. Court of Appeal panel on April 20 affirmed a grant of summary judgment to the claimant and a lower court’s outright award of benefits.

  • April 21, 2022

    Mental Health Providers See ERISA Compensation Suit Dismissed With Prejudice

    TRENTON, N.J. — Mental health and substance abuse providers continue to rely on the same conclusory statements about assignment of rights to vaguely defined “providers” and unidentified plan terms allegedly entitling them to additional compensation, a federal judge in New Jersey said April 19 in dismissing an action with prejudice.

  • April 20, 2022

    Industry Group, Insurer: DOL Can’t Rewrite ERISA Regulation In Amicus Brief

    DENVER — A court should not avoid a merits ruling but instead affirm an insurer’s conclusion that further treatment at a long-term residential treatment facility was not medically necessary, and the 10th Circuit U.S. Court of Appeals should reject the Department of Labor’s attempt to rewrite Employee Retirement Income Security Act regulations in an amicus curiae brief, an insurer and an industry group told the court in a pair of April 15 briefs.

  • April 19, 2022

    Man Seeks More Than $220K In Attorney Fees After Proton Beam Coverage Victory

    ASHEVILLE, N.C. — A man found to have been improperly denied proton beam radiation therapy by his insurer told a federal judge in North Carolina on April 12 that the specialized work generally involved in Employee Retirement Income Security Act cases and health care in particular warranted in excess of $220,000 in attorney fees.

  • April 18, 2022

    Texas Supreme Court Wants Briefing On Standing In Emergency Care Payment Case

    AUSTIN, Texas — The Texas Supreme Court on April 15 asked parties for additional briefing about whether a subject matter jurisdiction challenge is the proper vehicle for litigating a dispute over statutory construction and whether a law governing reimbursement for emergency care contains a private right of action.

  • April 18, 2022

    Supreme Court Won’t Review Nominal Damages Issue In ACA Discrimination Case

    WASHINGTON, D.C. — The U.S. Supreme Court on April 18 turned away a deaf woman’s petition asking whether the Patient Protection and Affordable Care Act discrimination provision permits nominal damages.

  • April 18, 2022

    Judge Dismisses Clinics’ UCL Claim Against Insurer For Refusal To Cover Services

    SAN FRANCISCO — A California federal judge on April 13 dismissed in part with leave to amend a complaint brought by mental health and substance abuse health care providers who accuse an insurer of violating California’s unfair competition law (UCL) and of committing fraud by allegedly denying coverage for “medically necessary” services for patients, most of whom are insured under plans governed by the Employee Retirement Income Security Act.

  • April 15, 2022

    9th Circuit Affirms Summary Judgment, Says Medicare Act Preempts State Law Claims

    SAN FRANCISCO — A Ninth Circuit U.S. Court of Appeals panel on April 13 affirmed a district court’s grant of summary judgment to a health insurance company in a suit filed by the wife of a deceased Medicare patient against the company regarding its administration of her deceased husband’s Medicare Advantage (MA) plan, finding that the Medicare Act’s “express preemption provision” barred her state law claims.

  • April 14, 2022

    Potential Recovery From Provider Sends Insurance Spat To State Court, Court Says

    SAN ANTONIO — Insurance-related defendants have not shown that an insured could not recover from a provider for allegedly misrepresenting insurance coverage for a double hip replacement, which defeats complete diversity and requires remanding the insured’s action, a federal magistrate judge in Texas said April 12 in recommending granting the insured’s remand motion.

  • April 14, 2022

    Air Transport Plaintiff Says Regulatory Move Shows Need For Immediate Action

    WASHINGTON, D.C. — New regulatory guidance shows that the government plans on doubling down on its litigation position despite recent precedent enjoining provisions of the No Surprises Act, air transport plaintiffs told a federal judge in the District of Columbia on April 12.

  • April 12, 2022

    Insurer Refutes Blue Cross’ Motion For Judgment In Antitrust Coverage Dispute

    KANSAS CITY, Kan. — An insurer assuming responsibility for Blue Cross Blue Shield of Kansas Inc.’s (BCBSKS) insolvent excess errors and omissions insurer on March 31 opposed BCBSKS’s motion for judgment on the pleadings in a Kansas federal court, refuting the health insurer’s challenge to two claims in an antitrust coverage dispute.

  • April 12, 2022

    9th Circuit: Air Ambulance Failed To Exhaust Remedies For Medicare Claims

    SAN FRANCISCO — A Ninth Circuit U.S. Court of Appeals panel on April 8 affirmed a district court’s dismissal of an air ambulance service’s claims for violation of California’s unfair competition law (UCL) and breach of contract against an insurer over its claims for transport of patients from Mexico to the United States, ruling that the company failed to exhaust administrative remedies under the Medicare Act before suing.

  • April 12, 2022

    Judge Finds No Basis In Plan For Out-Of-Network Provider’s Compensation Suit

    TRENTON, N.J. — An out-of-network surgery provider points to no Employee Retirement Income Security Act plan provision requiring an insurer to compensate it at a higher rate, a federal judge in New Jersey said in dismissing a case April 1.

  • April 11, 2022

    Parties Report On Subpoenas, Settlements, Related Case In Insolvent Health Plan Suit

    CHICAGO — Parties on April 7 filed a joint status report in a lawsuit alleging that insurance brokers breached their duty of care because they knew or should have known that a multiple employer welfare arrangement (MEWA) was not in compliance with its structural requirements and was not financially sound, indicating that the parties have issued a total of 87 third-party document subpoenas and that the plaintiff has now settled with five of the defendants.

  • April 08, 2022

    Court’s Preemption Ruling In Proton Beam Coverage Case Flawed, Federal Worker Says

    HOUSTON — A district court erred in finding that preemption and standing issues precluded a case challenging an insurer’s denial of coverage for proton beam radiation therapy, a federal employee tells the Fifth Circuit U.S. Court of Appeals in an April 6 brief.

  • April 07, 2022

    Parties Debate Need For Immediate Ruling In No Surprises Act Challenge

    WASHINGTON, D.C. — Whether a court should immediately rule on a challenge to the No Surprises Act to avoid wasting economic and judicial resources or wait for a forthcoming rule that will refine the process of determining how mediators decide the appropriate compensation for such providers came before a District of Columbia federal judge on April 4 in supplemental briefing.

  • April 04, 2022

    On De Novo Review, Judge Adopts Report Finding Insurer Violated ERISA

    CINCINNATI — De novo review applies to objections to a magistrate judge’s report, and the record shows that an insurer failed to properly explain the basis for denying coverage for lumbar decompression and discectomy, lacked the entire medical record before making its decision, deviated from the plan in relying on a single standard for its decision and improperly ignored a second-level appeal in an Employee Retirement Income Security Act case, a federal judge in Ohio said March 23 in adopting the report.

  • April 04, 2022

    Insolvent Insurers, Government Announce Settlement In ACA Risk-Corridor Dispute

    WASHINGTON, D.C. — Insolvent insurers and the U.S. government on March 31 filed a corrected stipulation for entry of partial judgment in the U.S. Court of Federal Claims based on their settlement of a lawsuit 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.

  • March 31, 2022

    Insurer: Georgia Hospital Contract Termination Law Can’t Support Injunction

    ATLANTA — A hospital presented no evidence in support of its request for injunctive relief precluding cancellation of an insurance contract, but even if it had, the state law prohibiting cancellation of such contracts is not in effect because the governor has not declared a public health emergency as required by the law, an insurer told the Georgia Supreme Court on March 8.

  • March 31, 2022

    Woman Says ACA Discrimination Case Permits Nominal Damages

    WASHINGTON, D.C. — Allowing nominal damages after a liability finding in health care discrimination cases would resolve a circuit split on the issue and eases the process of determining attorney fees and other costs based on the prevailing party, a deaf woman told the U.S. Supreme Court in urging it to grant review on March 29.

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