Mealey's Health Care / ACA
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April 20, 2018
Judge Certifies Class Of ACA Cost-Reduction Payment Plaintiffs
WASHINGTON, D.C. — A federal claims judge on April 17 certified a class action involving insurers’ claims that the federal government failed to make timely payments under the Patient Protection and Affordable Care Act (ACA) cost-reduction program (Common Ground Healthcare Cooperative v. The United States, No. 17-877C, Fed. Clms., 2018 U.S. Claims LEXIS 317).
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April 20, 2018
Federal Judge Again Finds Home Infusion Pharmacy’s Suit Untimely
LOS ANGELES — The statute of limitations on a home infusion pharmacy’s breach of contract claims began when an insurer made initial, incomplete payment, a federal judge in California said April 17 in granting reconsideration while remaining convinced that the suit was time-barred (IV Solutions Inc. v. Empire Healthchoice Assurance Inc., et al., No. 17-5615, C.D. Calif., 2018 U.S. Dist. LEXIS 64671).
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April 20, 2018
Federal Judge Dismisses Surgery Provider’s ERISA, New Jersey Law Claims
TRENTON, N.J. — ERISA preempts a state law that in any case lacks a private right of action, and failure to allege exhaustion of administrative remedies and a contract’s anti-assignment provision doom the remainder of a health care provider’s suit seeking reimbursement from an insurer, a federal judge in New Jersey held April 17 (Luis Zapiach, M.D. v. Empire Blue Cross Blue Shield, No. 17-10179, D. N.J., 2018 U.S. Dist. LEXIS 64887).
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April 19, 2018
Amicus Parties Urge 9th Circuit To Reject ACA Rules Challenge
SAN FRANCISCO — Updated rules providing more exemptions from the Patient Protection and Affordable Care Act (ACA) contraceptive mandate merely corrected unfair discrimination and disparate treatment in the initial rules that ran into constitutional issues, two amicus curiae parties told the Ninth Circuit U.S. Court of Appeals on April 16 in urging them to reject a challenge to the rules brought by a group of states challenge to those rules (California, et al. v. Alex M. Azar II, et al., Nos. 18-15144, 18-15166, 18-15255, 9th Cir.).
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April 18, 2018
Judge: Providing Medical Care To Insureds Doesn’t Confer Benefit On Insurer
MIAMI — Providing insureds with medical services does not sufficiently confer a benefit on an insurer to support an unjust enrichment claim under Florida law, a federal judge in the state held April 13 (John C. Nordt III, et al. v. Colina Insurance Limited, No. 17-21226, S.D. Fla.).
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April 18, 2018
Maryland Seeks Creation Of Reinsurance Program For ACA Exchange
BALTIMORE — The board governing Maryland’s Patient Protection and Affordable Care Act (ACA) exchange on April 16 voted to seek federal funding for a reinsurance program it hopes will save its struggling marketplace.
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April 17, 2018
Judge: Failure To Exhaust Administrative Remedies Dooms Health Care Case
TRENTON, N.J. — A woman must exhaust available administrative remedies before filing an Employee Retirement Income Security Act suit if her health care policy does not mandate an appeals process and should further specify the provisions, procedures and costs involved, a federal judge in New Jersey held April 12 (Charlene Lemoine v. Empire Blue Cross Blue Shield, et al., No. 16-6786, D. N.J., 2018 U.S. Dist. LEXIS 62535).
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April 16, 2018
Residential Treatment Exclusion Violates Federal Mental Health Law, Judge Says
NEW YORK — A man granted summary judgment on claims that his insurer violated federal law in denying health insurance coverage for his son’s mental health services filed a sealed brief on April 9 detailing the appropriate remedies. A federal judge in New York ordered the briefing after concluding that the insurer violated the law by excluding coverage for residential treatment facilities and that the issue was further complicated by exclusions for out-of-network care (Kevin Munnelly v. Fordham University Faculty and Administration HMO Insurance Plan, et al., No. 16-5632, S.D. N.Y.).
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April 16, 2018
Surgery Center Has Liability For Subagent’s Conduct With Insurer, Judge Says
LOS ANGELES — A bariatric surgery center likely knew that a bariatric surgeon relied on a subagent to receive insurance preauthorization for procedures and can therefore be liable for allegedly fraudulent representations, a federal judge in California held April 11 (Soma Surgery Center Inc. v. Aetna Life Insurance Co., et al., No. 16-5802, C.D. Calif.).
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April 13, 2018
Addiction Center Seeks Sanction For Ignoring Subpoena In Health Insurance Case
MIAMI — A drug treatment and urinalysis facility on April 12 asked a federal judge in Florida for sanctions and an order compelling production of documents from a second addiction treatment facility’s former medical director, saying failure to comply with a subpoena warranted the relief. The judge dismissed the center’s Employee Retirement Income Security Act and state law claims just days before, saying the allegations lacked sufficient specificity to determine contract details (Living Tree Laboratories LLC v. United Healthcare Services Inc., et al. v. A New Start Inc., et al., No. 16-24680, S.D. Fla.).
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April 13, 2018
Court: Health Care Provider’s Contract Claim Not Subject To Government Immunity
FORT WORTH, Texas — Governmental immunity does not shield a hospital from a health care provider’s breach of contract claim involving bills incurred while treating the son of one of the hospital’s employees, a Texas appeals court held April 5 (Cook Children’s Health Care System, et al. v. Nocona General Hospital, No. 02-17-00128-CV, Texas App., 2018 Tex. App. LEXIS 2439).
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April 13, 2018
Federal Judge Dismisses Insolvent Health Insurer’s Suit Against United States
LAS VEGAS — A Nevada federal judge on March 30 dismissed a defunct health insurer’s case for lack of subject matter jurisdiction because the monetary relief sought against the United States is available through the Court of Federal Claims (Barbara D. Richardson v. U.S. Department of Health and Human Services, et al., No. 17-775, D. Nev., 2018 U.S. Dist. LEXIS 54065).
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April 12, 2018
Intervenors Tell 9th Circuit Standing Lacking In ACA Birth Control Rules Case
SAN FRANCISCO — California and other states lack standing to challenge interim final rules expanding the scope of religious and moral exclusions to the Patient Protection and Affordable Care Act (ACA) contraceptive mandate, two intervenors in the case tell the Ninth Circuit U.S. Court of Appeal in April 9 briefs (California, et al. v. Alex M. Azar II, et al., Nos. 18-15144, 18-15166, 18-15255, 9th Cir.).
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April 11, 2018
Suit Alleging Stalled Health Insurance Claims Proceeds, Won’t Be Bifurcated
MIAMI — A federal judge in Florida on April 10 declined to bifurcate an Employee Retirement Income Security Act dispute involving more than 100,000 allegedly unprocessed claims worth more than $1 million, saying such a trial procedure is unnecessary in light of how much the evidence overlaps. On April 4, he largely allowed the claims to proceed, saying exhaustion of administrative remedies is not warranted given the allegations that the insurer breached its regulatory duties and that requiring more precise pleading as to the claims in question would not clarify the case (National Laboratories LLC, et al. v. UnitedHealth Group Inc., et al., No. 17-81178, S.D. Fla.).
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April 10, 2018
Insurer, Class Battle Over Scope Of Discovery In ACA Lactation Coverage Case
DES MOINES, Iowa — A magistrate judge improperly limited discovery in a case challenging a health insurer’s cost-sharing arrangement for lactation consultant services, plaintiffs told a federal judge in Iowa March 12. But the insurer fired back March 26, saying the ruling properly limits discovery to the lone remaining issue: whether the in-network coverage complies with the Patient Protection and Affordable Care Act (ACA) (Jillian York, et al. v. Wellmark Inc., et al., No. 16-627, S.D. Iowa).
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April 6, 2018
District Of Columbia Codifies Women’s Health Care Coverage
WASHINGTON, D.C. — Insurers in the District of Columbia must cover certain health care services without cost sharing and must provide up to 12 months of self-administered hormonal contraceptives, but can provide certain employers a religious exemption form or other accommodation under legislation that became effective on March 28.
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April 5, 2018
Judge: Health Insurer’s Control Warrants Arbitrary And Capricious Standard
ORLANDO, Fla. — Contract provisions clearly grant a health insurer discretion over plan benefits and terms, a federal judge in Florida held April 3 while saying nothing requires that the insurer retain full control for application of the arbitrary and capricious standard (Mark Atherley v. United Healthcare of Florida Inc., No. 17-332, M.D. Fla., 2018 U.S. Dist. LEXIS 56579).
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March 27, 2018
Judge Finds Insured Has Standing To Sue Health Care Insurer
TRENTON, N.J. — An insured, but not his health care provider, has standing to sue an insurer that allegedly failed to fully pay for health care services, a federal judge in New Jersey held March 22 (Atlantic Plastic and Hand Surgery, PA, et al. v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 17-4600, D. N.J., 2018 U.S. Dist. LEXIS 47181).
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April 3, 2018
COMMENTARY: When Strategies Go Awry: Part 6 In A Series On Cognitive Biases And Their Impact
By Laura A. Frase
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April 4, 2018
Magistrate Judge Finds Autism Treatment Case Under ERISA May Proceed
MIAMI — A man’s suit claiming that his son received medically necessary autism treatment and that he tried unsuccessfully to engage his insurer in the claim process adequately alleges exhaustion of administrative remedies and is specific enough to support an Employee Retirement Income Security Act claim, a federal judge in Florida held April 2 (Stephen A. Marino Jr. v. Blue Cross & Blue Shield of Florida Inc., et al., No. 17-22886, S.D. Fla.).