Mealey's Health Care / ACA

  • January 07, 2022

    Judge: Chiropractors Adjust Standing, But Can’t Keep Underpayment Claims Upright

    NEWARK, N.J. — Chiropractors now sufficiently allege that they have assignment of benefits which would give them standing to sue insurers, but the failure to establish that vendors enjoyed discretionary power over claims or cite any plan language entitling them to further payment dooms their case in part, a federal judge in New Jersey said Jan. 5 in ruling on a motion to dismiss.

  • January 06, 2022

    State Health Plan, Transgender Insureds Battle Over ACA Sovereign Immunity

    WASHINGTON, D.C. — When Congress intends to waive sovereign immunity, it must do so clearly, and a split among Fourth Circuit judges about how Congress did so in the Patient Protection and Affordable Care Act shows that no such clarity exists, a state health plan tells the U.S. Supreme Court in a Jan. 4 response to arguments by transgender individuals who claim that there is no reason to review their discrimination claims at this time.

  • January 05, 2022

    9th Circuit:  Insurer’s Substance Abuse Payment Satisfied Promised Rate

    SAN FRANCISCO — The evidence shows that an insurer’s “allowable rate” refers to an internal figure used to calculate payments to out-of-network providers and that the insurer paid that amount to a substance abuse provider, a Ninth Circuit U.S. Court of Appeals panel said Dec. 27 in affirming summary judgment.

  • January 04, 2022

    Insurer Says ER Billing Issue Dead; Warns Against Return To ‘Free-Wheeling’ Days

    AUSTIN, Texas — Any dispute over whether the law permits providers to sue insurers under emergency care laws “withered into oblivion,” and the Texas Supreme Court should reject attempts to “return to the days of yore, with the free-wheeling creation of private rights of action,” an insurer argues in a Dec. 29 brief.

  • January 04, 2022

    Respondents Downplay Need For Review In ACA Sovereign Immunity Case

    WASHINGTON, D.C. — Every court to have considered whether a state health plan waives sovereign immunity from discrimination suits by accepting federal funds answered the question in the affirmative, and the lack of division gives the U.S. Supreme Court no reason to grant review now, respondents tell the court in a Dec. 27 opposition to a petition.

  • December 30, 2021

    Medicare-Based Dialysis Rates Don’t Violate MSPA, Government Tells High Court

    WASHINGTON, D.C. — In three amicus curiae briefs filed Dec. 22 and 23, entities including the U.S. government join health plan defendants in urging the U.S. Supreme Court to reverse a split Sixth Circuit U.S. Court of Appeals panel’s ruling that a complaint over linking dialysis reimbursement rates to Medicare rates plausibly alleged violation of the Medicare Secondary Payor Act (MSPA) under a discrimination-by-proxy or a disparate-impact theory.

  • December 22, 2021

    ERISA Plan Says Medicare-Based Dialysis Rates Don’t Violate MSPA

    WASHINGTON, D.C. — Linking dialysis reimbursement rates to Medicare rates does not violate the Medicare Secondary Payor Act’s prohibition on taking into account program eligibility, and a ruling to the contrary would be an “affront” to Employee Retirement Income Security Act regulations, health plan defendants tell the U.S. Supreme Court in a Dec. 20 brief.

  • December 21, 2021

    Judge: Insurer’s Unsupported Residential Treatment Decision Arbitrary, Capricious

    SALT LAKE CITY — A health insurer’s explanation for why it began denying coverage for a child’s residential treatments leaves no way to determine whether the denial was proper and the decision was therefore arbitrary and capricious, a federal judge in Utah said Dec. 16 in remanding for a coverage determination.

  • December 17, 2021

    Judge Allows Provider’s Contract Claims In Amended Complaint

    BALTIMORE — Allegations that an insurer promised to pay set percentages of billed rates for substance abuse treatment services are sufficient for contract-based claims, but the balance of the provider’s claims fail, a federal judge in Maryland said Dec. 14 in partially granting a motion to file an amended complaint.

  • December 14, 2021

    Judge Again Rejects Federal Employee’s Proton Beam Coverage Case

    HOUSTON — A federal employee’s claims alleging that her insurer and the Office of Personnel Management improperly failed to cover proton beam radiation therapy (PBT) to treat her cancer are preempted or cannot escape sovereign immunity, and her allegations do not point to events sufficiently definitive for injunctive relief, a federal judge in Texas said Dec. 13.

  • December 14, 2021

    Over Insurer’s Objection, Judge Adopts Report Saving Promissory Estoppel Claim

    DALLAS — A federal judge in Texas on Dec. 3 adopted a report and recommendation finding a promissory estoppel claim sufficiently based on conduct outside two Employee Retirement Income Security Act health plans to avoid preemption, but otherwise dismissing the case.

  • December 13, 2021

    Providers See Harm From Surprise Billing Rule, Ask Court For Stay

    WASHINGTON, D.C. — An interim final rule interpreting a law creating a system for resolving billing disputes between insurers and out-of-network providers with the intent of ending surprise billing of patients improperly weights one of the six factors the law lays out in a way that creates the opposite of what Congress intended and will harm providers and insureds, medical providers tell a federal court in a Dec. 9 motion seeking a stay of the rule or summary judgment.

  • December 13, 2021

    ERISA Insurer: Reviewers’ Decisions Support Denial For Residential Treatments

    DENVER — The fact that three separate reviewers found residential treatment not medically necessary demonstrates that a denial of insurance coverage was not arbitrary or capricious and should end the analysis even if a separate reason for denying coverage was improper, an insurer tells the 10th Circuit U.S. Court of Appeals in a Dec. 8 opening brief.

  • December 13, 2021

    High Court Seeks U.S. View On ERISA Fiduciary Dispute Over Insurer, PBM Price-Setting

    WASHINGTON, D.C. — The U.S. Supreme Court on Dec. 13 invited the solicitor general to file a brief expressing the United States’ views on a petition by health plans and individual subscribers for review of a ruling that a health benefits provider and a pharmacy benefits manager (PBM) were not acting as fiduciaries under the Employee Retirement Income Security Act when they set prescription drug prices.

  • December 09, 2021

    Judge: U.S. Cannot Use Administrative Offset To Make ‘End-Run Around’ Liquidation

    WASHINGTON, D.C. — A federal judge on Nov. 30 held that the U.S. government cannot use an administrative offset to make an “end-run around” a state liquidation process, “particularly not where the government elected to participate in that process and had its claim decided,” finding that the Nevada commissioner of Insurance as receiver for the Nevada Health CO-OP (NHC) is entitled to judgment on all claims in her lawsuit alleging that the government improperly withheld payments under the Patient Protection and Affordable Care Act (ACA).

  • December 07, 2021

    Insurer Opposes Objections To Discovery Order In Antitrust Coverage Suit

    KANSAS CITY, Kan. — An insurer that recently assumed an insolvent excess insurer’s responsibility for claims and defenses in an antitrust coverage dispute filed an opposition on Nov. 23 to Blue Cross Blue Shield of Kansas Inc.’s objection to a Kansas federal magistrate judge’s discovery order.

  • December 08, 2021

    Supreme Court Grants More Time To Respond In ACA Sovereign Immunity Case

    WASHINGTON, D.C. — The U.S. Supreme Court on Dec. 3 granted an 45-day extension of time to respond to a petition over the objections of the state employees’ health plan, which argued that such a delay forces it to face summary judgment motions and potentially a trial before resolution of whether it is entitled to sovereign immunity from Patient Protection and Affordable Care Act discrimination claims.

  • December 08, 2021

    Health Plan Defendants Seek To Strike ACA Summary Judgment Motion

    WASHINGTON, D.C. — After plaintiffs filed a pair of summary judgment motions in a case alleging that a state employee health plan’s exclusion on transgender procedures violates the Patient Protection and Affordable Care Act prohibition on discrimination, defendants asked the court on Dec. 6 to strike them and for expedited consideration, saying the more than 12,000 combined words fail to comply with local rules and court rulings.

  • December 01, 2021

    California Court Won’t Publish Ruling Affirming Verdict In UCL Emergency Care Case

    LOS ANGELES — A California appellate court Nov. 30 declined to publish its opinion finding that a judge properly excluded an injunctive relief claim under California’s unfair competition law (UCL) while also affirming the exclusion of certain evidence and expert testimony and dismissal of tort claims arising from alleged underpayment for emergency services.

  • November 30, 2021

    Court Hears Arguments Over Emotional Distress Damages In ACA Discrimination Case

    WASHINGTON, D.C. — Whether the Patient Protection and Affordable Care Act (ACA) and the underlying anti-discrimination statutes from which it borrows put a federal funding recipient on notice of the potential for emotional distress damages or whether such damages are more akin to punitive damages and must be clearly imposed by Congress came before the U.S. Supreme Court during oral arguments on Nov. 30.

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