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).
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).
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).
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).
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.).
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).
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).
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).
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.).
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.).
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.).
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).
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).
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.).
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.).
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.).
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.).
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.).
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).
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.).