Mealey's Health Care / ACA
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December 12, 2022
Insurer Says Provider’s Compensation Case Ignores Precedent, Facts
SAN DIEGO — A health insurer told a California appeals court an appellant provider seeks additional compensation for health care services simply because it believes it should receive it, and the provider’s shifting argument never grapples with the Employee Retirement Income Security Act, precedent or facts of the case involving contract, fraud and California unfair competition law (UCL) claims.
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December 12, 2022
Providers Appeal No Surprises Act Constitutionality Ruling
NEW YORK — A surgeon and his medical practice filed a notice appealing to the Second Circuit U.S. Court of Appeals a federal judge in New York’s decision that the No Surprises Act (NSA) did not violate constitutional rights.
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December 12, 2022
9th Circuit Affirms Dismissal Of UCL Class Suit For Medical Record Fees
PASADENA, Calif. — A Ninth Circuit U.S. Court of Appeals panel affirmed a district court’s dismissal of a woman’s putative class action against three health care entities for violating California’s unfair competition law (UCL) and the California Evidence Code by overcharging her for medical records after the panel found the defendants exempt from the medical records requirements as they are not medical providers.
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December 08, 2022
Motion To Remand Disability Suit Denied; Diversity Of Citizenship Exists, Judge Says
LOS ANGELES — A California federal judge denied a disability claimant’s motion to remand a breach of contract and bad faith suit after determining that complete diversity of citizenship exists between the parties because the claimant fraudulently joined an individual who conducted surveillance video on behalf of the disability insurer in an attempt to avoid federal jurisdiction.
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December 08, 2022
Abuse-Of-Discretion Standard Applies In Substance Abuse Case, Insurer Says
LOS ANGELES — Various health care plans in a consolidated action clearly grant an insurer discretion, meaning abuse of discretion remains the proper standard for evaluating out-of-network substance abuse reimbursement claims, an insurer told a federal judge in California in supplemental briefing.
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December 07, 2022
Voluntary Dismissal Ends Putative Class ERISA Suit Over Telehealth Reimbursement
NEW HAVEN, Conn. — A health care plan participant’s putative class action asserting Employee Retirement Income Security Act claims against UnitedHealthcare Insurance Co. and United Behavioral Health over allegations of a “self-serving telehealth reimbursement policy” was closed Dec. 7 following a notice of voluntary dismissal without prejudice.
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December 07, 2022
Judge: State Health Plan Subject To ACA; Transgender Exclusion Discriminatory
GREENSBORO, N.C. — A health plan’s exclusion on transgender care violates the Patient Protection and Affordable Care Act (ACA) by discriminating on the basis of sex, and a state health plan falls within the law’s definition of a health program or activity, a federal judge in North Carolina said in granting summary judgment.
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December 07, 2022
Magistrate Judge: Repricing Entity Waived Privilege In Health Care Coverage Suit
OAKLAND, Calif. — MultiPlan Inc. must produce all documents listed in its privilege log after ignoring a previous court ruling and attempts at “tactical manipulation” of the discovery process, a federal magistrate judge in California said in a health care compensation dispute.
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December 07, 2022
Claimant Met Burden Of Showing She Is Disabled From Sedentary Occupation
LOS ANGELES — A disability claimant is entitled to long-term disability (LTD) benefits, a California federal judge said after determining that the claimant showed by a preponderance of the evidence that she is more than likely disabled from performing the duties of a sedentary occupation.
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December 07, 2022
Disability Insurer Entitled To Costs For Deposition Transcripts, Judge Says
LOUISVILLE, Ky. — A Kentucky federal judge awarded a disability insurer approximately $1,644 in costs for deposition transcripts costs after determining that the award of costs is appropriate and that the disability claimant failed to demonstrate that an award of costs is unreasonable or unnecessary.
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December 07, 2022
Rule Implementing No Surprises Act Arbitration Remains Flawed, Providers Say
TYLER, Texas — Medical providers say in opposition to summary judgment in a Texas federal court that a rule implementing the arbitration process under the No Surprises Act (NSA) does not fill a gap in the statute but instead creates a conflict with the statute by replacing discretion granted to the arbitrator with a flawed process involving “ghost rates.”
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December 05, 2022
Illinois Law Applies To Breach Of Contract, Bad Faith Claims In Disability Suit
LOS ANGELES — A California judge determined that Illinois law must be applied to breach of contract and bad faith claims in a suit filed against a disability income insurer because the policy was issued in Illinois, includes a choice-of-law provision designating Illinois law as the applicable law and does not contravene any fundamental policy of California.
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December 02, 2022
Judge Preliminarily Approves Settlement Of ERISA Residential Treatment Class
BOSTON — A federal judge granted preliminary approval to a settlement between a class and an insurer accused of deceptively describing the reason for its denial of residential treatment claims. The agreement provides compensation on a no-documentation basis to families denied coverage and requires the insurer to better explain denials going forward.
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December 02, 2022
Plaintiffs Argue Injuries From Cross-Plan Offsetting, Fiduciary Status And Breach
MINNEAPOLIS — Arguing in part that the defendants’ motion is based on “a misreading of Eighth Circuit caselaw,” the plaintiffs in a putative class Employee Retirement Income Security Act suit over the practice known as “cross-plan offsetting” contend that they have alleged concrete injuries-in-fact and urge a Minnesota federal court to deny dismissal.
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December 01, 2022
Magistrate Grants Motion To Seal Settlement Docs In Insolvent Health Plan Dispute
CHICAGO — A federal magistrate judge issued a minute docket entry granting an independent fiduciary’s motion to remove from the docket confidential settlement communications in a breach of duty of care suit against insurance brokers in connection with the sale of an insolvent health plan.
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November 29, 2022
New York Federal Judge Denies Reconsideration Of Autism Care Payment Ruling
NEW YORK — Plaintiffs in an applied behavioral analysis compensation case base their motion for reconsideration on sleight of hand and arguments they didn’t previously raise, a federal judge in New York said in denying the motion.
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November 29, 2022
Government Outlines Standing, Available Remedy In ACA Preventive Care Case
DALLAS — In a supplemental brief, the government told a federal judge in Texas in supplemental briefing that a single plaintiff has standing to challenge Patient Protection and Affordable Care Act preventive care provision and that any remedy should be narrowly tailored.
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November 29, 2022
Insurer Wants Immediate Review Of ACA Section 1557 Class Certification Ruling
TACOMA, Wash. — The Patient Protection and Affordable Care Act permits plan exclusions on transgender care, a case involving 398 self-funded plans covering 15 levels of coverage lacks commonality and the named plaintiff’s unique treatment route makes him untypical of the class he seeks to represent, an insurer tells the Ninth Circuit U.S. Court of Appeals in seeking interlocutory review of a class certification ruling.
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November 22, 2022
Judge: ACA Section 1557 Gender Dysphoria Experts Reliable, Admissible
TACOMA, Wash. — Outside a single untimely submission, cross-challenges to experts in a gender dysphoria discrimination class suit involving the Patient Protection and Affordable Care Act go to the weight of the testimony, and the opinions are admissible, a federal judge in Washington said Nov. 21 in mostly denying motions to exclude.
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November 22, 2022
Washington Court Reinstates Wilderness Treatment Case’s ACA Breach Of Contract Claim
SEATTLE — An individual denied residential treatment benefits may pursue a breach of contract claim based on allegations that the exclusion violates the Patient Protection and Affordable Care Act and that it constitutes a separate limitation on mental health treatments, a Washington appeals court said Nov. 21 in reversing a summary judgment ruling in part.
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November 21, 2022
Judge Dismisses ACA Risk Adjustment Fraud Claims, Clarifies Impact
SAN FRANCISCO — A federal judge in California granted a motion to clarify that his ruling dismissing some of a False Claims Act case against insurers that allegedly submitted fraudulent claims in the Patient Protection and Affordable Care Act risk adjustment program applied only to the original plaintiffs and not the United States as intervenor.
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November 21, 2022
High Court Will Not Review Denial Of Private Remedy For COVID Test Reimbursement
WASHINGTON, D.C. — The U.S. Supreme Court on Nov. 21 denied a petition for writ of certiorari before judgment submitted by a health care provider requesting that the court find that Congress had an “implicit intent” to create a private remedy in favor of providers of COVID-19 diagnostic testing services under the Coronavirus Aid, Relief, and Economic Security (CARES) Act after a California federal court dismissed several separate lawsuits the provider filed seeking full reimbursement for COVID-19 tests from a health insurer.
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November 21, 2022
Disability Insurer Breached Contract, Acted In Bad Faith, Insured Says In Complaint
SEATTLE — A disability insurer breached its contract and acted in bad faith by failing to properly calculate the amount of residual disability benefits available under two long-term disability policies, an insured maintains in a complaint filed in Washington federal court.
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November 17, 2022
Provider Challenges No Surprises Act Arbitration Award
TRENTON, N.J. — A plastic surgery provider filed suit in New Jersey federal court to vacate a No Surprises Act arbitration award in favor of an insurer, saying the one-sentence decision lacks any of the necessary explanation required by federal law.
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November 14, 2022
Judge Finds For Providers In ACA Section 1557 Discrimination Challenge
AMARILLO, Texas — Recent U.S. Supreme Court precedent does not apply to Patient Protection and Affordable Care Act Section 1557, and the plain language of the anti- discrimination statutes on which it relies clearly envision the term sex as a binary, a federal judge in Texas said Nov. 11, granting plaintiffs summary judgment but denying them injunctive relief .