Mealey's Health Care / ACA : Mealey's : Legal News & Analysis

Mealey's Health Care / ACA

February 07, 2024
Judge: Provider Can’t Show Misconduct In No Surprises Act Arbitration Challenge

TRENTON, N.J. — An arbitrator adequately explained the reason for its decision in a dispute over reimbursement for out-of-network health care, but even if it mistakenly failed to consider all the relevant factors in its decision, that would not warrant vacating the award, which requires evidence of misconduct, a federal judge said in dismissing a case with prejudice.
February 07, 2024
Cigna: ERISA Plans Bar Algorithm Health Care Claims; UCL Claims Lack Specificity

SACRAMENTO, Calif. — Insureds’ cannot demonstrate denial of claims based solely on review by an algorithm or that the use of such a tool would violate the provisions of their Employee Retirement Income Security Act plans, the insurer tells a federal judge in California in a motion to dismiss while arguing that the plaintiffs fail to plead their California unfair competition law (UCL) claims with requisite specificity.
February 06, 2024
Amici Tout Reasons Behind, Successes Of Medicare Drug Price Law

TRENTON, N.J. — Health and consumer advocates and experts in economics and health policy were among a handful of amici curiae filing briefs on Feb. 5 in a federal court in New Jersey touting the recently enacted Medicare drug negotiation program, its successes and why the program should survive manufacturers’ motion for summary judgment.
February 06, 2024
Government Wants ACA Gender Transition Case Stayed Pending New Rules

FARGO, N.D. — Government defendants asked a federal judge in North Dakota to stay a challenge to rules promulgated under the Patient Protection and Affordable Care Act (ACA) that require insurance plans cover gender transition services, saying forthcoming rule making will replace the challenged rules and likely simplify the case.
February 06, 2024
ERISA Fiduciary Breach Claims Asserted Over J&J Drug Plan That Used PBM

CAMDEN, N.J. — Calling herself a “whistleblower” and asserting fiduciary breach claims under the Employee Retirement Income Security Act, an employee on Feb. 5 filed a putative class case against Johnson and Johnson (J&J) and related entities and individuals over alleged “mismanagement of prescription-drug benefits” involving a pharmacy benefits manager (PBM).
February 02, 2024
DOL Files ERISA Suit Against TPA Over Handling Of MinnesotaCare Tax

MINNEAPOLIS — The U.S. Department of Labor (DOL) has sued a third-party administrator (TPA) in Minnesota federal court over what it alleges was at least $66.8 million the TPA collected from self-funded health benefit plans without authorization between 2016 and 2020 for a Minnesota provider tax.
February 02, 2024
11th Circuit Denies Dermatologist’s Bid To Void 8 Years Of ERISA Rulings

ATLANTA — Two 11th Circuit U.S. Court of Appeals judges have denied a request addressed to U.S. Supreme Court Justice Clarence Thomas but filed in their court in which a dermatologist sought relief including the voiding of nearly 20 rulings the 11th Circuit issued in her Employee Retirement Income Security Act cases over the last eight years.
February 01, 2024
Accounting Denied As To Disputed $185 Million Attorney Fees In Insurers’ ACA Row

WASHINGTON, D.C. — A U.S. Court of Federal Claims judge denied in part objecting class members’ motion for an accounting of a vacated $185 million attorney fee award in suits filed by insurers, some of which are insolvent, over risk-corridor payments under the Patient Protection and Affordable Care Act (ACA), finding that because the court has not yet considered a renewed fee request, the accounting is unnecessary at this time.
January 30, 2024
Judge: Twins’ Care Claims Survive ERISA Preemption, But Exhaustion Issues Remain

MIAMI — The Employee Retirement Income Security Act does not preempt contract claims brought by a medical provider seeking compensation for care provided to premature twins, but any future complaint must adequately allege exhaustion of administrative remedies, a federal judge in Florida said while granting a motion to dismiss in part.
January 24, 2024
Stay Pending Appeal Best Choice In ACA Discrimination Case, Judge Says

TACOMA, Wash. — Staying a case while an insurer appeals a ruling finding that it violated Patient Protection and Affordable Care Act (ACA) Section 1557’s prohibition on discrimination by imposing a blanket exclusion on gender-affirming care ensures that it does not have to take actions that would be difficult to undo and leaves the plaintiffs with the status quo, a federal judge in Washington said in granting the relief.
January 24, 2024
Court: Lost Income Allegations Can’t Form No Surprises Act Takings Clause Claim

NEW YORK — A medical provider’s vague allegation about the loss of future income as a result of the enactment of the No Surprises Act’s ban on balance billing and creation of a dispute resolution process do not allege a regulatory taking, a panel of the Second Circuit U.S. Court of Appeals said Jan. 23 in partially affirming dismissal of a case.
January 24, 2024
Certiorari, Summary Reversal Sought In ERISA Case Over Heart Transplant Denial

WASHINGTON, D.C. — Telling the U.S. Supreme Court that “every circuit to address the question presented was in agreement” before the Fourth Circuit U.S. Court of Appeals ruling at issue, a petitioner requests certiorari and also suggests summary reversal in an Employee Retirement Income Security Act suit concerning when monetary relief is equitable.
January 19, 2024
Air Ambulance Providers Seek To Add $3M In Claims To Arbitration Action

HOUSTON — Air ambulance providers challenging insurers’ failure to pay awards issued under the independent dispute resolution process created by the No Surprises Act (NSA) tell a federal judge in Texas that they should be able to supplement their pleading with more than $3 million in additional unpaid awards.
January 18, 2024
2nd Circuit: Judge In ERISA Row Over Facility Fees Didn’t Abuse Discretion

NEW YORK — In a Jan. 17 summary order affirming judgment for a health insurer and related entities in a suit over reimbursement for facility fees in New York, a Second Circuit U.S. Court of Appeals panel said in part that the trial court “did not abuse its discretion by admitting evidence related to” the insurer’s claims adjusting process.
January 17, 2024
High Court Told ‘Chaos’ Will Ensue ‘In A World Without Chevron’ Deference

WASHINGTON, D.C. — The U.S. Supreme Court was told Jan. 17 that “chaos” will ensue “in a world without Chevron” deference by government attorneys, who urged it to apply stare decisis and uphold Chevron, which is being challenged in two cases arising out of federal fishing regulations.
January 16, 2024
Judge Denies Walgreen’s Dismissal Motion In FCA Suit On Remand From 4th Circuit

ABINGDON, Va. — A Virginia federal judge on Jan. 13 denied Walgreen’s motion to dismiss after the Fourth Circuit U.S. Court of Appeals reversed and remanded the judge’s previous dismissal of a suit filed by federal and state governments alleging violations of the False Claims Act (FCA) and Virginia law, finding in part that the federal and state governments “have plausibly alleged a materially false representation” regarding Walgreens’ alleged misrepresentation that certain patients met Medicaid eligibility requirements for hepatitis C drugs.
January 16, 2024
In Reversal, 9th Circuit Says Assignments Give Surgery Center ERISA Standing To Sue

PASADENA, Calif. — Reversing and remanding dismissal of a suit, a Ninth Circuit U.S. Court of Appeals panel ruled that patient assignments give a surgery center derivative standing under the Employee Retirement Income Security Act to sue for nonpayment of approximately $5.4 million in services rendered.
January 16, 2024
Medical Insurers Again Seek Dismissal Of COVID-Testing Lab’s Reimbursement Claims

NEWARK, N.J. — In a lawsuit brought by a medical testing laboratory seeking reimbursement for COVID-19 testing from a pair of health insurers, the insurers renewed their motion to dismiss the laboratory’s amended complaint on Jan. 12 after an earlier motion was administratively terminated by a New Jersey federal judge and negotiations failed to result in a settlement.
January 16, 2024
Drug Pricing Challengers Defend Suit, Say Statute Is Anything But Voluntary

DAYTON, Ohio — A group of chambers of commerce told a federal judge in Ohio that they have associational standing to pursue their challenge to a law allowing the government to negotiate the prices of certain drugs in the Medicare program and that despite the defendants’ portrayal, manufacturer participation in the program is anything but voluntary.
January 12, 2024
Judge Puts Possible End To ‘Frankenstein’s Monster’ Of Health Insurance Case

DALLAS — A federal judge in Texas granted summary judgment on bellwether claims in a health care compensation case involving approximately 50 parties on each side but acknowledged that the ruling likely wouldn’t be the death knell of what he described as the “legal version of Frankenstein’s Monster.”
January 11, 2024
Provider: Insurer’s Contract Evasions Shouldn’t Be Rewarded With Dismissal

FLAGSTAFF, Ariz. — An insurer’s own contract shows that it cannot ignore a medical provider’s contract status simply because some physicians are contracted with the insurer, and the insurer should not be rewarded for conduct it hopes will allow it to avoid the No Suprises Act arbitration process, the provider tells a federal judge in Arizona in opposing dismissal.
January 10, 2024
Texas Health District Seeks Review Of Ruling Finding No Immunity From Suit

AUSTIN, Texas — A nonprofit health maintenance organization denied governmental immunity has asked the Texas Supreme Court for review of the ruling, saying it should reverse the finding and specify that the statutory scheme protects it from a medical provider’s suit seeking additional compensation.
January 09, 2024
Transgender Care Plaintiffs Urge Court Not To Stay Pending Appeal

TACOMA, Wash. — Plaintiffs in a class action opposed a stay of their case on Jan. 8, telling a federal judge in Washington state that they don’t have time to delay critical medical care while their insurer appeals a well-supported decision finding that it cannot violate anti-discrimination laws.
January 08, 2024
CMS: Drugmakers’ Possible Injuries Can’t Sustain Drug Negotiation Law Challenge

WILMINGTON, Del. — Agency guidance for how the government selects drugs for inclusion in the Medicare negotiation program complies with the language of the law, the alleged injuries from potential future guidance cannot form the basis of a suit and the fact that drug manufacturers find participation in the program lucrative does not render participation involuntary, the government tells a federal judge in Delaware in a Jan. 5 reply in support of a motion for summary judgment.
January 08, 2024
Washington High Court Finds Insureds’ Breach Claims Fall Short

TACOMA, Wash. — The federal parity law and Patient Protection and Affordable Care Act (ACA) cannot form the basis of a breach of contract claim, and state law at the time excluded the residential treatments at issue in the case, but when an insurer violates its quasi-fiduciary duty to an insured, emotional distress damages are foreseeable and available, the Washington Supreme Court said in partially affirming a ruling.