Mealey's Health Care / ACA

  • February 25, 2021

    Texas Court: Emergency Care Law Doesn’t Support Suit Against Health Insurer

    DALLAS — Providers of emergency medical care lack standing to sue an insurer for additional compensation under various Texas statutes, a state appeals court said Feb. 23 in affirming a lower court ruling.

  • February 25, 2021

    Surgery Provider Can’t Escape Preclusive Anti-Assignment Provision

    NEW YORK — Governing documents preclude assignment of health insurance plan rights, and it does not matter whether the assignment occurred before or after the surgery, a federal judge in New York said Feb. 19 in dismissing the action.

  • February 23, 2021

    Woman: ERISA Medical Benefits Review Standard Calls For Supreme Court Review

    BOSTON — The Supreme Court can resolve the hopelessly and starkly divided issues of whether traditional summary judgment rules apply in Employee Retirement Income Security Act benefit cases and whether judges must limit themselves to the administrative record or can go beyond it, a woman argues in a Feb. 5 petition for writ of certiorari.

  • February 22, 2021

    Supreme Court Takes On Title X Abortion, ACA Regulation Spat

    WASHINGTON, D.C. — The U.S. Supreme Court on Feb. 22 agreed to resolve the conflict between rules governing abortion services for Title X funding recipients and Patient Protection and Affordable Care Act (ACA) regulations preventing barriers to care.

  • February 18, 2021

    Provider, Insurer Both Lose Motions Seeking Summary Judgment

    SAN JOSE, Calif. — Allegations that a surgery provider made phone calls confirming insurance coverage and received a letter confirming benefits create questions about whether a contract exists between it and an insurer which would obligate payment at 70 percent of the usual and customary rate, but the provider has not eliminated questions about the legitimacy of a money had and received claim stemming from alleged overpayment on one of the benefits claims, a federal judge in California said Feb. 12 in denying two motions for summary judgment.

  • February 18, 2021

    Nationwide Health Coverage Doesn’t Equal Nationwide Jurisdiction, Judge Says

    SALT LAKE CITY — A Wyoming health insurance company’s provision of nationwide coverage does not give it the type of substantial connection to Utah for jurisdiction, a federal judge in Utah said Feb. 12 in dismissing an action alleging violation of the Parity Act.

  • February 17, 2021

    ERISA Overpayment Claims Equitable, Not Time-Barred, 2nd Circuit Says

    NEW YORK — Health plans’ Employee Retirement Income Security Act and Declaratory Judgment Act claims seeking reimbursement of alleged overpayments to providers are equitable in nature and not subject to a statute of limitations, the Second Circuit U.S. Court of Appeals said Feb. 10, allowing those claims to proceed while affirming dismissal of legal claims.

  • February 16, 2021

    Allegations Satisfy As-Applied Parity Act Claim, Federal Judge Says

    SALT LAKE CITY — Allegations that an insurer covers subacute inpatient care in the mental health and medical setting while imposing acute-level criteria to such care only in the mental health setting suffices for a Parity Act claim, a federal judge in Utah said Jan. 29 in denying dismissal of an as-applied claim and rejecting precedent from a case involving a facial challenge.

  • February 11, 2021

    In Change, United States Tells High Court ACA Remains Constitutional

    WASHINGTON, D.C. — The United States now believes the Patient Protection and Affordable Care Act (ACA) remains constitutional after the elimination of the individual mandate, a change in position articulated in a Feb. 10 letter to the U.S. Supreme Court.

  • February 09, 2021

    Parity Act Plaintiffs Don’t Allege Disparate Treatment, Judge Says

    SALT LAKE CITY — Plaintiffs alleging violation of the Parity Act adequately explain their efforts at obtaining coverage for behavioral health care, but not how the insurer would treat similar claims in the medical or surgical setting differently, a federal judge in Utah said Feb. 4 in dismissing the claim.

  • February 02, 2021

    Judge: As-Applied Parity Act Claim Fails For Lack Of Comparison

    SALT LAKE CITY — Father and son plaintiffs detail their own experience with seeking insurance coverage for mental health treatments, but fail to provide details regarding how their insurer treats those coverage decisions differently than similar care in the surgical or medical setting, a federal judge in Utah said Jan. 28 in dismissing a complaint.

  • February 02, 2021

    Single Sentence Didn’t Create ‘In-Network’ Payment Contract, Judge Says

    NEW YORK — A single line in an explanation of benefits sent after payment had already been made indicating reimbursement was at the in-network level does not create a contract, a federal judge in New York said in dismissing a surgery provider’s suit on Jan. 29.

  • February 01, 2021

    Insurer: Out-Of-Network Provider Can’t Sue Under Virginia Emergency Care Law

    RICHMOND, Va. — Nothing in a state law mirroring the Patient Protection and Affordable Care Act (ACA) and mandating insurance coverage for emergency care creates a private right of action for out-of-network providers, a conclusion buttressed by the fact that the Legislature later created a system for those types of claims in a subsequent amendment, an insurer tells the Virginia Supreme Court in a Jan. 27 opening brief.

  • January 29, 2021

    Coverage Denial, Out-Of-Pocket Payments Keep Proton Beam Suit Alive, Judge Says

    OAKLAND, Calif. — An insurer never denies the claims at the heart of a reimbursement case — that the company originally denied coverage for a man’s proton therapy on the grounds that it was investigational, causing the man to pay out of pocket — a federal judge in California said in a Jan. 25 opinion denying dismissal.  In a footnote, the judge rejected the insurer’s claim that the insured could not demonstrate injury because the provider was paid, saying the plan specifically envisions payments to the insured for out-of-network care.

  • January 28, 2021

    Judge Finds Health Care Reimbursement Suit Outside ERISA, Grants Remand

    PHILADELPHIA — Providers of emergency care base their suit seeking reimbursement on years of prices an insurer paid them as an out-of-network provider, a federal judge in Pennsylvania said Jan. 25 in granting remand after finding that the suit does not implicate the Employee Retirement Income Security Act and is not preempted .

  • January 27, 2021

    Judge: Texas Emergency Care Law Includes Right To Sue, Avoids ERISA Preemption

    HOUSTON — No contract exists between an out-of-network provider group and an insurer, but Texas law mandating arbitration before the filing of any lawsuit by an out-of-network provider seeking “usual and customary” reimbursement for emergency care recognizes a private right of action and avoids Employee Retirement Income Security Act preemption, a federal judge in Texas said Jan. 22 while largely denying a motion to dismiss.

  • January 27, 2021

    Government Says It Can Set Off ACA Risk-Corridor Liabilities Against Insolvent Insurers

    WASHINGTON, D.C. — The U.S. Court of Federal Claims has jurisdiction to decide claims seeking setoffs of debts against risk-corridor liabilities owed to insolvent health insurers under the Patient Protection and Affordable Care Act (ACA) risk corridor, the U.S. government argues in a Jan. 22 opposition brief to a motion to dismiss, also noting its authority to recover interest owed on ACA debts.

  • January 26, 2021

    Judge:  Health Insurer’s Interactions Waived Anti-Assignment Provision

    SALT LAKE CITY — Two years’ worth of interactions between an insurer and an emergency medical transport company provide sufficient grounds on which to find waiver of an anti-assignment provision, a federal judge in Utah said in citing recent precedent and allowing an Employee Retirement Income Security Act claim for benefits but otherwise dismissing the case on Jan. 20.

  • January 22, 2021

    ACA Transgender Rule Violates Religious Parties’ Rights, Judge Says

    BISMARCK, N.D. — Religious plaintiffs claiming injury from having to offer insurance coverage for abortions are “tilting at windmills” but have a stronger case challenging coverage of transgender procedures because the government has less restrictive means of advancing its interests, a federal judge in North Dakota said in partially granting summary judgment Jan. 19 and enjoining enforcement of the rule.

  • January 22, 2021

    Footnote Didn’t Preserve Ripeness Argument, Judge Says In Dialysis Rule Challenge

    WASHINGTON, D.C. — A dialysis group challenging elimination of Medicare Advantage time-and-distance standards waived the issue of ripeness by responding only in a footnote to a different motion with the contention that its standing and ripeness arguments were the same, a federal judge in the District of Columbia said Jan. 19 in dismissing a case.