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Mealey's Health Care / ACA

  • 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.).

  • January 30, 2019

    Aetna Points To Assignment, Preemption Issues With Sleep Center’s Suit

    TRENTON, N.J. — A sleep center’s claims invoke the Employee Retirement Income Security Act despite its best attempts to circumvent that fact and are preempted or barred by a health insurance plan’s anti-assignment provision, an insurer tells a federal judge in New Jersey in a Jan. 28 reply brief (Sleep Tight Diagnostic Center, et al. v. Aetna Inc., et al., No. 18-3556, D. N.J.).

  • January 24, 2019

    Anti-Abortion Group Says Oregon’s Motion To Intervene In ACA Spat Too Late

    SAN FRANCISCO — An anti-abortion organization told a federal judge on Jan. 22 that a state’s motion to intervene comes much too late in a case challenging rules expanding exemptions to the Patient Protection and Affordable Care Act (ACA) contraceptive mandate for moral and religious objectors (The State of California, et al. v. Alex M. Azar II, et al., No. 17-5783, N.D. Calif.).

  • January 23, 2019

    Department Of Labor Says Alleged Insurance Underpayment Provides Standing

    ST. LOUIS — A couple adequately allege injury from what they claim is an improper denial of health insurance coverage, and the fact that they assigned the right to any recovery in their ERISA suit to the provider does not strip them of it, the U.S. Department of Labor (DOL) tells a federal appeals court in a Jan. 22 amicus curiae brief (Ivan Mitchell, et al. v. Blue Cross Blue Shield of North Dakota, et al., No. 18-2784, 8th Cir.).

  • January 22, 2019

    Couple, Health Insurer Debate Air Transport Coverage Ruling In 8th Circuit

    ST. LOUIS — A health insurer had no policy for calculating air transport payments before receiving a claim, and in an effort to evade this fact created post-hoc rules and justifications, a couple told the Eighth Circuit U.S. Court of Appeals on Jan. 10 in an Employee Retirement Income Security Act suit (Ivan Mitchell, et al. v. Blue Cross Blue Shield of North Dakota, et al., No. 18-2784, 8th Cir.).

  • January 22, 2019

    ACA Discrimination Claims Against Rehab Provider Fail, Federal Judge Says

    DALLAS — A woman lacks standing to pursue equitable claims arising from alleged discrimination in the provision of physical therapy, and her claims for damages under the Patient Protection and Affordable Care Act (ACA) and other statutes are prohibited, a federal judge in Texas held Jan. 16 (Jane Cummings v. Premier Rehab P.L.LC., No. 18-649, N.D. Texas, 2019 U.S. Dist. LEXIS 7587).

  • January 22, 2019

    Insurer Appeals Judgment In Favor Of Out-Of-Network Health Care Provider

    LOS ANGELES — An insurer and employer on Jan. 4 appealed a California federal judge’s conclusion that they improperly paid insureds rather than an out-of-network provider and the resulting $418,326.6 judgment against them (Martin Luther King Jr. Community Hospital v. Community Insurance Co., d/b/a Anthem Blue Cross and Blue Shield, et al., No. 16-3722, C.D. Calif.).