Mealey's Health Care / ACA
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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.
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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.
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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.
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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.
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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.”
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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.
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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.
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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.
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January 31, 2022
Judge Faults Provider’s Vague Assignment, Contract Claims In Dismissing Action
CHICAGO — Broad allegations about assignments of rights without explanation of what rights were assigned are not enough for standing as an assignee, a federal judge in Illinois said Jan. 13, while also finding third-party and quasi-contract claims deficient.
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January 31, 2022
Federal Employee Appeals Ruling Rejecting Proton Beam Coverage Case
HOUSTON — A woman denied coverage for proton beam therapy by her federal health plan whose claims were found to be preempted by federal benefits law or sovereign immunity filed notice on Jan. 18 that she intends to appeal the decision.
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January 31, 2022
Judge: Reimbursement Rate Testimony Is Reliable; Portion Of Rebuttal Irrelevant
OKLAHOMA CITY — An Oklahoma federal judge in separate orders on Jan. 26 denied a motion to exclude a medical provider’s expert’s testimony on reimbursement rates and granted the provider’s motion to exclude a portion of the insurer’s rebuttal witness’s testimony, finding that it was irrelevant under Daubert v. Merrell Dow Pharmaceuticals Inc.
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January 31, 2022
California Supreme Court Denies Review, Depublication In UCL Hospital Pricing Suit
SACRAMENTO, Calif. — The California Supreme Court on Jan. 26 declined a petition for review and request for depublication of an opinion finding that even under the most generous standard, a hospital’s failure to disclose an emergency room fee separate from its listed charges did not constitute a violation of the California unfair competition law (UCL) or the California Consumers Legal Remedies Act (CLRA).
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January 31, 2022
Editor’s Note
The journalists and staff of Mealey’s Litigation Reports are saddened by the passing of co-founder Michael P. Mealey. He was a respected member of the newsletter community, being named publisher of the year by the National Newsletter Association and president of the National Newsletter Association. Mike and Judy Mealey started Mealey Publications Inc. in 1984. As president, Mike grew the Mealey’s Litigation Report portfolio, introduced email news bulletins and electronic CD formats and launched a continuing legal education conference business. Mealey’s was sold to LexisNexis in 2000. We hope to carry on his journalistic curiosity and integrity in the titles we continue to publish today under his name.
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January 27, 2022
Insurer Tells California Supreme Court Medical Group Lacks Standing For UCL Claim
SAN FRANCISCO — An insurer urges the California Supreme Court in its Jan. 25 answer brief to affirm an appellate court’s ruling that a physicians’ association lacks standing under California’s unfair competition law (UCL) to seek injunctive relief regarding the insurer’s policy of restricting physicians from making out-of-network referrals.
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January 26, 2022
2nd Circuit Affirms: Class Can Appeal Denial Of Medicare Coverage For Hospital Stays
NEW YORK — The Second Circuit U.S. Court of Appeals on Jan. 25 affirmed a lower court’s finding that the U.S. secretary of Health and Human Services (HHS) violated the due process rights of a class of Medicare beneficiaries placed on observation status after being admitted to the hospital as inpatients, depriving of them of their property interest in Part A coverage, and order that the secretary create a process to permit those members to appeal the denial of their coverage, finding “no merit” to the secretary’s challenges.
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January 26, 2022
Sometimes ‘Puzzled’ Judge Nixes Provider’s Implied Contract, Quantum Meruit Case
SAN JOSE, Calif. — A federal judge dismissed a provider’s implied contract and quantum meruit claims against an insurer on Jan. 21 after saying she was “puzzled” and “perplexed” by a couple of arguments where it seemingly ignored evidence or attacked arguments the insurer did not make.
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January 25, 2022
Individual ERISA, Class Claims Survive Dismissal In Mental Health Coverage Case
SALT LAKE CITY — An insured’s death does not preclude her estate from pleading Employee Retirement Income Security Act and Parity Act claims in the alternative, allegations that the largest employer in the state systemically underpays for mental health treatments by pegging out-of-network reimbursements to an outdated in-network chart support class claims and no precedent requires her to allege at the motion to dismiss stage that every class member exhausted administrative remedies, a federal judge in Utah said in denying a motion to dismiss on Jan. 20.
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January 21, 2022
Court: 4-Year Limitations Period Applies To ACA Discrimination Claim
CINCINNATI — A man’s claim alleging discrimination in violation of the Patient Protection and Affordable Care Act (ACA) arises under that statute and not the underlying discrimination statute from which it borrows, a Sixth Circuit U.S. Court of Appeals panel said Jan. 18, affirming denial of a motion to dismiss the action as untimely.
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January 21, 2022
Judge Partially Dismisses Claims Against Insurers, Network Developer
NEW YORK — A surgery provider’s claims against two insurers are not preempted, and contract claims against a preferred provider network developer seek to enforce contract terms, not hold it liable for failing to make payments, a federal judge in New York said in partially granting dismissal on Jan. 18.
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January 21, 2022
DaVita To High Court: Unique Need Makes Dialysis Plan Discriminatory Under MSPA
WASHINGTON, D.C. — Treating outpatient dialysis differently than other services by linking its reimbursement to Medicare rates “uniquely disadvantages” patients with end-stage renal disease (ESRD), a provider argues in a Jan. 19 brief, urging the U.S. Supreme Court to affirm a split Sixth Circuit U.S. Court of Appeals panel’s ruling that the provider plausibly alleged violation of the Medicare Secondary Payor Act (MSPA) under a discrimination-by-proxy or a disparate-impact theory.