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Mealey's Health Care / ACA

  • May 17, 2018

    3rd Circuit: Anti-Assignment Provision Bars ERISA Health Insurance Suit

    PHILADELPHIA — Anti-assignment provisions in health insurance contracts are enforceable and bar a provider’s Employee Retirement Income Security Act suit, the Third Circuit U.S. Court of Appeals held May 16 (American Orthopedic & Sports Medicine v. Independence Blue Cross Blue Shield, et al., No. 17-1663, 3rd Cir.).

  • May 15, 2018

    Judge Remands Suit Against Health Provider, Shows Concern Over ERISA’s Fairness

    BOSTON — A man’s suit against a provider who allegedly misled him regarding potential insurance coverage for his daughter’s mental health treatments in an effort to trump up prices does not implicate ERISA at this stage, a federal judge in Massachusetts held May 14 in remanding the case (Samuel S. Halberg, et al. v. McLean Hospital, No. 17-11341, D. Mass., 2018 U.S. Dist. LEXIS 80469).

  • May 15, 2018

    Surgery Provider Doesn’t Adequately Challenge Insurer’s Payment Rate, Judge Says

    TRENTON, N.J. — While not perfectly clear, nothing in a health insurance plan requires the insurer to pay an out-of-network provider the amount he billed them rather than the rate they set, a federal judge in New Jersey held May 10 (Rahul Shah, et al. v. Blue Cross Blue Shield of Michigan, No. 17-711, D. N.J., 2018 U.S. Dist. LEXIS 78948).

  • May 15, 2018

    RICO, ERISA Claims Rejected In Health Plan’s Suit Against Brokers, Administrators

    OMAHA, Neb. — Claims that various health insurance brokers and other entities misrepresented plan compliance with the Patient Protection and Affordable Care Act (ACA) and created a scheme to shift risk to the plan and insureds while illegally inflating their own revenue support some of plaintiffs’ Employee Retirement Income Security Act claim, but not their racketeering claim, a federal judge in Nebraska held May 1 (Central Valley AG Cooperative, et al. v. Anasazi Medical Payment Solutions Inc., et al., No. 17-379, D. Neb.).

  • May 14, 2018

    Employers Escape Transgender Discrimination Case; ACA Claim Dismissed

    MADISON, Wis. — Direct employers are not subject to liability in a case alleging discrimination against transgender individuals in the provision of health insurance, but claims against the providers of that insurance may proceed, and the plaintiffs can amend their Patient Protection and Affordable Care Act (ACA) claims, a federal judge in Wisconsin held May 11 (Alina Boyden and Shannon Andrews v. State of Wisconsin Department of Employee Trust Funds, et al., No. 17-264, W.D. Wis., 2017 U.S. Dist. LEXIS 191306).

  • May 14, 2018

    Judge Finds Federal Employees’ Insurance Law Preempts Health Care Claims

    ORLANDO, Fla. — While a man denied prostate ablation portrays his case as involving declaratory relief and breach of contract, in reality he seeks judicial review of the denial, and the law governing federal employees’ health care preempts his case, a federal judge in Florida held May 10 in adopting a magistrate judge’s report (Danny Nail v. Government Employees Health Association Inc., No. 17-1462, M.D. Fla.).

  • May 10, 2018

    Health Care Provider’s Letter Provided Notice Of Insured’s Appeal, Judge Says

    BOISE, Idaho — An out-of-network health care provider’s letter stating that “we” are appealing an insurer’s decision provided timely notice that its insured’s rights were at issue, a federal judge in Idaho held May 4 (Louie Abdilnour v. Blue Cross of Idaho Health Service Inc., No 17-412, D. Idaho, 2018 U.S. Dist. LEXIS 75950).

  • May 10, 2018

    Health Care Provider Wants Review Of Oklahoma Court’s ERISA Preemption Ruling

    WASHINGTON, D.C. — The Oklahoma Supreme Court decided an important federal question when it found state law claims against a health insurer outside of the Employee Retirement Income Security Act’s preemptive powers, a final decision that cannot be rectified later, a hospital group tells the U.S. Supreme Court in an April 30 petition for a writ of certiorari (INTEGRIS Health Inc. v. Elizabeth Cates, et al., No. 17-1501, U.S. Sup.).

  • May 4, 2018

    4th Circuit Finds Immunity Covers Outreach Company’s ACA Work

    RICHMOND, Va. — A Patient Protection and Affordable Care Act (ACA) outreach coordinator followed orders in placing phone calls in compliance with a federal contract, the Fourth Circuit U.S. Court of Appeals held April 24 in finding that sovereign immunity barred a man’s consumer protection law claims (Craig Cunningham, et al. v. General Dynamics Information Technology Inc., No. 17-1592, 4th Cir., 2018 U.S. App. LEXIS 10316).

  • May 3, 2018

    Insurer Says Medicare Preempts Hospital Group’s Breach Of Contract Claims

    LOS ANGELES — Medicare’s statutory and regulatory scheme preempts breach of contract claims brought by California’s largest for-profit operator of hospitals alleging underpayment of claims, a Medicare Advantage insurer told a federal judge April 30 (Prime Healthcare Services Inc. v. Humana Insurance Co. et al., No. 16-1097, C.D. Calif.).

  • May 2, 2018

    Insurer Says Coverage Confirmation Didn’t Create Implied Contract With Provider

    LOS ANGELES — Disclaimers in a confirmation of coverage and benefits fatally undermine a medical center’s implied contract claim, while its quantum meruit claim fails because the services provided to the insured did not benefit the insurer, an insurer told a federal judge in California on April 30 (Long Beach Memorial Medical Center v. Blue Cross and Blue Shield of South Carolina Inc., et al., No. 17-8181, C.D. Calif.).

  • May 2, 2018

    Judge Dismisses UCL Claim In Health Insurance Benefit Assignability Case

    LOS ANGELES — While not preempted by the Employee Retirement Income Security Act, substance abuse providers’ California unfair competition law (UCL) claim alleging that insurers misrepresented the assignability of health insurance benefits falls short of pleading an injury for standing purposes, a California federal judge held May 1 in dismissing the claim with prejudice (Dual Diagnosis Treatment Center Inc., et al. v. Blue Cross of California, et al., No. 15-736, C.D. Calif.).

  • May 1, 2018

    ACA Includes Implied Right Of Action, Jurisdiction Proper, Insureds Say

    SEATTLE — While not explicit, the Patient Protection and Affordable Care Act (ACA) impliedly includes a private right of action, and a company and its agents’ participation in a scheme to advertise quality health care insurance while offering “woefully little coverage” provides jurisdiction, a class of insureds told a federal judge in Washington on April 30 (Cynthia Harvey, et al. v. Centene Corp., et al., No. 18-12, E.D. Wash.).

  • May 1, 2018

    Court Rejects Anti-Abortion Group’s Rehearing Request In ACA Birth Control Case

    PHILADELPHIA — The Third Circuit U.S. Court of Appeals denied a petition for rehearing from a nonreligious employer seeking the protection of the Patient Protection and Affordable Care Act (ACA) contraceptive mandate exemption, with a judge who authored a dissent to the original opinion the lone judge to vote to grant the motion on April 27 (Real Alternatives Inc., et al. v. Secretary Department of Health and Human Services, et al., No. 16-1275, 3rd Cir.; 2017 U.S. App. LEXIS 14361).

  • May 1, 2018

    Judge Expands Discovery In Class’s ACA Lactation Insurance Coverage Challenge

    DES MOINES, Iowa — Class action plaintiffs’ discovery requests seeking evidence of how an insurer created and negotiated deals for in-network provider lists and how it coded claims bear directly on whether its coverage of lactation consultant complied with the Patient Protection and Affordable Care Act (ACA), a federal judge in Iowa held April 17 in sustaining objections to a magistrate judge’s discovery order (Jillian York, et al. v. Wellmark Inc., et al., No. 16-627, S.D. Iowa).

  • April 30, 2018

    Judge Allows Bad Faith, Aiding And Abetting Claims In Health Insurance Case

    CLARKSBURG, W.Va. — Allegations that a health care plan administrator acted as the agent of an insurer in denying coverage for cancer claims support statutory bad faith and aiding and abetting claims, but common-law bad faith and conspiracy claims fail, a federal judge in West Virginia held April 27 (Timothy Shaffer, et al. v. National Health Insurance Co., et al., No. 17-195, N.D. W.Va., 2018 U.S. Dist. LEXIS 70790).

  • April 26, 2018

    New Jersey Court Upholds Caps On Chiropractor Reimbursements

    TRENTON, N.J. — A New Jersey agency’s cap on payments for out-of-network chiropractic care violates neither the Patient Protection and Affordable Care Act (ACA) nor state law barring discrimination against health care providers, and state law provided the agency full authority to enact the measure, a state appellate court held April 25 (Association of New Jersey Chiropractors Inc., et al. v. State Health Benefits Commission, et al., No. A-5653-14T1, N.J. Super., App. Div.).

  • April 26, 2018

    New Jersey Court Upholds Caps On Chiropractor Reimbursements

    TRENTON, N.J. — A New Jersey agency’s cap on payments for out-of-network chiropractic care violates neither the Patient Protection and Affordable Care Act (ACA) nor state law barring discrimination against health care providers, and state law provided the agency full authority to enact the measure, a state appellate court held April 25 (Association of New Jersey Chiropractors Inc., et al. v. State Health Benefits Commission, et al., No. A-5653-14T1, N.J. Super., App. Div.).

  • April 25, 2018

    Religious Group May Intervene In Pennsylvania ACA Rules Case, 3rd Circuit Says

    PHILADELPHIA — A religious group may intervene in Pennsylvania’s action challenging October 2017 rules expanding moral and religious exemptions from the Patient Protection and Affordable Care Act (ACA) contraceptive mandate, the Third Circuit U.S. Court of Appeals held April 24 (Pennsylvania v. President of the United States, et al., No. 17-3679, 3rd Cir., 2018 U.S. App. LEXIS 10312).

  • April 24, 2018

    Dispute Over Kentucky Medicaid Work Requirements Will Stay In D.C. Court

    WASHINGTON, D.C. — In an April 10 ruling, a District of Columbia federal judge rejected efforts by the Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS) and other defendants to transfer a dispute over the new Kentucky Medicaid program to the Eastern District of Kentucky, deeming the case a matter of “national significance” (Ronnie Maurice Stewart, et al., v. Alex M. Azar II, et al., No. 18-152, D. D.C., 2018 U.S. Dist. LEXIS 60477).