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Mealey's Health Care / ACA

  • September 25, 2023

    Mental Health Insurer Never Meaningfully Engaged With Insureds, Judge Says

    SALT LAKE CITY — An insurer’s apparent failure to recognize that the program for which it originally approved treatment included both residential and transitional levels, its “cryptic denials” and its dismissal of the opinions of treating physicians evidence a failure to participate in meaningful dialogue with the insureds, a federal judge in Utah said in granting summary judgment on both Employee Retirement Income Security Act (ERISA) and Parity Act claims.

  • September 25, 2023

    AI Company:  Health Care Startup Stole Sci-Fi-Based Trademark

    NEW YORK — A startup health care company that uses artificial intelligence to tailor treatments skipped the hard part of earning its own reputation and instead simply stole an existing and completely unique name and established trademark in an effort to confuse consumers, an artificial intelligence technology company tells a New York federal court.

  • September 22, 2023

    COVID-19 Test Provider Denied Reimbursement From Insurer Requests Rehearing En Banc

    SAN FRANCISCO — A COVID-19 test provider petitioned the Ninth Circuit U.S. Court of Appeals for rehearing en banc after a panel of the court affirmed the judgment of a California federal court dismissing five complaints brought by the provider seeking reimbursement from an insurer for COVID testing services, asserting that the panel erred in determining that the Coronavirus Aid, Relief and Economic Security (CARES) Act does not provide an implied private right of action to diagnostic testing providers.

  • September 22, 2023

    AI Health Care Company Seeks To Defend Common-Law Trademark

    SAN FRANCISCO — A company’s registration of an already-in-use trademark and its intention to use the mark going forward sow confusion and tie the name’s existing goodwill to a disreputable entrepreneur in violation of the California unfair competition law (UCL), among others, a company hoping to use artificial intelligence in the medical education space says in a complaint.

  • September 21, 2023

    Amici Praise Pricing, Economics Behind Drug Price Negotiation Law

    WASHINGTON, D.C. — A law allowing federal health programs to negotiate drug prices represents a step toward affordability in a market otherwise clouded by complicated pricing signals, two AARP entities and a group of scholars and economists told a federal judge in the District of Columbia in amicus briefs.

  • September 21, 2023

    Full 4th Circuit Hears Arguments On Plan’s Gender Surgery Exclusion

    RICHMOND, Va. — The en banc Fourth Circuit U.S. Court of Appeals heard oral argument Sept. 21 over whether North Carolina’s health plan’s exclusion on gender transition procedures necessarily discriminates on the basis of sex of the patient or simply imposes an exclusion on certain treatments like any other designed to save it and the state money.

  • September 20, 2023

    Some Claims Proceed In Health Care Repricing Scheme Case Against UnitedHealth

    NEW YORK — Claims that various UnitedHealth Group Inc. entities collected billions of dollars in fees under a repricing scheme providing Employee Retirement Income Security Act plans with largely illusory savings suffice to overcome a motion to dismiss, a federal judge in New York said Sept. 19 in partly denying the motion.

  • September 18, 2023

    No Cure For Defective ACA Preventive Care Mandate, 5th Circuit Challengers Say

    NEW ORLEANS — The government cannot cure defects in an independent governmental body’s actions by simply by reappointing its group’s members, Patient Protection and Affordable Care Act (ACA) preventive care mandate challengers told the Fifth Circuit U.S. Court of Appeals while seven days later, a pair of amicus briefs warned about the potential risks of an unaccountable regulatory state.

  • September 18, 2023

    Government Urges High Court To Uphold ‘Bedrock Principle’ Of Chevron Deference

    WASHINGTON, D.C. — The U.S. secretary of Commerce, two National Oceanic and Atmospheric Administration (NOAA) officials and the National Marine Fisheries Service (NMFS) (collectively, the government) urge the U.S. Supreme Court in a Sept. 15 brief to not overrule the doctrine of Chevron deference in a challenge to fishery regulations that were upheld by the District of Columbia Circuit U.S. Court of Appeals, writing that doing so could “cause disruption” to complex federal regulatory schemes.

  • September 18, 2023

    Insurer Isn’t Honoring No Surprises Act Arbitration Payment Duty, Provider Says

    OAKLAND, N.J. — Despite a No Surprises Act (NSA) arbitration award against it, a 30-day payment mandate and repeated attempts to collect on that debt, an insurer has yet to make any payment, a provider says in a complaint filed in New Jersey federal court.

  • September 15, 2023

    California High Court Won’t Review UCL Mental Health Coverage Ruling

    SACRAMENTO, Calif. — The California Supreme Court denied a petition for review after a lower court published its opinion finding that two insureds adequately alleged standing under the California unfair competition law (UCL) and that the way the insurer handles mental health care results in shortages of that care.

  • September 15, 2023

    Texas HMO Wants Rehearing Over Question On Immunity From Provider’s Suit

    HOUSTON — An appellate ruling finding that a statutorily created hospital district’s nonprofit health maintenance organization was not a unit of local government and therefore not entitled to statutory immunity glosses over complicated issues and ignores Texas Supreme Court precedent and the very purpose for such organizations, an insurer told a Texas appeals court in seeking rehearing and rehearing en banc on Sept. 14.

  • September 15, 2023

    Certified Class: Insurer Used Single Experimental Treatment For Blanket Denials

    UTICA, N.Y. — A federal judge in New York on Sept. 14 certified a class of insureds who claim that United Behavioral Health violated the Employee Retirement Income Security Act by issuing blanket denials for residential treatments when it considered even a single aspect of the facility’s treatment experimental.

  • September 14, 2023

    Enforceability Of ACA, Parity Act Argued Before Washington High Court

    TACOMA, Wash. — A family denied coverage for their daughter’s residential treatments told the Washington Supreme Court during Sept. 14 oral arguments that a health plan explicitly incorporated federal and state parity law and that the Patient Protection and Affordable Care Act (ACA) can form a breach of contract claim; but in response, the insurer told the court that regulatory agencies are the proper venue to correct insurer behavior and that not every claim denial is an act of bad faith.

  • September 14, 2023

    Parties In ERISA Case With Large Class Denied Permission For Interlocutory Appeal

    RICHMOND, Va. — Bids by a health insurer and subcontractor for permission to file interlocutory appeals to the Fourth Circuit U.S. Court of Appeals over a class certification order in a suit concerning an alleged cost-shifting scheme were denied without explanation in a Sept. 13 order.

  • September 13, 2023

    Judge Affirms No Surprises Act Award, Says No Written Explanation Necessary

    TRENTON, N.J. — The No Surprises Act (NSA) imposes no written explanation requirement on arbitrators, and the record contains no evidence the arbitrator in this case relied on since-vacated rules, a federal judge in New Jersey said in confirming an arbitration award in favor of an insurer.

  • September 13, 2023

    Split 4th Circuit Panel Partly Remands ERISA Case In Equitable Remedy Ruling

    RICHMOND, Va. — Partly vacating dismissal of an Employee Retirement Income Security Act case over denial of a heart transplant, a Fourth Circuit U.S. Court of Appeals panel focused on the question of when monetary relief is equitable, splitting on an issue involving interpretation of a 2016 U.S. Supreme Court decision.

  • September 12, 2023

    California Court Revives Portion Of Air Transport Case Against School District

    FRESNO, Calif. — While questions remain about whether a school health plan is its own legal entity or a public one, those questions keep alive claims that it underpaid for emergency air transport, while the school district’s argument about its discretionary power ignores that the contract is with its insured and not the third-party provider, a panel of a California appeals court said Sept. 11 in reversing judgment for the district.

  • September 11, 2023

    9th Circuit Panel Affirms That CARES Act Does Not Provide Private Right Of Action

    SAN FRANCISCO — A panel of the Ninth Circuit U.S. Court of Appeals affirmed the judgment of a California federal court dismissing five complaints brought by a COVID-19 test provider seeking reimbursement from an insurer for COVID testing services, agreeing with the lower court that the Coronavirus Aid, Relief and Economic Security (CARES) Act does not provide a private right of action to diagnostic testing providers.

  • September 08, 2023

    2nd Class Action Targets Cigna’s Alleged Use Of AI In Denying Claims

    NEW HAVEN, Conn. — Health insurer Cigna Health and Life Insurance Co. denies claims en masse using artificial intelligence (AI) knowing that most insureds will either forgo care or not spend the time on an appeal, plaintiffs allege in a putative class action filed in Connecticut federal court.

  • September 08, 2023

    Insureds Seek Rehearing Of Case Where 10th Circuit Ordered Claim Reprocessing

    DENVER — Arguing that it is “time to bring an end to the extra-statutory practice of remanding [Employee Retirement Income Security Act] benefit cases,” insureds are seeking rehearing of a 10th Circuit U.S. Court of Appeals panel ruling that ordered reprocessing of claims for residential treatment for mental health and substance use.

  • September 08, 2023

    DOL Sues Big TPA Over Emergency, Drug Screening Claim Adjudication

    MADISON, Wis. — Alleging that the third-party administrator (TPA) of more than 2,100 self-funded employee welfare benefit plans is a named and functional fiduciary in regard to the challenged conduct, Acting U.S. Department of Labor Secretary Julie A. Su filed an Employee Retirement Income Security Act suit over adverse benefit determinations regarding hospital emergency services claims and urinary drug screening claims.

  • September 07, 2023

    Parties In ERISA Case With Large Class Dispute Bid For Interlocutory Appeal

    RICHMOND, Va. — Arguing that a health insurer and subcontractor “advance the same arguments that have already been rejected four times in this case,” the respondent in a suit concerning an alleged cost-shifting scheme urged the Fourth Circuit U.S. Court of Appeals to deny the bids for permission to file interlocutory appeals over a class certification order.

  • August 31, 2023

    In 2-1 Decision, 9th Circuit Reverses On Threshold Question In Preemption Row

    SAN FRANCISCO — In a 2-1 ruling concerning a threshold issue, a Ninth Circuit U.S. Court of Appeals panel reversed and remanded a summary judgment order against a trade organization that argued that a city and county of San Francisco ordinance concerning health insurance benefits for airline employees is preempted by federal law including the Employee Retirement Income Security Act.

  • August 30, 2023

    ERISA Suit On Out-Of-Network Spinal Surgery Dismissed For Missing Link To Policy

    NEWARK, N.J. — A federal judge in New Jersey dismissed without prejudice a medical center’s lawsuit and granted the center an extension to amend its claim that alleged that an employer and insurer underpaid for a patient’s emergency spinal surgery by approximately $117,547 and violated the Employee Retirement Income Security Act.