YAKIMA, Wash. — A plaintiff credibly alleges that her insurer overstated its provider network, causing her to spend money on out-of-network care, but the individualized issues required for a remedy and the existence of superior methods of seeking relief doom the class, a federal judge in Washington said May 12 (Cynthia Harvey, et al. v. Centene Corp., et al., No. 18-12, E.D. Wash., 2020 U.S. Dist. LEXIS 83642).
WASHINGTON, D.C. — Nothing prevents a dialysis provider from pursuing reimbursement claims under a federal health insurance policy as an assignee, a federal judge in the District of Columbia said May 8 (RAI Care Centers of Maryland I v. Office of Personnel Management, No. 18-3151, D. D.C., 2020 U.S. Dist. LEXIS 81431).
LOS ANGELES — A facility provided medically necessary treatments to insureds with plans covering mental health and substance abuse treatments but was not reimbursed for the care, a plaintiff alleges in a May 7 consolidated amended complaint (ABC Services Group Inc v. Health Net of California Inc., et al., No. 19-243, C.D. Calif.).
NEW YORK — A deaf woman’s testimony at trial that she requested American Sign Language (ASL) interpreters does not entitled her to judgment, and nothing in a trial over alleged discrimination under the Patient Protection and Affordable Care Act (ACA) and other laws warrants granting a new one, a federal judge in New York said March 26 (Lizzette Vega-Ruiz v. Montefiore Medical Center, No. 17-1804, S.D. N.Y., 2020 U.S. Dist. LEXIS 53285).
BALTIMORE — The ethical and financial implications of a rule requiring strict separation of medical and abortion services for Title X funding recipients featured heavily in oral arguments before the Fourth Circuit U.S. Court of Appeals on May 7 (Mayor and City Council of Baltimore v. Alex M. Azar II, et al., Nos. 19-1614, 20-1215, 4th Cir.).
SALT LAKE CITY — A woman denied coverage for residential mental health treatments under an Employee Retirement Income Security Act plan is entitled to discovery into documents showing how the insurers calculated reimbursements and imposed nonquantitative treatment limitations, a federal judge in Utah said May 6 (Jane Doe v. Intermountain Healthcare Inc., et al., No. 18-00807, D. Utah, 2020 U.S. Dist. LEXIS 80809).
WASHINGTON, D.C. — The U.S. Supreme Court on May 6 heard telephonic oral arguments over whether the Patient Protection and Affordable Care Act (ACA) and federal law protecting religious beliefs permit rules providing religious and moral objectors exemptions from the statute’s contraceptive mandate, whether the government properly formulated the rules and whether a district court can issue a nationwide injunction blocking the rules (Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania, et al., Donald J. Trump, et al. v. Pennsylvania, Nos. 19-431, 19-454, U.S. Sup.).
CLEVELAND — Despite involving Patient Protection and Affordable Care Act (ACA) language providing marketplace policies for those with an intent to reside in the United States, a case claiming that a health insurer improperly rescinded a policy on the mistaken belief that the insureds moved to Ohio for treatment with no intent of staying belongs in state court, a federal judge in Ohio said April 22 (Ajit Tolani, et al. v. Medical Mutual of Ohio, No. 19-2388, N.D. Ohio., 2020 U.S. Dist. LEXIS 71098).
TRENTON, N.J. — Emergency care providers fail to plead adequate assignments of rights, which dooms Employee Retirement Income Security Act claims, but the plaintiffs may amend their complaint to cure the defect or move for remand if they do not wish to pursue the claims, a federal judge in New Jersey said April 30 (Emergency Physicians of St. Clare’s LLC, et al. v. Horizon Blue Cross Blue Shield of New Jersey, et al., No. 19-12112, D. N.J., 2020 U.S. Dist. LEXIS 75921).
NEWARK, N.J. — Anti-assignment provisions largely free two of three insurers from providers’ suit seeking compensation, and the providers have failed to state a claim for all but the church-plan-based claims, a federal judge in New Jersey found April 27 (Somerset Orthopedic Associates, et al. v. Horizon Healthcare Services Inc., et al., No. 19-8783, D. N.J.).
WASHINGTON, D.C. — An insolvent insurer’s demand for payment under the Patient Protection and Affordable Care Act’s (ACA) reinsurance program fails because it had already been paid based on an offset of the amount owed by the insurer under the ACA’s risk adjustment program, the U.S. government argues in its April 27 opening brief to the Federal Circuit U.S. Court of Appeals (Michael Conway v. The United States, No. 20-1292, Fed. Cir.).
NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals on March 24 denied a petition for en banc rehearing without poll, leaving stand a panel ruling that the Patient Protection and Affordable Care Act (ACA) is spending clause legislation that acts as a contract and cannot support emotional distress damages (Jane Cummings v. Premier Rehab Keller PLLC, et al., No. 19-10169, 5th Cir.).
WASHINGTON, D.C. — The Patient Protection and Affordable Care Act (ACA) risk-corridor program mandated payments that subsequent appropriations riders did not eliminate, and an insolvent insurer and its fellow petitioners may pursue the billions of dollars in lost payments in federal court, a majority of the U.S. Supreme Court said April 27 (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.).
BATON ROUGE, La. — A judge found an expert qualified to testify on hospital policies, but her opinion is unreliable because it is based on a site visit she performed in a different case in an entirely different context, a hospital told a federal judge in Louisiana April 17 (Katrina Rivers LaBouliere, et al. v. Our Lady of the Lake Hospital Inc., No. 16-785, M.D. La.).
BALTIMORE — A district court erroneously established medical providers’ ethical concerns about a Title X rule as the governing law and ignored the proper standard of review and existing precedent in concluding that abortion rules violated the Patient Protection and Affordable Care Act (ACA), federal defendants and various states tells the Fourth Circuit U.S. Court of Appeals in April 17 supplemental briefing before the en banc court (Mayor and City Council of Baltimore v. Alex M. Azar II, et al., Nos. 19-1614, 20-1215, 4th Cir.).
SALT LAKE CITY — Allegations that an insurer imposed acute level criteria on subacute care in the mental health setting but not in other medical and surgical settings successfully allege a Parity Act violation, and the claim is not duplicative of the Employee Retirement Income Security Act claim seeking benefits, a federal judge in Utah said April 7 (M.S., et al. v. Premera Blue Cross, et al., No. 19-199, D. Utah).
WASHINGTON, D.C. — The U.S. Supreme Court on April 20 granted a request by the solicitor general for divided arguments in a pair of cases involving whether the Patient Protection and Affordable Care Act (ACA) and Religious Freedom Restoration Act (RFRA) permit expanded religious and moral exemptions to the contraceptive mandate. Originally scheduled for late April, oral arguments were postponed due to the coronavirus, and the cases are now set for telephonic arguments on May 6 (Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania, et al., Donald J. Trump, et al. v. Pennsylvania, Nos. 19-431, 19-454, U.S. Sup.).
GREENSBORO, N.C. — An insurer on April 15 appealed a decision by a federal judge in North Carolina finding that the Employee Retirement Income Security Act did not preempt a dispute over reimbursement because neither party enjoyed standing under the law and that a private contract with the provider did not give rise to federal officer removal simply because some beneficiaries were federal employees or covered by Medicare (LifeBrite Hospital Group of Stokes LLC v. Blue Cross and Blue Shield of North Carolina, No. 18-293, M.D. N.C.).
CHICAGO — Medical providers misconstrue insurers’ arguments in seeking reconsideration of an order finding derivative standing under the Employee Retirement Income Security Act (ERISA) and have not shown that Texas law would provide them with damages, a federal judge in Illinois said April 6 (Emerus Hospital, et al. v. Health Care Service Corp., et al., No. 13-8906, N.D. Ill., 2020 U.S. Dist. LEXIS 60269).
SACRAMENTO, Calif. — The Patient Protection and Affordable Care Act (ACA) does not preempt California’s charity care regulation requiring a hospital to provide a certain amount of indigent care or donate the equivalent amount of that care to entities that do, a Ninth Circuit U.S. Court of Appeals panel held April 2 (Deanco Healthcare LLC, et al. v. Xavier Becerra, et al., No. 19-55155, 9th Cir., 2020 U.S. App. LEXIS 10407).