Mealey's Health Care / ACA

  • March 01, 2023

    Justice Dismisses Providers’ Compensation Claims As Preempted, Unfounded

    NEW YORK — Because an out-of-network provider’s state law action seeking additional compensation from an insurer relates to Employee Retirement Income Security Act plans, it is preempted, and the agreement letters sent to insureds approving out-of-network treatment do not form a basis for a contract claim, a New York justice said in two slip opinions granting a motion to dismiss.

  • March 01, 2023

    Shared Saving Network Claims Don’t Trigger ERISA Preemption, Judge Says

    MIAMI — A dispute between a medical provider and an insurer over the proper compensation owed under a shared savings program does not invoke an insured’s Employee Retirement Income Security Act plan, and the allegations are sufficient to overcome dismissal, a federal judge in Florida said Feb. 28 in adopting a magistrate judge’s recommendation that the court deny a motion to dismiss.

  • March 01, 2023

    Judge: Insurer-Employer Dispute Invokes Contract, Not ERISA Fiduciary Duty

    DETROIT — A dispute between an employer and a Blue Cross entity contracted to administer the self-insured health plan that allegedly overpaid on some claims is at its heart a contract dispute and not one involving fiduciary duties under the Employee Retirement Income Security Act, a federal judge in Michigan said in granting a motion to dismiss.

  • February 24, 2023

    Blue Cross Wants Transgender Discrimination Class Undone

    TACOMA, Wash. — Recent precedent establishes that reprocessing of health insurance claims isn’t a remedy unto itself but instead a means to a remedy and making the type of individualized decisions on medical necessity and amount of coverage warrants decertifying a class alleging discrimination in a plan’s exclusion for gender-affirming care, an insurer says in a motion.

  • February 22, 2023

    9th Circuit Affirms Order Compelling Compliance With ERISA Oral Settlement

    LOS ANGELES — Because a written agreement did not deviate from the terms of the orally agreed settlement, a district court did not abuse its discretion by granting a motion to enforce the settlement between a provider of medical services and an insurer, a Ninth Circuit U.S. Court of Appeals panel said.

  • February 21, 2023

    Supreme Court Extends Time For Response In Medicaid Private Right Of Action Case

    WASHINGTON, D.C. — After asking for a response to a petition challenging a ruling finding that medical providers could bring suit for nonpayment under Medicaid, the U.S. Supreme Court on Feb. 17 granted the respondents additional time to make their filing.

  • February 21, 2023

    5th Circuit: ERISA Claim Moot After Texas Emergency Care Right-Of-Action Ruling

    HOUSTON — The Texas Supreme Court’s holding on a certified question that the state’s emergency care statutes lack a private right of action requires dismissal of that claim and moots an Employee Retirement Income Security Act claim, the Fifth Circuit U.S. Court of Appeals said.

  • February 21, 2023

    Texas High Court Seeks Response In Out-Of-Network Arbitration Award Case

    FORT WORTH, Texas — The Texas Supreme Court on Feb. 17 sought an insurer’s response to a petition alleging that an appeals court improperly reinstated an arbitration award in its favor despite a dearth of evidence supporting its proposed payment rate for out-of-network care.

  • February 16, 2023

    Federal Judge Rules On Qui Tam FCA Suit Against Behavioral Health Provider

    ALBUQUERQUE, N.M.  — A New Mexico federal judge granted in part insurers’ motion to dismiss a qui tam suit filed against them under federal and state false claims act statutes regarding the insurers’ alleged false representations in their bid to administer state behavioral health services, finding that the false representation claims are statutorily time-barred and that the relator failed to provide evidence to support a state law Medicaid fraud claim.

  • February 15, 2023

    Discretionary Authority, Plan Assets Arguments Made In 1st Circuit In ERISA TPA Row

    BOSTON — In oral argument before the First Circuit U.S. Court of Appeals that featured many questions, the appellants and amicus curiae the U.S. Labor secretary’s office contended that the third-party administrator (TPA) of a self-funded plan was a functional fiduciary under the Employee Retirement Income Security Act, and the TPA contended that it was not.

  • February 15, 2023

    Judge Dismisses COVID Test Provider’s Class Suit Alleging Underpayment By Insurer

    SAN FRANCISCO — A California federal judge granted a motion to dismiss a coronavirus testing site operator’s amended putative class complaint against an insurer for failure to reimburse providers for COVID-19 tests allegedly in violation of the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and other statutes, dismissing all claims without leave to amend except the claim that the insurer violated California’s unfair competition law (UCL) under the unlawful prong.

  • February 14, 2023

    Judge Dismisses Liquidating Trustee’s Suit Against Aetna Per Joint Stipulation

    DALLAS — Per a joint stipulation of dismissal, a Texas federal judge dismissed with prejudice a suit filed by a collection agent for a company in liquidation, asserting that Aetna failed to reimburse the company, which obtained assignments of benefits for medical services provided to Aetna’s insureds under their benefit plans, some of which are governed by the Employee Retirement Income Security Act.

  • February 14, 2023

    Rule Adopting Insurers’ Drug Payment Limiting Program Unlawful, Amici Argue

    WASHINGTON, D.C. — The government’s “disastrous and discriminatory” condoning of insurers’ program excluding prescription drug assistance programs from deductibles and other out-of-pocket calculations violates the Patient Protection and Affordable Care Act (ACA) and the regulatory definition cost sharing, three amici argue in support of a policy group’s motion for summary judgment in the U.S. District Court for the District of Columbia.

  • February 13, 2023

    Now Facing Summary Judgment, Provider Must Respond To Standing, Other Defenses

    NEW YORK — A federal judge in New York said Feb. 10 that to consider a health insurer’s claims chart appearing to show that the majority of more than 1,800 claims are barred by anti-assignment provisions, he would convert a motion to dismiss into one for summary judgment and give the chiropractic plaintiff a chance to defend against standing and preemption challenges.

  • February 13, 2023

    Summary Judgment On Takings Claim Sought In ACA Transitional Reinsurance Row

    WASHINGTON, D.C. — With entry of judgment pending on an illegal exaction claim in a case concerning the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA), the government moved in U.S. Federal Claims Court for summary judgment as to a takings claim.

  • February 08, 2023

    Insurers Say Third-Party Assignee Lacks Standing In ERISA Appeal

    PASADENA, Calif. — A company that was assigned rights that a medical provider received on assignment from patients does not fall under the narrow exception for standing under the Employee Retirement Income Security Act and never identifies the specific plan terms that would entitle it to additional payment, insurers tell the Ninth Circuit U.S. Court of Appeals in an appellee brief.

  • February 09, 2023

    Medical Providers: Unlawful No Surprises Act Fee Hike ‘Economically Crippling’

    TYLER, Texas — A surprise sevenfold increase in the No Surprises Act administrative fee will be “economically crippling” and effectively bars specialty medical providers and others with small-value claims from the process entirely, providers warn in a complaint filed in Texas federal court.

  • February 08, 2023

    4 New Suits Challenge 2014 ACA Transitional Reinsurance Program Payments

    WASHINGTON, D.C. — Alleging illegal exaction of contributions under the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA), four entities that say they have self-insured, self-administered employee health and welfare benefit plans (SISAs) have filed separate suits in the U.S. Federal Claims Court against the government.

  • February 08, 2023

    Judge Vacates Rule Implementing No Surprises Act Arbitration Process

    TYLER, Texas — While the government rephrased language governing the No Surprises Act (NSA) arbitration process that a court found troublesome, its resulting final rule continues to improperly restrict arbitrators and overweight certain factors, a federal judge in Texas said.

  • February 07, 2023

    Certification In ACA Transitional Reinsurance Row Claims Nearly $183M In Damages

    WASHINGTON, D.C. — The government would owe 354 self-insured, self-administered (SISA) employee health and welfare benefit plans damages totaling $182,826,889.42 under a certification of class membership filed in the U.S. Federal Claims Court in a case concerning the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA).

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