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Mealey's Health Care / ACA

  • February 25, 2019

    Medical Provider’s State Law Claims Survive Dismissal, Federal Judge Says

    TRENTON, N.J. — A surgeon’s state law claims alleging that an insurer failed to fully compensate him for breast surgery services survives a motion to dismiss, as it is not preempted and the state law claims all appear valid at this stage, a federal judge in New Jersey held Feb. 21 (Tzvi Small, M.D. v. Oxford Health Insurance Inc., et al., No. 18-13120, D. N.J., 2019 U.S. Dist. LEXIS 27878).

  • February 25, 2019

    Anti-Assignment Provision A Valid Bar To Provider’s Insurance Suit, Judge Says

    TRENTON, N.J. — A pair of health insurance plans’ anti-assignment provisions are valid and enforceable and bar a provider’s action seeking in excess of $100,000 in Employee Retirement Income Security Act benefits, a federal judge in New Jersey held Feb. 22 (Neurosurgical Associates of NJ PC, et al. v. Aetna Inc., No. 17-13210, D. N.J., 2019 U.S. Dist. LEXIS 28353).

  • February 21, 2019

    Government Urges 3rd Circuit To Reject ACA Birth Control Rules Injunction

    HARRISBURG, Pa. — States lack standing to challenge rules expanding the Patient Protection and Affordable Care Act (ACA) contraceptive mandate exemptions and cannot prevail even if they did because the rules comply with the law and procedural requirements, the federal defendants defending the rules told a Third Circuit U.S. Court of Appeals panel in a Feb. 15 brief (Commonwealth of Pennsylvania, et al. v. President, United States of America, et al., Nos. 17-3752, 18-1253,19-1129, 19-1189, 3rd Cir.).

  • February 21, 2019

    Judges Find United States Owes Insurers Under ACA Cost-Sharing Program

    WASHINGTON, D.C. — Congress created an implied contract when it implemented the Patient Protection and Affordable Care Act (ACA) cost-sharing program, an obligation it breached when it never authorized payments, a pair of U.S. Court of Federal Claims judges held in a trio of rulings issued Feb. 14 and Feb. 15 (Community Health Choice Inc. v. The United States, No. 18-5C, Common Ground Healthcare Cooperative v. The United States, No. 17-877C, Local Initiative Health Authority, et al. v. The United States, No. 17-1542C, Fed. Clms.).

  • February 15, 2019

    Judge Allows Oregon To Intervene In ACA Contraceptive Rules Suit

    SAN FRANCISCO — Oregon filed a timely motion seeking intervention in a suit over Patient Protection and Affordable Care Act (ACA) rules, and adding it as a plaintiff would have no negative impact on the case, a federal judge in California held Feb. 1 (California, et al. v. Alex M. Azar II, et al., No. 17-5783, N.D. Calif.).

  • February 15, 2019

    Judge: Mental Health Provider May Fall Outside Plan’s Wilderness Exclusion

    SALT LAKE CITY — Because an insurer apparently failed to fully assess the services provided by a mental health care provider who happens to provide those services outdoors, its denial was arbitrary and capricious, a federal judge in Utah said Feb. 13 in remanding a case for further review (Michael and Madeline D. v. Anthem Health Plans of Kentucky, No. 17-675, D. Utah, 2019 U.S. Dist. LEXIS 24367).

  • February 15, 2019

    Judge: ‘Surprise Bill’ Assignment Exemption Permits Amended Complaint

    NEW YORK — An exemption in an anti-assignment clause for surprise bills potentially provides grounds for avoiding the exclusion and warrants allowing a brain surgery provider to amend his complaint against a patient’s insurer, a federal judge in New York held Feb. 1 (Jeffrey Farkas, M.D. LLC, et al. v. Group Health Inc., et al., No. 18-8535, S.D. N.Y., 2019 U.S. Dist. LEXIS 17756).

  • February 15, 2019

    Judge Says Provider Must Exhaust Medicare Remedies Before Filing Suit

    CENTRAL ISLIP, N.Y. — A home nursing care provider must exhaust all administrative remedies before filing suit because its claim involves authorization for services covered by a Medicare plan, a federal judge in New York held Jan. 29 (Sarene Services Inc., et al. v. Empire Blue Cross/Blue Shield, an Anthem Co., No. 17-5276, E.D. N.Y., 2019 U.S. Dist. LEXIS 15605).

  • February 14, 2019

    Medicaid Expansion Passes Constitutional Muster, Idaho Supreme Court Says

    BOISE, Idaho — The 2018 law expanding Medicaid in Idaho withstands constitutional scrutiny, a majority of the state’s high court held Feb. 5 (Brent Regan, et al. v. Lawrence Denney, et al., No. 46545, Idaho Sup., 2019 Ida. LEXIS 22).

  • February 14, 2019

    Judge: Surgery Provider’s Reimbursement Claims Implicate ERISA, Are Preempted

    TRENTON, N.J. — Because all of a surgery provider’s allegations flow through an Employee Retirement Income Security Act-governed plan, its claims seeking reimbursement are preempted and must be dismissed, a federal judge in New Jersey held Jan. 23 (Atlantic Shore Surgical Associates v. United Healthcare/Oxford, et al., No. 18-9506, D. N.J., 2019 U.S. Dist. LEXIS 14413).

  • February 14, 2019

    Substance Abuse Provider: Insurer’s ‘Feigned Ignorance’ Merely An Attempt At Delay

    LOS ANGELES — A substance abuse provider who claims in a Feb. 11 brief that its patients’ insurer reneged on promised payment for treatment and the insurer who claims in a motion that the action includes only vague and conclusory allegations await a judge’s decision on the case (TML Recovery v. Humana, No. 18-462, C.D. Calif.).

  • February 14, 2019

    Judge Finds Lack Of Private Right Of Action Dooms ACA Class Action

    ORLANDO, Fla. — The lack of a private right of action dooms federal claims alleging that an insurer improperly terminated Patient Protection and Affordable Care Act (ACA) insurance policies, a federal judge in Florida held Jan. 31 while remanding the remaining state law claims (Heather Rosenberg, et al. v. Blue Cross and Blue Shield of Florida Inc., No. 18-2648, M.D. Fla., 2019 U.S. Dist. LEXIS 15461).

  • February 13, 2019

    Judge Boots Case Seeking Coverage For Residential Mental Health Care

    ST. LOUIS — An insurer properly denied coverage for residential mental health treatments for which preauthorization was never granted and that was at a higher level of care than required, a federal judge in Missouri held Feb. 11 in granting summary judgment in an Employee Retirement Income Security Act case (Angela Dailey v. Blue Cross and Blue Shield of Kansas City, et al., No. 17-1036, W.D. Mo., 2019 U.S. Dist. LEXIS 21587).

  • February 11, 2019

    Judge: ACA Doesn’t Preempt Charity Care Condition In Hospital Purchase Agreement

    SACRAMENTO, Calif. — A health care company has not shown how the Patient Protection and Affordable Care Act (ACA) or other federal law conflicts with a charity care provision imposed on it as a condition of its purchase of a California hospital, a federal judge in California held Feb. 6 in dismissing the case without leave to amend (Deanco Healthcare LLC, et al. v. Xavier Becerra, et al., No. 18-3934, C.D. Calif., 2019 U.S. Dist. LEXIS 19459).

  • February 7, 2019

    ACA Insurers Seek High Court Review Of Risk-Corridor Cases

    WASHINGTON, D.C. — Congress’ promise to cover Patient Protection and Affordable Care Act (ACA) risk-corridor liabilities only to revoke that duty in vaguely worded appropriations riders is a “bait-and-switch” tactic that leaves the government completely unaccountable, a quartet of insurers tell the U.S. Supreme Court in a trio of Feb. 4 petitions (Land of Lincoln Mutual Health Insurance Co. v. United States, No. N/A, Moda Health Plan Inc. v. United States, No. 18-1028, Blue Cross and Blue Shield of North Carolina v. United States, No. 17-2154, Maine Community Health Options v. United States, No. 18-1023, U.S. Sup.).

  • February 7, 2019

    Class Claims Anthem Misrepresented Coverage In ACA Exchanges

    ATLANTA — The lone Patient Protection and Affordable Care Act (ACA) insurer for many counties in Georgia represented coverage of the state’s largest health network, knowing all the while that it would not contract with the provider for 2019, a class claims in a Feb. 5 complaint (Frances Kirby, et al. v. Anthem Inc., et al., No. 19-597, N.D. Ga.).

  • February 4, 2019

    Sky Isn’t Falling; Maryland Lacks Standing To Pursue ACA Lawsuit, Judge Says

    BALTIMORE — President Donald Trump’s public disdain for, and regulatory response to, the Patient Protection and Affordable Care Act (ACA) are not evidence that the sky is falling and are not sufficient to give Maryland standing to sue to protect the law, a federal judge in Maryland held Feb. 1 (Maryland v. United States, et al., No. 18-2849, D. Md.).

  • January 31, 2019

    Health Insurer Escapes Claims In Parity Act Wilderness Coverage Case

    CINCINNATI — An insurer’s blanket exclusion on wilderness therapy coverage applies equally to mental health and other medical claims and does not violate the federal law, a federal judge in Ohio held Jan. 28 (A.G., et al. v. Community Insurance Co., et al., No. 180300, S.D. Ohio, 2019 U.S. Dist. LEXIS 13168).

  • January 31, 2019

    Dismissal Of Provider’s ACA Discrimination Case Affirmed By 11th Circuit

    ATLANTA — A medical provider presents no evidence suggesting that an employer chooses to impose anti-assignment provisions only when used by women or minorities, the 11th Circuit U.S. Court of Appeals said Jan. 28 in affirming dismissal of a Patient Protection and Affordable Care Act (ACA) discrimination action (W.A. Griffin v. General Electric Co., et al., No. 18-10046, 11th Cir.; 2019 U.S. App. LEXIS 2756).

  • January 30, 2019

    Health Insurer Says Standing, Failure To State Claim Doom ERISA Action

    SANTA ANA, Calif. — A surgery center lacks valid assignments of rights, but even if it had standing to pursue its Employee Retirement Income Security Act claims, it fails to adequately state any of them, an insurer tells a California federal judge in a Jan. 28 memo (California Surgical Institute Inc., et al. v. Aetna Life and Casualty [Bermuda] Ltd., et al., No. 18-2157, C.D. Calif.).