CINCINNATI — A health insurance administrator’s decision to make all dialysis companies out-of-network providers does not violate the Medicare Secondary Payor Act (MSPA), and the provider’s assignment is limited to insurance benefits and does not include the right to litigate, a federal judge in Ohio held Sept. 20 (DaVita Inc., et al. v. Marietta Memorial Hospital Employee Health Benefit Plan, et al., No. 18-1739, S.D. Ohio, 2019 U.S. Dist. LEXIS 160793).
TRENTON, N.J. — A man’s “completely unsubstantiated” allegations seeking usual and customary medical expenses for which his plan clearly does cover warrant an award of attorney fees, but the plan sponsor must submit more evidence demonstrating that its requested fees constitute reasonable charges, a federal judge in New Jersey held Sept. 24 (Clifford Robinson v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 17-4600, D. N.J., 2019 U.S. Dist. LEXIS 162702).
NEW ORLEANS — A federal judge in Louisiana largely rejected a couple’s Employee Retirement Income Act claims in Sept. 19 and 24 rulings and found that the law’s conflict preemption statute doomed the state law claims (Soileau & Associates LLC, et al. v. Louisiana Health Service & Indemnity Co., Nos. 18-310, 18-7613, E.D. La., 2019 U.S. Dist. LEXIS 159622).
NEW YORK — Allegations that health care providers treated individuals in government and church plans outside the reach of the Employee Retirement Income Security Act precludes preemption, and while the breach of contract claim survives, the remaining 10 claims are largely duplicative and must be dismissed, a federal judge in New York held Sept. 17 (Perry A. Frankel, et al. v. U.S. Healthcare Inc., et al., No. 18-6378, S.D. N.Y., 2019 U.S. Dist. LEXIS 159794).
WASHINGTON, D.C. — The U.S. Supreme Court lacks jurisdiction over a Kentucky top court ruling on standing, and nothing in a ruling precluding a hearing after an insurer denied coverage under Medicaid would warrant review, the insurer tells the court in a Sept. 19 respondent brief (Lettie Sexton, et al. v. Commonwealth of Kentucky, et al., No. 18-1446, U.S. Sup.).
SAN JOSE, Calif. — A medical provider’s allegation that an insurer confirmed a 70 percent reimbursement rate supports breach of contract claims because it goes beyond simple coverage verification, a federal judge in California held Sept. 17 (California Spine and Neurosurgery Institute v. United Healthcare Insurance Co., et al., No. 19-2417, N.D. Calif., 2019 U.S. Dist. LEXIS 159286).
SALT LAKE CITY — There is no evidence that plaintiffs seeking to recover Employee Retirement Income Security Act benefits for mental health treatments are part of other class actions, and they successfully allege disparate treatment, a federal judge held Sept. 13 (David S., et al. v. United Healthcare Insurance Co., No. 18-803, D. Utah, 2019 U.S. Dist. LEXIS 157046).
WASHINGTON, D.C. — Direct payments to health care providers do not waive anti-assignment provisions or transform the provider into the type of party that can sue an insurer under the Employee Retirement Income Security Act, industry groups tell the U.S. Supreme Court in a Sept. 13 amicus curiae brief opposing review (Louisiana Health Service & Indemnity Co. v. Encompass Office Solutions, Inc., No. 19-196, U.S. Sup.).
WASHINGTON, D.C. — In Sept. 6 amicus briefing and Aug. 30 briefs by the petitioners, the U.S. Supreme Court heard details regarding the harm caused by the government’s failure to follow through on billions of dollars of promised Patient Protection and Affordable Care Act (ACA) risk corridor payments and that later appropriations riders cannot be read as repealing those obligations (Land of Lincoln Mutual Health Insurance Co. v. United States, No. 18-1038, Moda Health Plan Inc., et al. v. United States, No. 18-1028, Maine Community Health Options v. United States, No. 18-1023, U.S. Sup.).
NEW YORK — A judge on Aug. 22 clarified that all parties have until Sept. 23 to respond to an amicus curiae brief in which the United States says the state cannot enact regulations that alter the Patient Protection and Affordable Care Act (ACA) risk corridor program (UnitedHealthcare of New York Inc., et al. v. Maria T. Vullo, et al., No. 18-2583, 2nd Cir.).
CENTRAL ISLIP, N.Y. — Assignments of rights give medical providers standing to pursue their action, and their dismissal of Employee Retirement Income Security Act claim strips the court of jurisdiction, a federal magistrate judge in New York held in a Sept. 3 report and recommendation (Long Island Thoracic Surgery, et al. v. Building Service 32BJ Health Fund, No. 17-163, E.D. N.Y., 2019 U.S. Dist. LEXIS 150761).
NEW YORK — Allegations that an insurer improperly denied coverage for out-of-network facility fees for certain providers support certification of a class seeking declaratory and injunctive relief, but not classwide benefit awards, a federal judge in New York held Sept. 11 (The Medical Society of the State of New York, et al. v. UnitedHealth Group Inc., et al., No. 16-5265, S.D. N.Y.).
NEW ORLEANS — A district court erred in finding ambiguous an anti-assignment provision in an Employee Retirement Income Security Act plan and that Tennessee law making insurers liable to third-party providers necessarily implicates the plan and is preempted, a panel of the Fifth Circuit U.S. Court of Appeals held Sept. 11 (Dialysis Newco Inc., et al. v. Community Health Systems Group Health Plan, et al., No. 18-40863, 5th Cir., 2019 U.S. App. LEXIS 27418).
CORPUS CHRISTI, Texas — An out-of-network health care provider may proceed to trial on claims that an insurer did not reimburse it at the appropriate rate and has standing as the assignee of the plan beneficiaries, a Texas appeals court held Sept. 12 in reversing a directed verdict and ordering a new trial (South Coast Spine & Rehabilitation, PA v. Brownsville Independent School District, et al., No. 13-18-00006-CV, Texas App., 13th Dist., 2019 Tex. App. LEXIS 8258).
WEST PALM BEACH, Fla. — A spinal surgery provider’s allegations that it continues to serve an insurer’s customers provides a basis for a declaratory relief action, but its state law claims fail as it is not a party to the contract and did not provide services to the insurer, a federal judge in Florida held Sept. 11 (Columna Inc. v. Aetna Health Inc., No. 19-80522, S.D. Fla., 2019 U.S. Dist. LEXIS 155449).
LOS ANGELES — A gynecological surgeon provided sufficient evidence that an insurer improperly denied claims seeking payment for vitamin injections, a federal judge in California held in an Aug. 30 finding of fact and conclusion of law that otherwise largely affirmed the insurer’s decisions (Adel F. Samaan M.D. v. Aetna Life Insurance Co., et al., No.17-1690, C.D. Calif.).
FORT LAUDERDALE, Fla. — A federal judge in Florida on Sept. 5 rejected a health care provider’s objections and affirmed a report and recommendation in which a magistrate judge concluded that the plaintiff had not adequately demonstrated exhaustion of administrative remedies under the Employee Retirement Income Security Act (GVB MD LLC, et al. v. United Healthcare Insurance Co., No. 19-20727, S.D. Fla.).
OMAHA, Neb. — Insurance brokers were not fiduciaries of an Employee Retirement Income Security Act plan or did not violate their duties while helping secure health care plan contracts, a federal judge in Nebraska held in granting summary judgment on Aug. 30 (Central Valley AG Cooperative, et al. v. Daniel K. Leonard, et al., No. 17-379, D. Neb., 2019 U.S. Dist. LEXIS 148337).
TRENTON, N.J. — A health plan never explains why its Medicare-based reimbursement rate would permit it to deny claims for sterile supplies or anesthesia, a federal magistrate judge in New Jersey recommended Aug. 16 in granting a provider summary judgment on the issue while also partially granting a dueling motion by the provider (Montefiore Medical Center v. Local 272 Welfare Fund, et al., No. 17-10213, S.D. N.Y., 2019 U.S. Dist. LEXIS 140293).
SAN ANTONIO — A former executive for bankrupt medical providers may not attend depositions related to an insurer’s cross-claim alleging that the companies operated a scheme designed to increase billing rates, a federal magistrate judge in Texas held Aug. 30 (Neil Gilmour III, et al. v. Aetna Health Inc., et al., No. 17-510, W.D. Texas, 2019 U.S. Dist. LEXIS 148232).