NEW ORLEANS — A Medicare provider fighting recoupment of payments had the opportunity to be heard in the first two of the four-step appeals process where it received a reduction in the amount owed, a Fifth Circuit U.S. Court of Appeals panel said Sept. 18 in affirming (Sahara Health Care Inc. v. Alex. M. Azar II, et al., No. 18-41120, 5th Cir., 2020 U.S. App. LEXIS 29927).
WASHINGTON, D.C. — The liquidator and special deputy liquidator of an insolvent health insurer on Aug. 28 asked the U.S. Supreme Court to hear their case on whether they should be compelled to arbitrate common-law tort claims against an actuarial firm based upon an arbitration provision in a preinsolvency agreement between the insurer and the firm (Doug Ommen, et al. v. Milliman, Inc., et al., No. 20-249, U.S. Sup., 2020 U.S. S. CT. BRIEFS LEXIS 2654).
WASHINGTON, D.C. — An actuarial services company on Sept. 3 asked the U.S. Supreme Court to take up its case on whether the Louisiana insurance commissioner, as rehabilitator for a health insurance cooperative, can pursue a professional negligence suit in court or is bound by an arbitration clause in an agreement between it and the cooperative (Milliman, Inc. v. James J. Donelon, No. 20-299, U.S. Sup., 2020 U.S. S. CT. BRIEFS LEXIS 2728).
SALT LAKE CITY — A family adequately alleges that an insurer imposed acute-care level standards on subacute-level mental health residential therapies that it would not in the medical or surgical setting, and the Mental Health Parity and Addiction Equity Act claim is not duplicative of Employee Retirement Income Security Act claims, a federal judge in Utah said Sept. 11 in denying a motion to dismiss (Theo M., et al. v. Beacon Health Options, et al., No. 19-364, D. Utah, 2020 U.S. Dist. LEXIS 166903).
SALT LAKE CITY — A Mental Health Parity and Addiction Equity Act claim is factually and legally distinct from an Employee Retirement Income Security Act claim, and to limit discovery to the administrative record would "improperly hamstring" plaintiffs, a federal judge in Utah said Aug. 31 (Anne M., et al. v. United Behavioral Health, et al., No. 18-808, D. Utah, 2020 U.S. Dist. LEXIS 159453).
WASHINGTON, D.C. — Discrimination often imposes only emotional distress, and such damages should be available under the Patient Protection and Affordable Care Act (ACA) and other laws precluding the conduct, a deaf and blind woman allegedly denied an interpreter by her medical provider told the U.S. Supreme Court on Aug. 21 in a petition for writ of certiorari (Jane Cummings v. Premier Rehab Keller PLLC, et al., No. 20-219, U.S. Sup.).
HOUSTON — Because Texas medical providers' underpayment lawsuit targets insurers' behavior before amendments adding "usual and customary" language to state law governing payments, the claims are preempted, a federal judge in Texas said Aug. 17 (ACS Primary Care Physicians Southwest P.A., et al. v. UnitedHealthCare Insurance Co., et al., No. 20-1282, S.D. Texas.).
WASHINGTON, D.C. — A rule expanding short-term insurance plans attempts to blur the difference between those plans and comprehensive Patient Protection and Affordable Care Act-compliant plans, to the detriment of nearly all parties, two states and a collection of advocacy groups said Sept. 8 in urging rehearing of a ruling allowing the rule to stand (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 19-5212, D.C. Cir.).
BOSTON — An insurer and district court did not err in relying on experts who referenced 24-hour care when determining that residential treatments were not medically necessary, and review in Employee Retirement Income Security Act cases is limited to the administrative record and does not require live testimony or cross-examination, a First Circuit U.S. Court of Appeals panel held Sept. 9 (Jane Doe v. Harvard Pilgrim Health Care Inc., et al., No. 19-1879, 1st Cir.).
SALT LAKE CITY — An insurer is entitled to review of its Employee Retirement Income Security Act benefit decision under the arbitrary and capricious standard, and under that standard demonstrated sufficient evidence in defense of its denial of benefits for residential treatments, a federal judge in Utah said Sept. 3 in granting judgment to the insurer (Mark M., et al. v. United Behavioral Health, No. 18-18, D. Utah, 2020 U.S. Dist. LEXIS 162455).
BALTIMORE — A Title X rule limiting physicians' abortion communications and requiring separate facilities for such services is arbitrary and capricious because the government ignored substantial concerns about the impact and the rule violates Patient Protection and Affordable Care Act (ACA) regulations precluding barriers to care, a divided en banc Fourth Circuit U.S. Court of Appeals said Sept. 3 (Mayor and City Council of Baltimore v. Alex M. Azar II, et al., Nos. 19-1614, 20-1215, 4th Cir., 2020 U.S. App. LEXIS 28127).
WASHINGTON, D.C. — A federal agency's apparent disregard for the potential impact Bostock v. Clayton County, Georgia could have on the validity of a Patient Protection and Affordable Care Act (ACA) rule excluding sex stereotyping and gender identity from the definition of discrimination and the harm LGBTQ health providers face from the rule's fallout warrant partially enjoining the rule, a federal judge in the District of Columbia said Sept. 2 (Whitman-Walker Clinic, et al. v. U.S. Department of Health and Human Services, et al., No. 20-1630, D. D.C., 2020 U.S. Dist. LEXIS 159951).
SEATTLE — A judge granted judgment in a residential treatment coverage case based on a theory that no party pursued, a Ninth Circuit U.S. Court of Appeals panel said Sept. 1 in vacating judgment in an Employee Retirement Income Security Act case (Todd R., et al. v. Premera Blue Cross Blue Shield of Alaska, No. 19-35475, 9th Cir., 2020 U.S. App. LEXIS 27831).
LOS ANGELES — A surgery provider fails to adequately support California unfair competition law and other claims arising from an insurer's alleged underpayment, a federal judge in California said Aug. 28 in granting dismissal (Avanguard Surgrey Center LLC v. Cigna Healthcare of California Inc., No. 20-3405, C.D. Calif., 2020 U.S. Dist. LEXIS 156826).
SEATTLE — In light of Washington state's own argument that Bostock v. Clayton County requires that sex discrimination laws cover discrimination based on gender identity and sexual orientation, the state cannot show an injury on which to challenge a Patient Protection and Affordable Care Act (ACA) rule, a federal judge in the state said Aug. 28 in denying a preliminary injunction (Washington v. United States Department of Health and Human Services, et al., No. 20-1105, W.D. Wash., 2020 U.S. Dist. LEXIS 159271).
LOS ANGELES — Class action allegations claiming violation of the Employee Retirement Income Security Act and Racketeer Influenced Corrupt Organizations Act in the alleged underpayment for out-of-network mental health and substance abuse treatments are not adequately supported and must be dismissed, a federal judge in California said Aug. 26 (LD, et al. v. United Behavioral Health, et al., No. 20-2254, N.D. Calif., 2020 U.S. Dist. LEXIS 155224).
LOS ANGELES — An insurer and related entities refuse to fully compensate for out-of-network substance abuse treatments, even though the plans in question call for full payment in instances where insureds exceed out-of-pocket maximums or where provider networks are inadequate, a group of consolidated plaintiffs alleges in an Aug. 26 amended complaint covering 1,306 insureds (In re: Out of network substance use disorder claims against UnitedHealthcare, No. 19-2075, C.D. Calif.).
SACRAMENTO, Calif. — By a 63-1 vote, the California Assembly on Aug. 26 passed legislation designed to overhaul and modernize the state's mental health coverage law by imposing more comprehensive mental health coverage requirements on insurers while placing limits on the ability of insurers to avoid coverage. The amended bill heads back to the Senate, where earlier this year the measure passed by a 30-5 vote.
LOS ANGELES — A gynecologist has not met his burden of showing that an insurer's payment on claims was improper or that it did not constitute a reasonable and customary reimbursement, a federal judge in California said Aug. 21 (Adel F. Samaan M.D. v. Aetna Life Insurance Co., et al., No.17-1690, C.D. Calif., 2020 U.S. Dist. LEXIS 153280).
SACRAMENTO, Calif. — The California Department of Managed Health Care (DMHC) on Aug. 25 demanded that insurer Aetna Health of California Inc. comply with state law regarding coverage for emergency room care and cease using its national standard. The agency also fined Aetna $500,000 for repeated failure to comply (In the Matter of Aetna Health of California Inc., Calif. Dept. Managed Care, Nos. 19-268, 19-1151, 19-766, 19-977).