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Mealey's Health Care / ACA

  • July 18, 2018

    Health Insurer UCL Claims Lack Specifics; Anti-Assignment Provision Bars Action

    SANTA ANA, Calif. — Anti-assignment provisions preclude a plastic surgery center’s suit challenging denial of health insurance claims, and the provider lacks the necessary specificity to plead California unfair competition law (UCL) claims, an insurer says July 16 in asking a California federal judge to dismiss the claims (California Surgical Institute Inc. v. Aetna Life And Casualty [Bermuda] Ltd., et al., No. 17-310, C.D. Calif.).

  • July 18, 2018

    Judge: Air Transport’s Lien Against Insurance Recovery Keeps Some Claims Alive

    ST. LOUIS — A membership-based emergency air transport’s contract is ambiguous as to whether it may recover only from health insurance or is entitled to recovery from broader insurance as well, and its apparent attempts at collecting the proceeds of a tort settlement are enough to permit some breach of contract and injunctive relief claims against it by one of its members alive, a federal judge in Missouri held July 16 (Doris Ergle Lindsey Pratt v. Air Evac Lifeteam, et al., No. 17-3097, W.D. Mo., 2018 U.S. Dist. LEXIS 117854).

  • July 18, 2018

    Class Drops ACA Claims From Action Alleging Insurance ‘Bait-And-Switch’

    YAKIMA, Wash. — Plaintiffs claiming that insurers engaged in a bait-and-switch scheme in which they advertised Affordable Care Act (ACA)-compliant plans but provided only “woefully little coverage” after enrollment may amend their complaint to drop those and other claims, a federal judge in Washington said July 17 while striking pending motions to dismiss the case (Cynthia Harvey, et al. v. Centene Corp., et al., No. 18-12, E.D. Wash.).

  • July 16, 2018

    Judge Won’t Expand Record To Evidence Outside ERISA Health Insurance Review

    BOSTON — Medical records and communications predating a woman’s bulimia treatments and evidence of her long struggle with the disease were not part of an insurer’s process in denying her coverage and cannot be made part of the judicial record, a federal judge in Massachusetts said July 13 in denying a motion to expand the record in an ERISA case (Addie Fisher v. Harvard Pilgrim Health Care of New England Inc., No. 17-11232, D. Mass., 2018 U.S. Dist. LEXIS 116751).

  • July 16, 2018

    Judge: Recent 3rd Circuit ERISA Case Affirms Validity Of Anti-Assignment Clause

    CAMDEN, N.J. — Third Circuit U.S. Court of Appeals precedent recently confirmed the validity of anti-assignment clauses in the Employee Retirement Income Security Act setting, and a health insurer’s interactions with a provider during the administrative appeals process did not waive the defense, a federal judge in New Jersey held July 13 (Rahul Shah, et al. v. Horizon Blue Cross Blue Shield of New Jersey, et al., No. 17-166, D. N.J.).

  • July 12, 2018

    Hospital Group Says Medicare Exhaustion Split Is ‘Real,’ Requires Review

    WASHINGTON, D.C. — A Medicare Advantage insurer cherry-picks quotes and misrepresents precedent in an attempt to avoid the very real conflict regarding whether noncontracted providers must exhaust of administrative remedies prior to filing suit, a hospital group tells the U.S. Supreme Court in a July 10 brief (Atlanta Medical Center Inc., et al. v. Care Improvement Plus South Central Insurance Co., No. 17-1283, U.S. Sup.).

  • July 11, 2018

    Insurance Parties Debate Discrimination In Gender Dysphoria Surgery Exclusion

    MADISON, Wis. — A Wisconsin federal judge received reply briefs July 9, laying before him the issue of whether a health insurance plan’s exclusion on cosmetic vaginoplasties discriminates against transgendered individuals and violates the Patient Protection and Affordable Care Act (ACA) and the U.S. Constitution (Alina Boyden and Shannon Andrews v. Wisconsin Department of Employee Trust Funds, et al., No. 17-264, W.D. Wis.).

  • July 10, 2018

    Florida Law Claim Survives Dismissal In Hospital-Insurer Spat

    JACKSONVILLE, Fla. — A federal judge in Florida on July 5 adopted a magistrate judge’s report, dismissing breach of contract claims against an insurer brought by a hospital group but saying a state law claim survived (Southern Baptist Hospital of Florida Inc., et al. v. Celtic Insurance Co., etc., No. 17-1214, M.D. Fla.)

  • July 5, 2018

    Judge Won’t Reconsider Remand Of Liquidation Action Featuring ACA Insurer

    CHICAGO — A liquidation procedure involving a Patient Protection and Affordable Care Act (ACA) nonprofit health insurer is exactly the type of proceeding where Congress defers to states, a federal judge in Illinois held July 2 in once again finding that the case should be remanded (Melissa Dowling v. United States Department of Health and Human Services, No. 17-494, N.D. Ill., 2018 U.S. Dist. LEXIS 110554).

  • July 2, 2018

    Some Named Class Members Prevail On Judgment Motions In ACA Lactation Case

    SAN FRANCISCO — The Patient Protection and Affordable Care Act (ACA) recognizes lactation support services as preventive care and does not carve out situations where women receive the services in response to symptoms, a federal judge in California held in partially granting judgment to named class members on ACA and ERISA claims June 27 (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 17-183, N.D. Calif.).

  • June 26, 2018

    Birth Control Defendants Tell 9th Circuit Injury Lacking In ACA Rules Case

    SAN FRANCISCO — States have not shown that federal regulations expanding moral and religious exemptions to the Patient Protection and Affordable Care Act (ACA) contraceptive mandate would result in any women turning to them for coverage or that the rules would impact state budgets in any way, two intervenors and the federal defendants told the Ninth Circuit U.S. Court of Appeals on June 11 in arguing that the plaintiffs lack standing (California, et al. v. Alex M. Azar II, et al., Nos. 18-15144, 18-15166, 18-15255, 9th Cir.).

  • June 26, 2018

    Supreme Court Sees Challenge To Abortion Disclosure Law As Likely To Prevail

    WASHINGTON, D.C. — Crisis pregnancy centers are likely to prevail on the merits of their challenge to a California law imposing certain disclosures on similar providers, a 5-4 majority of the U.S. Supreme Court held June 26 (NIFLA, et al. v. Xavier Becerra, et al., No. 16-1140, U.S. Sup.).

  • June 25, 2018

    Medicare Exhaustion Ruling Properly Diagnosed Law, Insurer Tells Supreme Court

    WASHINGTON, D.C. — An appeals court properly recognized the difference between contracted Medicare providers and non-contracted providers in requiring exhaustion of administrative remedies prior to filing suit, an insurer told the U.S. Supreme Court June 22 (Atlanta Medical Center Inc., et al. v. Care Improvement Plus South Central Insurance Co., No. 17-1283, U.S. Sup.).

  • June 25, 2018

    Medicare Doesn’t Preempt Breach Of Contract Claims By Hospital Group, Judge Says

    LOS ANGELES — Medicare doesn’t preempt a hospital group’s breach of contract action alleging that an insurer downcoded claims in an effort to underpay on bills, a federal judge in California held June 22 (Prime Healthcare Services Inc. v. Humana Insurance Co., et al., No. 16-1097, C.D. Calif.).

  • June 20, 2018

    Insurer Says ERISA Preempts Hospital Group’s Case; Facts Don’t Support Claims

    SALT LAKE CITY — The Employee Retirement Income Security Act preempts a hospital group’s claims alleging underpayment of medical bills, but the claims would fail in any case because they involve insurer-insured rights and cannot be assigned to third parties, an insurer tells a federal judge in Utah in a June 15 memo (IHC Health Services Inc., et al. v. Blue Cross and Blue Shield of Texas Inc., No. 18-277, D. Utah).

  • June 18, 2018

    Plethora Of Interest Groups Urge Court Not To Enjoin ACA

    FORT WORTH, Texas — Striking down the Patient Protection and Affordable Care Act (ACA) because the government will no longer impose sanctions for not complying with the law’s individual mandate would harm public health and the economy and do violence to the separation of powers, a slew of medical, legal, business, economic, and social benefit amici argue in briefs filed in a federal court in Texas on June 14 (Texas, et al. v. U.S.A., et al., No. 18-167, N.D. Texas).

  • June 18, 2018

    Judge Finds Jurisdiction Over Deaf Man’s ACA Discrimination Claims Lacking

    BIRMINGHAM, Ala. — A man musters “no authority even remotely” suggesting that personal jurisdiction can arise from simply registering to do business in a state, a federal judge in Alabama held June 13 in dismissing Patient Protection and Affordable Care Act (ACA) and other claims against hospital entities for allegedly failing to provide a deaf man with an interpreter (Teddy Beasley v. Providence Hospital, et al., No. 18-0004, S.D. Ala., 2018 U.S. Dist. LEXIS 99572).

  • June 18, 2018

    Supreme Court Won’t Review ERISA Ruling Allowing Insured To Sue Hospital

    WASHINGTON, D.C. — The U.S. Supreme Court on June 18 declined to review a ruling by Oklahoma’s top court finding an insured’s class action challenging a health care provider’s billing practices outside of the Employee Retirement Income Security Act’s preemptive powers (INTEGRIS Health Inc. v. Elizabeth Cates, et al., No. 17-1501, U.S. Sup.).

  • June 15, 2018

    Appeals Court Says Insurers Can’t Recover ACA Risk-Corridor Payments

    WASHINGTON, D.C. — Health insurers may not collect billions in Patient Protection and Affordable Care Act (ACA) risk-corridor funds because Congress specifically blocked payments, a majority of the Federal Circuit U.S. Court of Appeals said June 14 (Land of Lincoln Mutual Health Insurance Co. v. United States, Moda Health Plan Inc. v. United States, Nos. 2017-1224, 2017-1994, Fed. Cir.).

  • June 14, 2018

    Spine Center’s Insurance Claims Belong In Ohio, Federal Judge Says

    TRENTON, N.J. — A spine center’s Employee Retirement Income Security Act suit seeking hundreds of thousands of dollars from a health insurance plan offered by an Ohio insurer and administered in that state should be litigated in the state as well, a New Jersey federal judge held in transferring the case June 12 (University Spine Center v. Anthem Blue Cross and Blue Shield, No. 17-8676, D. N.J., 2018 U.S. Dist. LEXIS 97947).