Mealey's Health Care / ACA

  • February 15, 2022

    Providers: Molina Casts Doctors As ‘Greedy’ In Hopes Of Avoiding Payment

    AUSTIN, Texas — An insurer casts doctors as “greedy villains” in hopes of dodging the fact that the statutory text of the Texas emergency care laws and precedent permit medical providers to sue insurers who underpay for care, doctors tell the Texas Supreme Court in a Feb. 11 reply brief on the merits.

  • February 15, 2022

    Court: Filed Rate Doctrine Doesn’t Bar Insureds’ Network Misrepresentation Claims

    ATLANTA — A lawsuit alleging that an insurer overstated the extent of its network and violated plan terms by requiring insureds to obtain a referral before seeing specialists doesn’t challenge premiums and doesn’t run afoul of the filed rate doctrine, a Georgia appeals court said Feb. 7 in affirming denial of the insurer’s motion to dismiss.

  • February 14, 2022

    Judge: Unexplained Insurance Payment Calculations An Abuse Of Discretion

    CHARLOTTE, N.C. — Plan language capped an insurer’s responsibility at the “allowed amount,” but its varying means of calculating that amount and its failure to explain why it relied on different methods constitute an abuse of discretion, as does its complete denial of coverage where it concedes that some form of treatment was medically necessary, a federal judge in North Carolina said Feb. 9 in granting the insured summary judgment and remanding the case.

  • February 14, 2022

    Provider’s Implied Contract, Unjust Enrichment Claims Lack Basis, Judge Says

    MIAMI — Verification of coverage is not a promise to pay any specific amount, and any benefit a plastic surgery center’s treatment of an insured bestowed upon an insurer was indirect at best, a federal judge in Florida said Feb. 9 in dismissing with prejudice breach of implied contract and unjust enrichment claims against the insurer.

  • February 11, 2022

    Panel Affirms Dismissal Of Patient’s UCL Claim For Outpatient Facility Fee

    SAN DIEGO — A California appellate panel on Feb. 3 ruled that a trial court correctly dismissed a woman’s claim that a hospital violated California’s unfair competition law (UCL) by failing to properly notify her of an outpatient facility’s fees that she says cost her more than $3,000, ruling that the hospital properly provided patients with its “chargemaster.”

  • February 11, 2022

    Insurer Appeals Injunction Barring Termination Of Hospital Contract

    ATLANTA — An insurer on Feb. 8 filed an amended notice indicating that it is appealing to the Georgia Supreme Court a pair of judges’ decisions enjoining the insurer from terminating its contract with a hospital under state law enacted in response to the COVID-19 pandemic.

  • February 11, 2022

    Judge: Federal Laws Permit Provider’s COVID Testing, ERISA Billing Claims

    HOUSTON — Federal laws mandating payment for COVID testing and providing no other enforcement mechanism create an implied right of action, were enacted with providers as beneficiaries and related Employee Retirement Income Security Act claims survive arguments regarding assignment of rights and exhaustion of remedies, a federal judge in Texas said in largely denying a motion to dismiss on Jan. 19.

  • February 11, 2022

    Insured Says Blanket Wilderness Exclusion Violates Law, Contract

    SEATTLE — A health insurance contract incorporates Patient Protection and Affordable Care Act and state law requirements mandating equal treatment of medical patients and mental health patients, laws an insurer violated when it imposed a blanket exclusion on wilderness therapy treatments without regard for medical necessity, an insured tells a Washington appeals court in a Dec. 6 brief.

  • February 10, 2022

    Air Transport Company Says Surprise Billing Rule Violates Law, Upsets Process

    WASHINGTON, D.C. — A government rule’s anchoring of the arbitration process for out-of-network reimbursement disputes to the level for in-network compensation violates the surprise billing act’s intention, and following the law’s actual “baseball-style” process would not grant the arbiter unfettered power but instead promote parties to submit reasonable offers, an air transport company tells a federal judge in the District of Columbia in a Feb. 8 reply in support of staying the rule or summary judgment.

  • February 08, 2022

    Providers Prevail On Aetna’s Fraud Counterclaims, But Can’t Secure Sanctions

    OKLAHOMA CITY — A federal judge in Oklahoma granted emergency care providers summary judgment on counterclaims alleging that a 36% upcoding rate constituted fraud but denied their motion alleging pretrial misconduct and seeking sanctions on Jan. 17.

  • February 08, 2022

    Amici Call Insurer’s Scheme Shifting Dialysis Costs To Medicare Discriminatory

    WASHINGTON, D.C. — Petitioners’ “backdoor” scheme shifting the cost of dialysis treatments to Medicare threatens a decades-long balance that splits those costs between the program and private insurance that ensures that a robust network of providers exists, and its defenses cannot be squared with either the law or the reality of the system, six amici told the U.S. Supreme Court in urging affirmance Jan. 26.

  • February 08, 2022

    Aetna’s Proton Beam Denials De Novo Wrong; Class Prevails, Federal Judge Says

    FORT LAUDERDALE, Fla. — An insurer’s proton beam radiation therapy (PBRT) coverage decision was de novo wrong because it was based not on plan language but entirely on a clinical policy bulletin and saying that the “record is replete” with evidence of the treatments use that the insurer ignored when making a medical necessity determination, a federal judge in Florida said Jan. 27 in granting summary judgment.

  • February 04, 2022

    Judge: Anti-Assignment, Lack Of Payment Promise Doom Provider’s Action

    BOWLING GREEN, Ky. — Anti-assignment provisions in health plans bar an eating-disorder provider’s payment claims, and nothing in coverage verification letters supports a promissory estoppel claim, but because it was only recently disclosed that the Employee Retirement Income Security Act doesn’t govern all claims, supplemental briefing on the balance of the action is necessary, a federal judge in Kentucky said Jan. 14.

  • February 04, 2022

    Hospitals Take Emergency Care Compensation Claims To Texas High Court

    AUSTIN, Texas — Texas’ emergency care law’s mandate that insurers pay for specified care at specified rates creates an implied right of action, and nothing in the law leaves exclusive authority to the Insurance Department, hospitals argue in a Jan. 18 petition for review with the Texas Supreme Court.

  • February 03, 2022

    9th Circuit Cites Bristol In Reversing Judge’s Ruling On ERISA Derivative Standing

    PASADENA, Calif. — Citing Bristol SL Holdings, Inc. v. Cigna Health & Life Ins. Co. as “new case law,” the Ninth Circuit U.S. Court of Appeals in a Jan. 20 memorandum disposition reversed and remanded a California federal judge’s ruling as to its dismissal of a health care provider’s assignee’s Employee Retirement Income Security Act claims for lack of standing; however, the Ninth Circuit affirmed the lower court’s ruling as to dismissal of contract and quantum meruit claims.

  • February 02, 2022

    7th Circuit Denies Interlocutory Appeal Challenging Claim Reprocessing Ruling

    CHICAGO — The Seventh Circuit U.S. Court of Appeals on Jan. 31 denied interlocutory review for a challenge to a remand for reprocessing as a classwide remedy in a case involving an insurer’s denials of coverage for substance abuse treatments.

  • February 02, 2022

    1st Circuit In Partial Reversal:  Speech Therapy Denial May Violate Parity Act

    BOSTON — A health plan’s refusal to cover nonrestorative speech therapy because a beneficiary suffers from autism spectrum disorder (ASD) may violate the Mental Health Parity and Addition Equity Act (Parity Act), the First Circuit U.S. Court of Appeals ruled Jan. 31, partly reversing dismissal of a suit brought by the child’s parents and saying a Massachusetts federal court bought “into the defendants' representations of how the Plan works too much for this stage in the litigation.”

  • February 01, 2022

    Special Master Orders Sampling Of Insurer’s Residential Treatment Denials

    SAN FRANCISCO — An insurer must sample coverage denials to ascertain whether it denied coverage of certain ASAM levels and whether denials of coverage on these grounds falls within a remedies order, a special master said Jan. 20 in rejecting complaints that there is no evidence of denials based on specific ASAM levels and that performing a retroactive sampling would be overly burdensome while in a separate Jan. 5 order the judge in the case awarded $1,230,729.86 in costs and $19,628,071.88 in fees.

  • February 01, 2022

    Judge: Hospitals’ Failure To Establish Market Rate Dooms Emergency Care Claims

    MIAMI — Florida law governing compensation for emergency care requires establishing the fair market rate for those services, and because plaintiffs fail to produce evidence beyond the amount they would charge for those services, an insurer is entitled to summary judgment, a federal judge in Florida said Jan. 14.

  • January 31, 2022

    Deaf Woman Tells Top Court ACA Discrimination Case Permits Nominal Damages

    WASHINGTON, D.C. — Contract law and court precedent do not require a showing of intention discrimination for recovery of nominal damages, and allowing a ruling finding otherwise to stand threatens antidiscrimination statutes, a deaf woman pursuing a Patient Protection and Affordable Care Act (ACA) claim based on the provision of an inadequate interpreter told the U.S. Supreme Court in urging review on Jan. 12.

Can't find the article you're looking for? Click here to search the Mealey's Health Care / ACA archive.