Mealey's Health Care / ACA
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March 11, 2020
Health Insurer’s Outsourcing Of Out-Of-Network Claims Frees It From $500K Suit
NEWARK, N.J. — An insurer outsourced the handling of out-of-network insurance claims, giving it no fiduciary role in a provider’s attempts at recovering $595,833.53, a federal judge in New Jersey said March 6 (IJKP Opco LLC, et al. v. General Trading Co, et al., No. 17-6131, D. N.J., 2020 U.S. Dist. LEXIS 39585).
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March 11, 2020
ACA Discrimination Case Supports Emotional Distress Damages, Woman Says
NEW ORLEANS — A discrimination claim under the Patient Protection and Affordable Care Act (ACA) permits an award of emotional distress damages, a deaf and blind woman argues in asking the Fifth Circuit U.S. Court of Appeals for en banc rehearing on March 8 (Jane Cummings v. Premier Rehab Keller PLLC, et al., No. 19-10169, 5th Cir.).
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March 10, 2020
Billing Error Can’t Free Insurer From Emergency Care Payment, Court Says
LOS ANGELES — Allowing an insurer to sidestep California law mandating that providers receive reasonable rates for emergency care would not be following the intent of the law, a state appeals court held Feb. 27 (San Jose Neurospine v. Aetna Health of California Inc., et al., No. B296716, Calif. App., 2nd Dist.).
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March 05, 2020
Judge Cuts Out Portions Of Skull Surgery Payment Case
BROOKLYN, N.Y. — A provider group’s claim to full compensation for a member’s surgical procedure is not supported by the plan language, but it is impossible to tell from the existing record whether the payments the insurer did make complied with the plan, a federal judge in New York held March 2 (Long Island Neurological Associates P.C. v. Empire Blue Cross Blue Shield, et al., No. 18-3963, E.D. N.Y.).
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March 04, 2020
Judge Adopts Report Finding Education Exclusion Creates Parity Act Violation
MINNEAPOLIS — A health insurance plan violated the Parity Act by denying coverage at residential treatment facilities despite covering similar treatment in the skilled nursing setting, a federal judge in Minnesota said Feb. 28 in adopting a report and recommendation in a case the magistrate judge termed not “run-of-the-mill” (L.P., et al. v. BCBMS Inc., et al., BCBSM Inc., et al. v. J.P. No. 18-1241, D. Minn.).
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March 02, 2020
Supreme Court To Decide If ACA Individual Mandate Remains Constitutional
WASHINGTON, D.C. — The U.S. Supreme Court on March 2 agreed to decide whether eliminating the Patient Protection and Affordable Care Act (ACA) individual mandate penalty rendered the entire law unconstitutional (California, et al. v. Texas, et al, No. 19-840, United States House of Representatives v. Texas, et al., No. 19-841, U.S. Sup.).
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February 27, 2020
Judge: Insurer Never Requested Procedures, Dooming Provider’s Quantum Meruit Claim
SAN JOSE, Calif. — There is no evidence that an insurer requested that a spine surgery provider perform procedures on insureds, dooming the provider’s quantum meruit claim, a California federal judge held Feb. 24 (California Spine and Neurosurgery Institute v. United Healthcare Insurance Co., et al., No. 19-2417, N.D. Calif., 2020 U.S. Dist. LEXIS 32056).
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February 24, 2020
ACA Mandate Petitioners: Cross-Petition Is Wrong, But Appropriate
WASHINGTON, D.C. — While wrong on the merits, various states’ cross-petition provides the opportunity for consideration of all issues surrounding a Patient Protection and Affordable Care Act (ACA) individual mandate challenge, two petitioners told the U.S. Supreme Court in letter briefs filed Feb. 19 (Texas, et al. v. State of California, et al., No 19-1019, U.S. Sup.).
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February 20, 2020
Insured Still Can’t Link Payment Claims, Health Plan, Judge Says
TRENTON, N.J. — In once again dismissing an action seeking additional compensation under a health plan for reconstructive breast surgery, a federal judge in New Jersey said Feb. 18 that the conclusory allegations do not give rise to an Employee Retirement Income Security Act claim (K.S. v. Thales USA Inc., et al., No. 17-7489, D. N.J., 2020 U.S. Dist. LEXIS 26812).
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February 20, 2020
Medical Provider’s Boilerplate Pleading Goes Too Far, Judge Says
TRENTON, N.J. — Two medical providers’ suit takes “boilerplate pleading too far” by never adequately alleging standing to pursue an Employee Retirement Income Security Act suit, or even any relationship between the patient and insurer, a federal judge in New Jersey held Feb. 18 (University Spine Center, et al. v. Anthem Blue Cross of California, et al., No. 19-12639, D. N.J., 2020 U.S. Dist. LEXIS 27549).
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February 19, 2020
Judge Enjoins Title X Abortion Rules In Maryland
BALTIMORE — A federal judge in Maryland on Feb. 14 enjoined rules governing Title X funding and the separation of abortion services from other medical services after largely finding for the plaintiffs. An appeal of an earlier ruling that the rules violated the Patient Protection and Affordable Care Act (ACA) remains pending before the Fourth Circuit U.S. Court of Appeals (Mayor and City Council of Baltimore v. Alex M. Azar II, et al., No. 19-1103, D. Md., 2020 U.S. Dist. LEXIS 26061).
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February 18, 2020
Deaf Woman Takes ACA Discrimination Suit To 2nd Circuit
NEW YORK — A deaf woman on Jan. 23 filed a notice of appeal indicating that she would take to the Second Circuit U.S. Court of Appeals a judge’s ruling applying New York state’s three-year statute of limitations to her Patient Protection and Affordable Care Act (ACA) discrimination case (Lissette Vega-Ruiz v. Northwell Health, et al., No. 19-537, S.D. N.Y.).
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February 13, 2020
Magistrate Judge Recommends Remanding Insurance Billing Spat
FORT LAUDERDALE, Fla. — An orthopedic specialist challenges only the rate of compensation and seeks payment under Florida law, putting it outside the reach of the Employee Retirement Income Security Act, a federal magistrate judge said Feb. 10 in recommending remand (Orthopaedic Care Specialists v. Aetna Life Insurance Co., No. 19-81381, S.D. Fla., 2020 U.S. Dist. LEXIS 23983).
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February 13, 2020
Florida Federal Judge Allows Some Claims Despite ‘Shotgun Pleading’
FORT LAUDERDALE, Fla. — Only the portion of an orthopedic surgery provider’s claims based on health insurance plans without an anti-assignment provision may proceed, a federal judge in Florida said Feb. 6 in again warning the plaintiff not to continue with its “shotgun pleading” style (Columna Inc. v. Cigna Health and Life Insurance Co., No. 19-80170, S.D. Fla.).
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February 12, 2020
Parity Act, ERISA Claims Proceed In Mental Health Coverage Case, Judge Says
SALT LAKE CITY — Father-daughter plaintiffs adequately allege that their health insurer applies different standards to mental health and substance abuse claims than they would medical and surgical claims when making coverage decisions, a federal judge in Utah said Feb. 7 (David P., et al. v. United Healthcare Insurance Co., et al., No. 19-225, D. Utah).
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February 12, 2020
Categorical Exclusions Keep Parity Act Claims Alive, Federal Judge Says
SALT LAKE CITY — An action alleging that a health insurer categorically denies coverage for wilderness and substance abuse programs may go forward after a federal judge in Utah on Feb. 7 declined to dismiss the claims (Johnathan Z., et al. v. Oxford Health Plans, No. 18-383, D. Utah., 2020 U.S. Dist. LEXIS 21968).
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February 11, 2020
Magistrate Judge Dismisses Hospital’s Underpayment Case Against Insurer
MIAMI — Nothing mandates that health insurance policies incorporate Patient Protection and Affordable Care Act (ACA) protections or state law governing emergency care payments, and a hospital’s suit seeking unpaid bills largely fails, a federal magistrate judge in Florida said Feb. 6 (Boca Raton Regional Hospital Inc., et al. v. Celtic Insurance Co., et al., No. 19-80650, S.D. Fla., 2020 U.S. Dist. LEXIS 21612).
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February 06, 2020
CalPERS Escapes Hospital’s Payment Suit, Court Says
LOS ANGELES — A contract between California’s public retirement system and an insurer does not confer benefits on a health care provider, and the provider’s own contract with the insurer does not create a payment obligation on the part of the system, a California appeals court held Feb. 5 (County of Monterey v. California Employees Retirement System, No. H045977, Calif. App., 6th Dist., 2020 Cal. App. Unpub. LEXIS 848).
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February 05, 2020
Respondents: Supreme Court Should Wait To Review ACA Individual Mandate Case
WASHINGTON, D.C. — There is no need for the U.S. Supreme Court to weigh in on an interlocutory order finding standing and that the individual mandate is unconstitutional when it can simply bide its time and address a more full record later, three respondents and an amicus curiae party tell the court in Feb. 3 briefs (California, et al. v. Texas, et al, No. 19-840, United States House of Representatives v. Texas, et al., No. 19-841, U.S. Sup.).
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January 30, 2020
5th Circuit Won’t Take ACA Individual Mandate Case En Banc
NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals on Jan. 29 declined en banc rehearing in a Patient Protection and Affordable Care Act (ACA) individual mandate case after one of its members asked that the court be polled on the question. A pair of petitions for review are pending before the U.S. Supreme Court (Texas, et al. v. United States, et al., No. 19-10011, 5th Cir.).