Mealey's Health Care / ACA
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March 16, 2023
Panel Deems Arbitration Agreement Unenforceable In Pharmacies’ UCL Suit
SAN FRANCISCO — A California appellate panel on March 15 held that an arbitration agreement between a pharmacy benefits manager (PBM) and 22 independent pharmacies was “unconscionable” and affirmed a trial court’s ruling allowing the pharmacies to sue the PBM for violating California’s unfair competition law (UCL) and other statutes for conduct allegedly including price-fixing and diverting their business to its own mail-order pharmacy.
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March 16, 2023
Blanket Wilderness Therapy Exclusion Doesn’t Violate Parity Act, Judge Says
SALT LAKE CITY — A health insurance plan’s blanket exclusion on wilderness therapy does not violate the Parity Act, an outcome that is not avoided by a claimant’s arguments about licensing or how an independent reviewer reached a conclusion affirming the benefits decision, a federal judge in Utah said.
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March 15, 2023
Class Wants 9th Circuit To Take Another Look At ERISA Claim Reprocessing Ruling
SAN FRANCISCO — The Ninth Circuit U.S. Court of Appeals deviated from a “unanimous chorus of authority” when it determined that claims reprocessing is a means to an end rather than a remedy itself in an Employee Retirement Income Security Act case, a ruling that will produce “nightmarish” results for courts, a class argues in a petition for rehearing.
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March 15, 2023
5th Circuit: Statutory, Regulatory Regimes Support Proton Beam Coverage Decision
NEW ORLEANS — A Fifth Circuit U.S. Court of Appeals panel sympathized with a woman’s challenge to the denial of coverage for proton beam therapy in the face of a “maddening” and “byzantine” health care system but said in affirming dismissal of her claims that its hands were tied by the statutory and regulatory realities.
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March 15, 2023
Class Motions On Takings Claim In ACA Reinsurance Row Stayed For Summary Judgment
WASHINGTON, D.C. — Pending resolution of a motion for partial summary judgment, a U.S. Court of Federal Claims judge has stayed two motions related to class certification of a takings claim in a case concerning the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA).
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March 15, 2023
COVID Test Provider’s Suit Alleging Underpayment By Insurer Dismissed By Judge
SAN FRANCISCO — A California federal judge entered judgment dismissing a lawsuit for failure to file an amended complaint by a coronavirus testing site operator that had accused an insurer of failure to reimburse providers for COVID-19 tests allegedly in violation of the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and other statutes.
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March 14, 2023
D.C. Circuit Affirms Summary Judgment In Uncompensated Care Case
WASHINGTON, D.C. — The way the Department of Health and Human Services (HHS) calculates uncompensated care provided by hospitals after passage of the Patient Protection and Affordable Care Act (ACA) is not subject to challenge and falls outside the type of procedural challenge that can be brought, the District of Columbia Circuit U.S. Court of Appeals said.
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March 13, 2023
Preliminary OK Sought For Amended Class Settlement In ERISA Surgery Coverage Row
SAN FRANCISCO — An amended class settlement proposal addresses the concerns that resulted in its predecessor being denied preliminary approval, both parties in a class suit over a health plan’s denial of coverage for a specialized form of liposuction to treat lipedema told a California federal court.
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March 09, 2023
Judge Dismisses ACA, ERISA, CARES Act Compensation Claims
BRIDGEPORT, Conn. — A federal judge in Connecticut dismissed claims alleging underpayment for testing and treatment for COVID-19 with leave to amend, finding that the Patient Protection and Affordable Care Act (ACA) and two other statutes governing payments for COVID-19 procedures lack a private right of action and that Employee Retirement Income Security Act claims are not specific enough.
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March 09, 2023
Judge: As Pleaded, COVID-Testing Lab’s Reimbursement Claims Preempted By ERISA
NEWARK, N.J. — In a lawsuit brought by a medical testing laboratory seeking reimbursement for COVID-19 testing from a group of health insurers, a New Jersey federal court granted the insurers’ motion to dismiss with leave to amend five of the counts, ruling that there was either no private right of action for reimbursement or the claims were preempted by the Employment Retirement Income Security Act, and denied a motion to dismiss one of the defendants from the complaint.
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March 07, 2023
Head And Neck Cancer Class Seeks Approval Of Proton Beam Therapy Settlement
PHILADELPHIA — A class of head and neck cancer sufferers has asked a federal judge in Pennsylvania for preliminary approval of a settlement resolving claims that denial of insurance coverage for proton beam therapy (PBT) violated Employee Retirement Income Security Act fiduciary duties.
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March 06, 2023
Judge Finds Removal Untimely In Medicare Care Payment Dispute
LOS ANGELES — A spreadsheet provided to defendants accused of underpaying for medical care put them on notice that the case involved in-network claims, and it does not matter that the plaintiff eventually updated the document, a federal judge in California said Feb. 23 in remanding the case.
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March 02, 2023
Judge Says Pre-Authorization Communications All ‘Relate To’ ERISA Plan
PRINCETON, N.J. — Pre-authorization communications between a surgical provider and an insurer didn’t involve separate and independent promises to pay but instead related to payment under the terms of the insured’s Employee Retirement Income Security Act plan, and claims for alleged underpayment are preempted by ERISA, a federal judge in New Jersey said in granting a motion to dismiss.
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March 02, 2023
Government Seeks Exclusion For Almost Half Of Class In ACA Reinsurance Row
WASHINGTON, D.C. — Arguing that close to half the entities certified as members of a class are not true SISAs — self-insured, self-administered employee health and welfare benefit plans — the government filed an objection on March 1 in a U.S. Court of Federal Claims case concerning the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA).
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March 01, 2023
Justice Dismisses Providers’ Compensation Claims As Preempted, Unfounded
NEW YORK — Because an out-of-network provider’s state law action seeking additional compensation from an insurer relates to Employee Retirement Income Security Act plans, it is preempted, and the agreement letters sent to insureds approving out-of-network treatment do not form a basis for a contract claim, a New York justice said in two slip opinions granting a motion to dismiss.
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March 01, 2023
Shared Saving Network Claims Don’t Trigger ERISA Preemption, Judge Says
MIAMI — A dispute between a medical provider and an insurer over the proper compensation owed under a shared savings program does not invoke an insured’s Employee Retirement Income Security Act plan, and the allegations are sufficient to overcome dismissal, a federal judge in Florida said Feb. 28 in adopting a magistrate judge’s recommendation that the court deny a motion to dismiss.
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March 01, 2023
Judge: Insurer-Employer Dispute Invokes Contract, Not ERISA Fiduciary Duty
DETROIT — A dispute between an employer and a Blue Cross entity contracted to administer the self-insured health plan that allegedly overpaid on some claims is at its heart a contract dispute and not one involving fiduciary duties under the Employee Retirement Income Security Act, a federal judge in Michigan said in granting a motion to dismiss.
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February 24, 2023
Blue Cross Wants Transgender Discrimination Class Undone
TACOMA, Wash. — Recent precedent establishes that reprocessing of health insurance claims isn’t a remedy unto itself but instead a means to a remedy and making the type of individualized decisions on medical necessity and amount of coverage warrants decertifying a class alleging discrimination in a plan’s exclusion for gender-affirming care, an insurer says in a motion.
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February 22, 2023
9th Circuit Affirms Order Compelling Compliance With ERISA Oral Settlement
LOS ANGELES — Because a written agreement did not deviate from the terms of the orally agreed settlement, a district court did not abuse its discretion by granting a motion to enforce the settlement between a provider of medical services and an insurer, a Ninth Circuit U.S. Court of Appeals panel said.
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February 21, 2023
Supreme Court Extends Time For Response In Medicaid Private Right Of Action Case
WASHINGTON, D.C. — After asking for a response to a petition challenging a ruling finding that medical providers could bring suit for nonpayment under Medicaid, the U.S. Supreme Court on Feb. 17 granted the respondents additional time to make their filing.
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February 21, 2023
5th Circuit: ERISA Claim Moot After Texas Emergency Care Right-Of-Action Ruling
HOUSTON — The Texas Supreme Court’s holding on a certified question that the state’s emergency care statutes lack a private right of action requires dismissal of that claim and moots an Employee Retirement Income Security Act claim, the Fifth Circuit U.S. Court of Appeals said.
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February 21, 2023
Texas High Court Seeks Response In Out-Of-Network Arbitration Award Case
FORT WORTH, Texas — The Texas Supreme Court on Feb. 17 sought an insurer’s response to a petition alleging that an appeals court improperly reinstated an arbitration award in its favor despite a dearth of evidence supporting its proposed payment rate for out-of-network care.
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February 16, 2023
Federal Judge Rules On Qui Tam FCA Suit Against Behavioral Health Provider
ALBUQUERQUE, N.M. — A New Mexico federal judge granted in part insurers’ motion to dismiss a qui tam suit filed against them under federal and state false claims act statutes regarding the insurers’ alleged false representations in their bid to administer state behavioral health services, finding that the false representation claims are statutorily time-barred and that the relator failed to provide evidence to support a state law Medicaid fraud claim.
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February 15, 2023
Discretionary Authority, Plan Assets Arguments Made In 1st Circuit In ERISA TPA Row
BOSTON — In oral argument before the First Circuit U.S. Court of Appeals that featured many questions, the appellants and amicus curiae the U.S. Labor secretary’s office contended that the third-party administrator (TPA) of a self-funded plan was a functional fiduciary under the Employee Retirement Income Security Act, and the TPA contended that it was not.
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February 15, 2023
Judge Dismisses COVID Test Provider’s Class Suit Alleging Underpayment By Insurer
SAN FRANCISCO — A California federal judge granted a motion to dismiss a coronavirus testing site operator’s amended putative class complaint against an insurer for failure to reimburse providers for COVID-19 tests allegedly in violation of the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and other statutes, dismissing all claims without leave to amend except the claim that the insurer violated California’s unfair competition law (UCL) under the unlawful prong.