SAN FRANCISCO — The Ninth Circuit on Dec. 9 said that while the Patient Protection and Affordable Care Act (ACA) does not create a health care-specific discrimination standard, allegations that an insurer improperly limited HIV drug purchasers’ access to critical care by requiring mail order and pick up services meet the applicable standard and also keeps a California unfair competition law claim alive (John Doe One, et al. v. CVS Pharmacy Inc., et al., No. 19-15074, 9th Cir.).
MIAMI — A lawsuit alleging that two re-pricing entities deceive providers by prominently displaying a well-known payment system while understating limitations the plan places on compensation satisfies Florida deceptive practices law claims and is not preempted by the Employee Retirement Income Security Act, a federal judge in Florida said Dec. 3 (South Broward Hospital District, et al. v. ELAP Services LLC, et al., No. 20-61007, S.D. Fla., 2020 U.S. Dist. LEXIS 226859).
ASHEVILLE, N.C. — Allegations that an insurer employed unqualified reviewers who then placed outsized importance on outdated medical criteria information support an Employee Retirement Income Security Act claim, but the balance of the man’s claims are duplicative and fail, a federal judge in North Carolina said Dec. 4 in partially granting a motion to dismiss (Jeffrey Greenwell v. Group Health Plan for Employees of Sensus USA Inc., et al., No. 19-577, W.D. N.C., 2020 U.S. Dist. LEXIS 227618).
SAN FRANCISCO — An insurer on Nov. 20 asked a federal judge in California to stay a case while it appeals what it says are serious defects in rulings on causation and in the standard applied in the case, arguing that forcing reprocessing of 67,000 claims before the appellate court weighs the challenges threatens it with irreparable harm (David Wit, et al. v. United Behavioral Health, No. 14-2346, Gary Alexander, et al. v. United Behavioral Health, No. 14-5337, N.D. Calif.).
NEW ORLEANS — Neither recent case law nor the Employee Retirement Income Security Act precludes cross-plan offsetting of debts an insurer discovered in post hoc audits, a federal judge in Louisiana on Dec. 1 said in a wide-ranging opinion, but he found that the lack of clear record precluded him from granting judgment (Omega Hospital LLC v. United Healthcare Services Inc., et al., No. 16-560, M.D. La., 2020 U.S. Dist. LEXIS 224996).
SAN FRANCISCO — A record’s scant evidence a man posed a risk of harm to himself or others supports a health insurer’s conclusion that residential treatments were not medically necessary, a Ninth Circuit U.S. Court of Appeals panel said Dec. 2 (Brian H., et al. v. Blue Shield of California, et al., No. 19-16775, 9th Cir., 2020 U.S. App. LEXIS 37632).
CINCINNATI — An individual’s own medical records indicate that residential treatment was not medically necessary and by themselves constitute dispositive evidence that an insurer’s denial of coverage was not arbitrary and capricious, a federal judge in Ohio said Nov. 30 in granting the defendant judgment (A.G., et al. v. Community Insurance Co., et al., No. 18-300, S.D. Ohio).
SAN FRANCISCO — The Medicare Secondary Payer Act (MSP) private right of action does not require the program to have actually made a payment, a Ninth Circuit U.S. Court of Appeals panel held Nov. 24 in largely reinstating a dialysis reimbursement action (DaVita Inc. v. Virginia Mason Memorial Hospital, et al., No. 19-35692, 9th Cir., 2020 U.S. App. LEXIS 37080).
SAN FRANCISCO — A health plan’s uniform handling of dialysis claims does not violate the Medicare as Secondary Payor Act, even if the impact of lower payments for that service tend to fall mostly on those with end-stage renal disease, a Ninth Circuit U.S. Circuit Court of Appeals panel said Nov. 24 (DaVita Inc., et al. v. Amy’s Kitchen Inc., et al., No. 19-15963, 9th Cir., 2020 U.S. App. LEXIS 37081).
LOS ANGELES — A group of medical providers forfeited any challenge to a demurrer by not responding to the arguments despite having nearly a year to do so, and a court properly rejected its unsupported motion to file a second amended complaint, a California appeals court said Nov. 20 (Namdy Consulting Inc. v. UnitedHealthcare Insurance Co., No. B301865, Calif. App., 2nd Dist., 2020 Cal. App. Unpub. LEXIS 7688).
SHERMAN, Texas — Plaintiffs in a class action claiming that an insurer imposes annual and yearly caps on autism treatments that it does not impose for similar services in the medical or surgical setting in violation of the Mental Health Parity and Addiction Equity Act adequately allege injury and have shown that they can represent individuals in unnamed plans, a federal judge in Texas said in denying a motion to dismiss on Nov. 23 (C.C. & L.C., et al. v. Baylor Scott & White Health, et al., No. 18-828, E.D. Texas, 2020 U.S. Dist. LEXIS 219259).
CHICAGO — A woman seeks coverage for 80 percent of two air transport bills stemming from a health emergency she experienced while vacationing in the Dominican Republic, but never alleges that the entire billed amount constitutes a covered service compensable under the Employee Retirement Income Security Act, a federal judge in Illinois said Nov. 23 (Renatta Lubinski v. CVS Health Welfare Benefit Plan, et al., No. 20-89, N.D. Ill., 2020 U.S. Dist. LEXIS 218459).
SAN FRANCISCO — Neither the Employee Retirement Income Security Act nor the specific plan in question supports awarding the full billed amount for residential care, but the evidence supports an award of $142,205 plus interest based on other single case agreements the insurer entered into, a federal judge in California said Nov. 19 (Jamie F. v. UnitedHealthcare Insurance Co., No. 19-1111, N.D. Calif., 2020 U.S. Dist. LEXIS 217170).
WASHINGTON, D.C. — A group of largely insolvent insurers argue in their Nov. 20 motion to dismiss with the U.S. Court of Federal Claims that the U.S. government is reverse-preempted under the McCarran-Ferguson Act from seeking setoffs of debts against risk-corridor liabilities owed to the insurers under the Patient Protection and Affordable Care Act (ACA) risk corridor (Health Republic Insurance Company v. United States, No. 16-259, Fed. Clms.).
WASHINGTON, D.C. — A District of Columbia U.S. Circuit Court of Appeals panel on Oct. 15 heard oral arguments in a case questioning whether a hospital price disclosure rule effective January 2021 merely requires advertising of various existing price tiers or imposes impossible hurdles that would have the “perverse” outcome of mandating that hospitals list prices no patient actually pays (The American Hospital Association, et al. v. Alex M. Azar II, et al., No. 20-5193, D.C. Cir.).
SACRAMENTO, Calif. — No precedent supports a court’s cherry-picking of which documents it wanted included as health insurance plan documents, and had it properly considered all the documents, it would have found that anti-assignment provisions barred a hospital’s Employee Retirement Income Security Act claim seeking reimbursement, an insurer argues in an Oct. 16 petition for rehearing and en banc rehearing (Martin Luther King Jr. Community Hospital v. Community Insurance Co., et al., No. 19-55053, 9th Cir.).
PHOENIX — A federal judge in Arizona refused to permit transfer of a Patient Protection and Affordable Care Act (ACA) transgender discrimination case on Oct. 20, saying it differs sufficiently from a further advanced transgender discrimination case already before her (Russell B. Toomey v. State of Arizona, et al., No. 19-35, D. Ariz.).
BATON ROUGE, La. — Any flaw in testimony based on an expert’s visit to a hospital and review of its policies produced in support of a Patient Protection and Affordable Care Act (ACA) discrimination claim can be raised during cross-examination, a federal judge in Louisiana said Nov. 10 in denying reconsideration (Sandra King v. Our Lady of the Lake Hospital Inc., No.17-530, M.D. La., 2020 U.S. Dist. LEXIS 209958).
SAN FRANCISCO — A federal judge in California did not err in finding that two state and federal statutes that require health plans governed by the Employee Retirement Income Security Act to cover mental illnesses and physical illnesses equally were not violated by a denial of benefits for the treatment of anorexia, the Ninth Circuit U.S. Court of Appeals held Nov. 9 (Suzanne Stone v. UnitedHealthcare Insurance Co., et al., No. 19-16227, 9th Cir., 2020 U.S. App. LEXIS 35276).
WASHINGTON, D.C. — Whether the Patient Protection and Affordable Care Act (ACA) individual mandate’s failure to produce revenue creates an injury, how the zeroing out of the tax affects precedent finding the tax as the basis for the law’s constitutionality, congressional intent in eliminating the tax and whether the provision can be severed from the law as a whole all came before the U.S. Supreme Court in Nov. 10 oral arguments (California, et al. v. Texas, et al, No. 19-840, Texas, et al. v. California, et al., No 19-1019, U.S. Sup.).