Mealey's Health Care / ACA
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June 09, 2023
Citing Health Plan Exclusion, 8th Circuit Upholds Judgment Against Beneficiary
ST. LOUIS — An Eighth Circuit U.S. Court of Appeals panel ruled in part that a self-insured health plan’s exclusion means that it doesn’t have to cover medically necessary treatment for complications of weight-reduction surgery, and Iowa law and Affordable Care Act (ACA) provisions regarding emergency services don’t change that.
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June 07, 2023
Plan And Member Classes Certified In Suit Over Alleged Cost-Shifting On Remand
ASHEVILLE, N.C. — On remand, a North Carolina federal judge ruled that the plaintiff in an Employee Retirement Income Security Act suit against a health insurer and its subcontractor has standing to assert certain equitable claims “both as an individual participant and on behalf of her Plan, without proof of a financial loss.”
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June 06, 2023
Provider: Injury Stems From No Surprises Act Duties, Not Health Insurers
NEW YORK — It is the government’s failure to enforce statutory deadlines and provisions and not health insurers’ failure to comply that delays the No Surprises Act process and injures providers awaiting payment, a medical practice told a federal judge in New York on June 5 in support of its request for injunctive relief and in opposition to a motion to dismiss.
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June 01, 2023
Government Says Brief Shows Stay During Appeal Won’t Harm ACA Care Challengers
NEW ORLEANS — A party’s concession that it and other employers will not drop Patient Protection and Affordable Care Act mandated preventive care coverages until an ultimate ruling in the case shows there is no harm from staying a ruling on the provision’s constitutionality and that the injunction is impermissibly broad, the government tells the Fifth Circuit U.S. Court of Appeals.
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June 01, 2023
Health Insurance Suit Parties Debate Certified Questions In Connecticut Dispute
NEW HAVEN, Conn. — A medical provider urged a federal judge in Connecticut to certify questions about Connecticut’s Surprise Billing Law to the state’s Supreme Court, while an insurer argued against the move, saying that its billing scheme was approved by regulators and that the provider could not prevail even if the certified questions were answered in its favor.
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May 31, 2023
California Court Affirms Medi-Cal Insurer’s Post-Stabilization Payments
LOS ANGELES — Post-stabilization services are subject to payment at Medi-Cal’s diagnosis-related rate, and that federal law does not preempt the state law, a California appeals court said May 30 in affirming a trial court’s demurrer ruling.
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May 30, 2023
New York Court Affirms Injunction Preventing Senior Care Copayments
NEW YORK — A preliminary injunction preventing collection of a $15 copayment under New York’s Senior Care program will likely prevent harm in the form of delayed or skipped medical care or the inability to pay for other essentials, a New York appellate court said in affirming issuance of the injunction.
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May 30, 2023
Medical Provider Wants Court To Enjoin Insurers’ No Surprises Act Violations
NEW YORK — Health plans are ignoring provisions in the No Surprises Act requiring prompt payment, and any forthcoming payments are likely to be “too little, too late” and threaten irreparable harm, a medical provider says in a motion for preliminary injunction filed in a New York federal court.
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May 30, 2023
Tennessee Top Court: Agency’s Cap On Emergency Care Payments Required Rulemaking
NASHVILLE, Tenn. — Tennessee’s cap on reimbursements for certain emergency medical procedures is an agency statement of general applicability and does not fall within the exception for internal management, the Tennessee Supreme Court said in finding that the cap is a “rule” and should have been issued as such.
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May 26, 2023
Panel: Florida Hospitals’ Payment Data Creates Question On Proper Compensation
ATLANTA — Eight hospitals’ evidence that they traditionally received five times what an insurer paid them for emergency care is sufficient to at least create questions about what the “community” rate is under Florida law, an 11th Circuit U.S. Court of Appeals panel said May 25 in reversing summary judgment for a health insurer.
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May 26, 2023
Magistrate: AI Concerns Among Reasons To Preclude Evidence Release In ERISA Case
SALT LAKE CITY — Citing in part potential concerns that competitors could use artificial intelligence and machine learning to create derivative products if a vendor’s health care guidance information were publicly released, a federal magistrate judge in Utah granted a motion for a protective order and rejected the argument that the Employee Retirement Income Security Act mandated release of the evidence.
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May 25, 2023
Insured Dismisses Need To Amend Judgment In Proton Beam Therapy Case
ASHEVILLE, N.C. — Having known about but failed to raise a termination agreement that allegedly precludes recovery of benefits for proton beam therapy, defendants cannot claim that the evidence is new, a man tells a federal judge in North Carolina in opposing a motion to amend the judgment in his favor.
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May 25, 2023
Hospital, Deaf Woman Brief 2nd Circuit On Viability Of Interpreter ACA Claim
NEW YORK — A deaf woman’s interactions with hospital staff indicated that she wished to proceed with her daughter as her interpreter, and doing so violated neither the Patient Protection and Affordable Care Act (ACA) nor New York law, a hospital tells the Second Circuit U.S. Court of Appeals in an appellee brief.
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May 23, 2023
Judge Says Insurer Entitled To Judgment On Promissory Estoppel Claims
LOUISVILLE, Ky. — A medical provider’s late response largely ignores the actual issues before the court, a federal judge in Kentucky said May 22 in granting an insurer summary judgment after finding that precertification letters at best constitute the insurer’s conditional agreement to make payments.
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May 23, 2023
Lack Of Fiduciary Power, Coverage Disparity Doom Mental Health Coverage Suit
DETROIT — An insurer lacked the fiduciary power required to be liable under the Employee Retirement Income Security Act, and there is no evidence that it employed different standards for evaluating mental health and surgical or medical claims, a federal judge in Michigan said May 22 in granting the insurer’s motion to dismiss.
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May 22, 2023
Appellees Urge 2nd Circuit To Uphold Facility Fees Ruling In ERISA Class Case
NEW YORK — Contending that materials were properly considered and an argument that interpretations were unreasonable lacks merit, a health insurer and related entities urged the Second Circuit U.S. Court of Appeals to affirm judgment for them in an Employee Retirement Income Security Act suit over reimbursement for facility fees in New York.
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May 19, 2023
Judge Wants Briefing On Potential Certified Questions In Surprise Billing Law Spat
NEW HAVEN, Conn. — A federal judge said that she believed certifying a trio of questions to the Connecticut Supreme Court on issues of first impression about the state’s Surprise Billing Law was the best way forward but that in light of the parties’ objections she would allow briefing before taking any action.
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May 18, 2023
Dismissal Motion Tossed For Lack Of Pre-Motion Conference Letter In COVID Test Suit
NEWARK, N.J. — In a lawsuit brought by a medical testing laboratory seeking reimbursement for COVID-19 testing from a pair of health insurers, a New Jersey federal judge administratively terminated the insurers’ motion to dismiss the laboratory’s amended complaint, citing the insurers’ failure to comply with judge’s procedures requiring a short letter requesting a pre-motion conference before filing a motion to dismiss.
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May 18, 2023
ERISA, Discrimination Claims Survive In Dialysis Coverage Case
COLUMBUS, Ohio — A dialysis provider’s discrimination and Employee Retirement Income Security Act claims may proceed, a federal judge in Ohio said in granting a health plan summary judgment on a single claim under the Medicare Secondary Payor Act (MSPA) in the wake of a U.S. Supreme Court ruling.
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May 18, 2023
California Court Publishes UCL, Mental Health Coverage Ruling
SAN FRANCISCO — A California appeals court on May 17 published an opinion after insureds, the California attorney general and the city of San Diego argued that the ruling finding that courts could interpret health care statutes and that payment for mental health insurance coverage that was not accessible created standing for a California unfair competition law (UCL) claim was unique and of wide importance.
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May 17, 2023
Clinical Staffing Firm Envision Seeks Bankruptcy Protection
HOUSTON — Clinical staffing company Envision Healthcare Corp. filed for Chapter 11 protection in a Texas federal bankruptcy court, citing the “whiplash-inducing onslaught” caused by the coronavirus, changes in the regulatory atmosphere and other complications.
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May 16, 2023
Court: ERISA Insurer Can’t ‘Shut Its Eyes’ To Available Medical Evidence
DENVER — An Employee Retirement Income Security Act health plan administrator did not need to credit treating physicians’ opinions, but it also couldn’t simply “shut its eyes” and fail to engage with readily available medical evidence, the 10th Circuit U.S. Court of Appeals said in finding the insurer’s coverage denials arbitrary and capricious and affirming and award of benefits.
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May 16, 2023
5th Circuit Stays ACA Preventive Care Ruling Pending Appeal
NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals on May 15 stayed a judge’s nationwide vacatur of the Patient Protection and Affordable Care Act (ACA)’s preventive care mandate while it considers an appeal in the case after being told that the ruling undoes more than a decade’s worth of action ensuring cost-effective access to health care, lacks legal justification and threatens public health.
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May 16, 2023
No Surprises Act Violates Jury Trial, Property Rights, Provider Says
NEW YORK — The No Surprises Act (NSA) unconstitutionally strips jury trial rights and constitutes an illegal taking, a doctor and his medical office tell the Second Circuit U.S. Court of Appeals.
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May 16, 2023
Provider May Sue Insurer Under Power Of Attorney, Judge Says
TRENTON, N.J. — A valid anti-assignment provision does not preclude a medical provider from pursuing compensation claims under a power of attorney, which conveys a separate sort of power, a federal judge in New Jersey said in ruling on a motion to dismiss.