SANTA ANA, Calif. — Having approved medical procedures and then denied claims, an insurer cannot now point to the existence of anti-assignment provisions as the reason in a late attempt to avoid paying, a provider told a California judge on April 8 in an Employee Retirement Income Security Act case (California Surgical Institute Inc., et al. v. Aetna Life and Casualty [Bermuda] Ltd., et al., No. 18-2157, C.D. Calif.).
PHOENIX — A hospital staff discriminated against a deaf woman by lacking proper training on how to identify when a patient requires a live, in-person interpreter, violating the Patient Protection and Affordable Care Act (ACA) and other statutes, the woman claims in a March 21 complaint filed in Arizona federal court (Ella Mae Hammack v. Scottsdale Healthcare Hospitals, et al., No. 19-1890, D. Ariz.).
FORT MYERS, Fla. — Florida law lends an independent basis for some of a provider’s 32 cases against an Employee Retirement Income Security Act health insurer, and sufficient questions remain over the balance of the claims to grant remand, a federal judge in Florida said March 29 (Premier Inpatient Partners LLC, et al. v. Aetna Health and Life Insurance Co., No. 18-621, M.D. Fla., 2019 U.S. Dist. LEXIS 62678).
CENTRAL ISLIP, N.Y. — An administrative service agreement (ASA) is not a plan document, and the anti-assignment provision referenced therein does not bar a patient from assigning rights to a provider, a New York federal judge held March 20 (Long Island Neurological Associates v. Highmark Blue Shield, et al., No. 18-81, E.D. N.Y., 2019 U.S. Dist. LEXIS 46176).
WASHINGTON, D.C. — In its April 15 orders list, the U.S. Supreme Court denied certiorari in a dispute between a medical provider and United Healthcare Insurance Co. over an anti-assignment provision in a group health benefit plan (W.A. Griffin v. United Healthcare of Georgia Inc. et al., No. 18-1033, U.S. Sup.).
LOS ANGELES — Assignments provide a debt purchaser with standing to pursue medical providers’ underpayment claims against an insurer, but its repeated failure to adequately support the claims dooms its case, a federal judge in California held April 3 in dismissing the claims without leave to amend (Namdy Consulting Inc. v. UnitedHealthcare Insurance Co., No. 18-1283, C.D. Calif., 2019 U.S. Dist. LEXIS 57624).
SAN FRANCISCO — A final rule restricting dissemination of information about abortion violates the Patient Protection and Affordable Care Act (ACA) and Title X and would force California to insure a wave of unintended pregnancies, the state argues in an April 11 reply in support of a motion seeking to enjoin the rule (State of California, et al. v. Alex Azar, et al., No. 19-1184, N.D. Calif.).
NASHVILLE, Tenn. — A son’s Patient Protection and Affordable Care Act (ACA) claim alleging that a hospital discriminated against his 93-year-old mother lacks evidence that he exhausted administrative remedies as required by the underlying discrimination law, a federal judge in Tennessee held April 9 (Alvin Galuten, et al. v. Williamson Medical Center, et al., No. 18-519, M.D. Tenn., 2019 U.S. Dist. LEXIS 61207).
NEW ORLEANS — The Fifth Circuit U.S. Court of Appeal ordered expedited oral arguments April 10 after receiving nearly two dozen briefs from a diverse group of amici urging it not to strike down the Patient Protection and Affordable Care Act (ACA) simply because Congress zeroed out the individual mandate penalty (Texas, et al. v. U.S.A., et al., No. 19-10011, 5th Cir.).
HACKENSACK, N.J. — New Jersey courts have specific personal jurisdiction over a Michigan employer and its Michigan-based health insurer because both companies availed themselves of the state by operating an office there and offering insurance to those employees, a New Jersey judge held March 20 (Tsvi Small, M.D., v. Blue Cross Blue Shield of Michigan, et al., No. BER-L-4141-18, N.J. Super., Bergen Co.).
NEW ORLEANS — Hundreds of Indian tribes, more than 50 economic scholars, a handful of constitutional law experts who in the past opposed the Patient Protection and Affordable Care Act (ACA) and two Republican-led states said striking down the entire law simply because Congress zeroed out the individual mandate penalty lacks any historic or legal precedent while warning about the far-reaching impact doing so would have. The amici were among 21 parties filing briefs on April 1 (Texas, et al. v. U.S.A., et al., No. 19-10011, 5th Cir.).
WASHINGTON, D.C. — A Patient Protection and Affordable Care Act (ACA) rule expanding the availability of association health plans “does violence” to the Employee Retirement Income Security Act by exploding the definition of an employer, a federal judge in the District of Columbia said March 28 (New York, et al. v. U.S. Department of Labor, et al., No. 18-1747, D. D.C.).
FORT WORTH, Texas — The Fifth Circuit U.S. Court of Appeals should strike down the entire Patient Protection and Affordable Care Act (ACA) in light of changes to the individual mandate the Department of Justice says in a letter filed March 25 alongside opening briefs arguing that the plaintiff states lack standing to challenge the law’s constitutionality and that striking it down goes against legislative intent (Texas, et al. v. U.S.A., et al., No. 19-10011, 5th Cir.).
WASHINGTON, D.C. — Whether an insurance advocacy group has standing to challenge a rule expanding the availability of Patient Protection and Affordable Care Act (ACA) short-term, limited duration insurance (STLDI) health insurance plans lies at the heart of a pair of March 22 reply briefs filed in the District of Columbia federal court (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 18-2133, D. D.C.).
SAN FRANCISCO — Plaintiffs seeking class certification in a challenge to the availability of in-network lactation services under the Patient Protection and Affordable Care Act (ACA) ignore that any such determination requires individualized evidence and defenses, an insurer told a federal judge in California March 21 (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 17-183, N.D. Calif.).
NEW ORLEANS — A Texas federal judge did not abuse her discretion in finding, following a bench trial, that Blue Cross & Blue Shield of Louisiana (BCBSLA) violated the Employee Retirement Income Security Act when it arbitrarily denied claims for covered services submitted by a company that facilitates in-office surgical procedures, a divided Fifth Circuit U.S. Court of Appeals ruled March 19 (Encompass Office Solutions Inc. v. Louisiana Health Service & Indemnity Company, d/b/a Blue Cross & Blue Shield of Louisiana, 17-10736, 5th Cir., 2019 U.S. App. LEXIS 8165).
LOS ANGELES — An insurer’s categorization of settlement funds it paid in settling claims that it misstated the size of its network coverage as incurred claims under the medical loss ratio (MLR) calculation did not violate the Patient Protection and Affordable Care Act (ACA), a Ninth Circuit U.S. Court of Appeals panel held March 18 (Rebecca Morris, et al. v. Blue Shield of California, et al., No. 17-55878, 9th Cir., 2019 U.S. App. LEXIS 7994).
CHICAGO — One of an insured’s providers falls outside the guise of a residential treatment program and is excluded by her health insurance, but her treatment at a second health care facility clearly constituted medically necessary care, a federal judge in Illinois held March 18 in partially granting judgment in an Employee Retirement Income Security Act case for both the insured and insurer (Alice F. v. Health Care Service Corp., et al., No. 17-3710, N.D. Ill., 2019 U.S. Dist. LEXIS 43150).
TRENTON, N.J. — A health care provider is not the type of entity able to bring an Employee Retirement Income Security Act claim, and his claims are not preempted, a federal judge in New Jersey held March 15 in adopting a magistrate judge’s recommendation that the case be remanded (Tzvi Small, M.D. v. Anthem Blue Cross Blue Shield, et al., No. 18-399, D. N.J., 2019 U.S. Dist. LEXIS 42450).
SALT LAKE CITY — An alleged assignment of benefits gives a hospital standing to sue an insurer, and its allegation that the insurer improperly calculated the reasonable and customary rate for treatment provides grounds for its Employee Retirement Income Security Act suit, a federal judge in Utah held March 15 (IHC Health Service d/b/a McKay-Dee Hospital v. Central States, et al., No. 17-1327, D. Utah, 2019 U.S. Dist. LEXIS 42786).