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).
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).
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).
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.).
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.).
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.
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).
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.).
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.).
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.).
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).
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).
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.).
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.).
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).
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.
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).
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).
By Laura A. Frase
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.).