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).
WASHINGTON, D.C. — Appropriations riders simply limited Patient Protection and Affordable Care Act (ACA) risk-corridor funding and cannot be read as repealing payments obligations under the program, five insurers told the U.S. Supreme Court on Aug. 30 (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.).
WASHINGTON, D.C. — Louisiana Health Service & Indemnity Co., doing business as Blue Cross and Blue Shield of Louisiana (BCBSLA), filed a petition for a writ of certiorari on Aug. 14 asking the U.S. Supreme Court to decide whether a federal court may expand the boundary of a state law and whether medical providers may pursue an action under the Employee Retirement Income Security Act (Louisiana Health Service & Indemnity Co. v. Encompass Office Solutions, Inc., No. 19-196, U.S. Sup.).
SEATTLE — Plaintiffs challenging an insurer’s blanket exclusion of applied behavior analysis therapy as used for those with autism asked a federal court in Washington on Aug. 15 to certify the case as a class action (J.R., et al. v. Blue Cross and Blue Shield of Illinois, et al., No. 18-01191, W.D. Wash.).
TRENTON, N.J. — A health insurer ask a federal judge in New Jersey to dismiss an orthopedic medical provider’s “kitchen-sink approach” to allegations in a July 17 memo, but the provider says in an Aug. 20 opposition that Aetna relies on outdated plan documents and attacks claims pleaded in the alternative (Somerset Orthopedic Associates, et al. v. Aetna Inc., et al., No. 19-12544, D. N.J.).
TRENTON, N.J. — A proposed class of self-insured health plans in which Aetna Life Insurance Co. allegedly imposes undisclosed internal standards for coverage would require access to plan documents the plaintiffs have not submitted, a federal judge in New Jersey said Aug. 20 in dismissing the expanded class (E.S., et al. v. Marsh & McLennan Companies Inc. Benefits Administration Committee, et al., No. 17-3351, D. N.J., 2019 U.S. Dist. LEXIS 141163).
SALT LAKE CITY — A Utah federal judge on Aug. 13 granted summary judgment to an interpreter service accused of discrimination under the Patient Protection and Affordable Care Act (ACA) and other laws. The couple filed a notice on Aug. 18 that they intended to take the issue to the 10th Circuit U.S. Court of Appeals (Zach Johnston, et al. v. Intermountain Healthcare, et al., No. 18-3, D. Utah).
FORT LAUDERDALE, Fla. — Failure to exhaust administrative remedies provides an absolute bar to Employee Retirement Income Security Act claims, and there is no evidence that the provider’s services conferred a benefit on the insurer, dooming the remainder of the case, a federal magistrate judge in Florida said Aug. 14 (GVB MD LLC, et al. v. United Healthcare Insurance Co., No. 19-20727, S.D. Fla.).
LOS ANGELES — Aetna Life Insurance Co. asked a federal judge in California on Aug. 13 for dismissal of what remains of an Employee Retirement Income Security Act case as a sanction for health care providers’ failure to comply with a court deadline for settlement negotiations (Infoneuro Group, et al. v. Aetna Life Insurance Co., No. 16-5083, C.D. Calif.).
CHICAGO — A federal judge in Illinois on Aug. 13 held that she lacked jurisdiction over a case filed by an insolvent health insurer’s liquidator against the Centers for Medicare and Medicaid Services (CMS) and the U.S. government in which the liquidator sought to have an offset payment system be declared unlawful (Kevin Fry v. Centers for Medicare and Medicaid Services, et al., No. 19-1320, N.D. Ill., 2019 U.S. Dist. LEXIS 136175).
JACKSONVILLE, Fla. — Collateral estoppel prevents a woman from pursuing breach of contract claims in a health insurance coverage case, and conduct regulated by the office of insurance is exempt from the state’s unfair competition law, a Florida appeals court held Aug. 13 (Meghan Hotchkiss v. Blue Cross and Blue Shield of Florida Inc., No. 1D17-4097, Fla. App., 1st Dist., 2019 Fla. App. LEXIS 12382).
BROOKLYN, N.Y. — Simply arguing that a health insurer could have or should have covered residential mental health treatments is not enough to support an Employee Retirement Income Security Act suit, a federal magistrate judge in New York said July 30 (Samuel Halberg, et al. v. United Behavioral Health, et al., No. 16-6622, E.D. N.Y., 2019 U.S. Dist. LEXIS 128966).
ST. LOUIS — The Patient Protection and Affordable Care Act (ACA) cannot simultaneously require coverage for lactation services while permitting insurers to place administrative barriers that make obtaining that care impossible, two women tell the Eighth Circuit U.S. Court of Appeals in an Aug. 7 reply brief (Jillian York, et al. v. Wellmark Inc., et al., No. 19-1705, 8th Cir.).