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

Mealey's Health Care / ACA

January 08, 2024
11th Circuit Affirms Dismissal Of Dermatologist’s Case For Lack Of ERISA Standing

ATLANTA — Saying in an unpublished per curiam opinion that a dermatologist “abandoned” any challenge to the dispositive holding in the challenged dismissal order, an 11th Circuit U.S. Court of Appeals panel affirmed the lower court’s ruling in the suit concerning a patient’s purported assignments of benefits.
January 08, 2024
Employer Asks 3rd Circuit To Uphold Dismissal In ERISA Row Over Drug Rebates

NEWARK, N.J. — Urging the Third Circuit U.S. Court of Appeals to affirm dismissal of an Employee Retirement Income Security Act suit, an employer argues primarily that the trial court correctly ruled that former participants in its self-funded health care plan who sued over approximately $65 million in drug rebates didn’t allege an injury in fact.
January 05, 2024
Provider Says Portal’s Reopening Doesn’t Moot Arbitration Process Claims

BROOKLYN, N.Y. — The unauthorized closing and reopening of the No Surprises Act (NSA) independent dispute resolution (IDR) portal does not moot claims stemming from the government’s failure to comply with the requirements of the law, a medical provider tells a federal judge in New York in a response to the government’s bid to halt the filing of an amended complaint.
January 04, 2024
Citing Previous Ruling,11th Circuit Affirms Dismissal Of ERISA Assignment Row

ATLANTA — Citing a ruling the 11th Circuit U.S. Court of Appeals issued in a different case brought by the same dermatologist, a panel affirmed dismissal of her suit and the “finding that the assignments upon which [she] relied did not include sufficiently explicit language to transfer the right to bring non-payment, statutory penalty suits under” the Employee Retirement Income Security Act.
January 03, 2024
Judge Wolfson Appointed Special Master In Prescription Saving Program Dispute

NEWARK, N.J. — Freda L. Wolfson, who in early 2023 retired as a chief judge of the U.S. District Court for the District of New Jersey, has been appointed special master in a case pending in the District Court in which a Johnson & Johnson affiliate alleges that a prescription saving program improperly offloads costs onto the drugmaker’s discount drug program.
January 03, 2024
Citing APA, Amicus Groups Urge Review Of 10th Circuit Health Benefits Ruling

WASHINGTON, D.C. — The U.S. Supreme Court should review a ruling that “significantly alter[ed] claims administrators’ obligations in health-benefits denial cases” by adopting “a revisionist interpretation” of U.S. Department of Labor (DOL) regulations, the ERISA Industry Committee (ERIC) and The Chamber of Commerce of the United States of America say in a Jan. 2 joint amicus curiae brief.
January 03, 2024
10th Circuit Denies Fee Request After Reversing Dismissal Of Parity Act Claim

DENVER — Saying the insureds “have not yet prevailed” on their Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA or Parity Act) claim in a case over residential mental health treatment, a 10th Circuit U.S. Court of Appeals panel denied their opposed motion for attorney fees without prejudice.
December 28, 2023
Judge OKs Lipedema Class Settlement, Awards $100,000 Attorney Fee For Now

SAN FRANCISCO — A class settlement over denial of coverage for a specialized form of liposuction to treat lipedema has been granted final approval, but a California federal judge awarded class counsel only about a tenth of the attorney fees they requested, saying in part that they can seek more once the case’s results are clearer.
December 22, 2023
Insurer: Price Negotiations With Providers Aren’t Antitrust Violations

FLAGSTAFF, Ariz. — Negotiating medical facility reimbursement rates is not an antitrust violation, and while the out-of-network plaintiffs clearly appreciate the No Surprises Act independent dispute resolution process, it does not apply because there are contracts with individual physicians, an insurer tells a federal judge in Arizona in a motion to dismiss.
December 20, 2023
GAO: Twentyfold More Claims Than Expected Swamped Health Care Arbitration System

WASHINGTON, D.C. — The arbitration process designed to resolve disagreements over payment for out-of-network health care has reopened, and the government received more than 20 times the expected number of disputes in its first 15 months of operation, which contributed to the challenging rollout of the system, according to a report by the General Accounting Office (GAO).
December 20, 2023
Government Seeks Clarification On Drug Assistance Program Ruling

WASHINGTON, D.C. — If a federal judge’s ruling finding rules governing how insurers handle drug manufacturers’ assistance programs under the Patient Protection and Affordable Care Act (ACA) mandated certain actions by the government it would create an extraordinary situation, and to the extent that it did the court should clarify the specific enforcement actions the ruling envisions, the government says in a reply brief in support of a motion to clarify.
December 19, 2023
Study: AI Outperforms Human Clinicians In Limited Settings

BOSTON — Large language model (LLM) artificial intelligence (AI) ChatGPT-4 performed better than humans at diagnosing five diseases in pre- and post-test situations, but only when the test results were negative, according to a new peer-reviewed study released on the JAMA Network.
December 18, 2023
Government Says Portal’s Reopening Moots Health Care Complaint, Injunction

BROOKLYN, N.Y. — The government told a federal judge in New York on Dec. 15 that the reopening of the federal independent dispute resolution (IDR) portal mooted a medical provider’s attempt to file an amended complaint and motion for a preliminary injunction.
December 15, 2023
Plaintiffs: Humana Uses Artificial Intelligence, Denies Senior Care In Bad Faith

LOUISVILLE, Ky. — Humana Inc. denies elderly patients Medicare Advantage Plan coverage to which they are entitled through the employment of artificial intelligence in place of actual doctors, plaintiffs claim in a class action filed in a Kentucky federal court.
December 14, 2023
Judge Dismisses Breast Reduction Payment Suit With Prejudice

NEW YORK — An insurer’s explanation of plan terms during a preauthorization phone call does not constitute a promise to pay a medical provider any specific amount, and the failure to seek leave to amend and “glaring legal deficiencies” require granting the insurer’s motion to dismiss the provider’s case with prejudice, a New York federal judge said.
December 11, 2023
Parties Settle Emergency Care Compensation Case Featuring Discovery Scope Dispute

TEXARKANA, Texas — A federal judge in Texas on Dec. 8 issued an order canceling an upcoming status conference after parties reported that with the help of a mediator, they reached a confidential settlement resolving a freestanding emergency care compensation case in which the judge ordered discovery that the insurer warned could require 1.4 million man hours to fulfill.
December 11, 2023
Government Defends Drug Price Negotiation Law As Voluntary

WASHINGTON, D.C. — Construing a law allowing for negotiation of drug prices in the Medicare program as anything other than voluntary given the clear ability to exit the program would “radically rework” how government spending operates and upset existing programs already blessed by the courts, defendants told a federal judge in the District of Columbia in opposing summary judgment.
December 08, 2023
Motion For Preliminary Settlement OK Filed In ACA Hearing Discrimination Case

SEATTLE — Plaintiffs in a case involving whether covering cochlear implants to the exclusion of all other hearing loss care violates the Patient Protection and Affordable Care Act (ACA) filed unopposed motions for class certification and preliminary approval of a settlement in Washington federal court.
December 07, 2023
Acting Labor Secretary, Big TPA Spar Over Retrospective Claims In ERISA Case

MADISON, Wis. — Arguing that Congress left “retrospective benefits claims only to participants and beneficiaries,” the third-party administrator (TPA) of hundreds of self-funded employee welfare benefit plans urged a Wisconsin federal court to dismiss all backward-looking claims in Acting U.S. Department of Labor Secretary Julie A. Su’s suit over hospital emergency services and urinary drug screening claims.
December 06, 2023
10th Circuit Reverses, Finds ERISA Arbitrary And Capricious Standard Viable

DENVER — The arbitrary and capricious review standard still applies in Employee Retirement Income Security Act cases, but an insurer’s denial letter fails to meet the standard under recent precedent requiring that such documents provide a comprehensive and specific explanation of the reasons for denying coverage, a 10th Circuit U.S. Court of Appeals panel said Dec. 5 in reversing summary judgment in favor of the insurer.
December 04, 2023
Drug Companies: Procedural Focus Belies Government’s Weakness In Drug-Pricing Case

WILMINGTON, Del. — Briefing by the government on its recent drug price negotiation law focuses on procedural issues because it lacks footing for an actual argument on the merits, a drugmakers say in a Dec. 1 brief to a federal judge in Delaware arguing that it is clearly injured by the unlawful application of the law, which it says will remove incentives to research and develop new drugs.
December 04, 2023
Petitioners Argue ‘New Burdens’ In Seeking Review Of 10th Circuit ERISA Ruling

WASHINGTON, D.C. — Challenging two aspects of a 10th Circuit U.S. Court of Appeals ruling concerning long-term residential treatment facility coverage and arguing that the opinion improperly “imposes new burdens on health benefits plans,” one such plan and the insurer that administers it have petitioned the U.S. Supreme Court for a writ of certiorari.
December 01, 2023
9th Circuit Denies Rehearing After Split Panel Vote In ADA Suit Against Care Home

SAN FRANCISCO — After one judge of a Ninth Circuit U.S. Court of Appeals panel voted to grant a petition for rehearing en banc, rehearing was denied when no Ninth Circuit judge requested a vote for en banc consideration of the court’s decision affirming a district court’s ruling in favor of a nonprofit advocating against housing discrimination in its suit against a nursing home alleging violations of the Americans with Disabilities Act (ADA) for the nursing home’s alleged refusal to provide an American Sign Language (ASL) interpreter to a fictitious prospective resident.
November 30, 2023
Montana Asbestos Screener Says No Evidence It Intended To Defraud ACA Program

MISSOULA, Mont. — Claims submitted under a special Patient Protection and Affordable Care Act (ACA) program for Libby, Mont., asbestos-disease sufferers complied with federal law and guidance and the jury was able to conclude otherwise only because the judge ignored the statutory language, imposed a heightened standard and rejected evidence indicating that the medical company believed its claims to be legitimate, the provider tells the Ninth Circuit U.S. Court of Appeals in a Nov. 29 opening brief.
November 30, 2023
Judge: Conclusory Claims About Assignment Of Rights Can’t Save ERISA Action

TRENTON, N.J. — A chiropractic and acupuncture services provider’s conclusory statements about assignment of rights do not suffice for Employee Retirement Income Security Act claims, and any amended complaint should lay out the specific contract provisions the insurer allegedly violated, a federal judge in New Jersey said in dismissing a case on Nov. 29.