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

Mealey's Health Care / ACA

August 31, 2023
In 2-1 Decision, 9th Circuit Reverses On Threshold Question In Preemption Row

SAN FRANCISCO — In a 2-1 ruling concerning a threshold issue, a Ninth Circuit U.S. Court of Appeals panel reversed and remanded a summary judgment order against a trade organization that argued that a city and county of San Francisco ordinance concerning health insurance benefits for airline employees is preempted by federal law including the Employee Retirement Income Security Act.
August 30, 2023
ERISA Suit On Out-Of-Network Spinal Surgery Dismissed For Missing Link To Policy

NEWARK, N.J. — A federal judge in New Jersey dismissed without prejudice a medical center’s lawsuit and granted the center an extension to amend its claim that alleged that an employer and insurer underpaid for a patient’s emergency spinal surgery by approximately $117,547 and violated the Employee Retirement Income Security Act.
August 30, 2023
Provider Says Statutory Mandate Claims Save NSA Complaint

BROOKLYN, N.Y. — An amended complaint for the first time identifies the statutory mandate requiring federal defendants to adequately staff the No Surprises Act’s (NSA’s) independent dispute resolution (IDR) system and regulatory guidance holding that the process does not apply because New York law imposes a similar process, a medical provider on Aug. 29 told a federal judge in New York in opposing dismissal.
August 29, 2023
Air Ambulance Plaintiffs Defend Venue In NSA Arbitration Award Suit

AUSTIN, Texas — Air ambulance plaintiffs told a federal judge in Texas on Aug. 28 that he should ignore attempts at maligning the industry and instead recognize that a Texas-regulated insurer’s operations in the state provide venue for a lawsuit alleging that the insurer fails to pay arbitration awards under the No Surprises Act (NSA).
August 29, 2023
Medicare Drug Price Law Flawed, Health Care Company, Generic Drug Advocate Say

AUSTIN, Texas — A law restricting prices on Medicare drugs will strip away various constitutional protections, and its impact on competition threatens the generic drug marketplace that provides lower-cost drugs, a global health care company and a generic drug advocacy group tell a federal judge in Texas in Aug. 28 and 24 amicus briefs.
August 28, 2023
QPA, Air Ambulance Rules Violate No Surprises Act, Federal Judge Says

DALLAS — A federal judge in Texas vacated various portions of the No Surprises Act (NSA) rules, finding unlawful provisions incorporating “ghost rates” into the calculation of the qualifying payment amount, how to batch air ambulance transports and how to calculate when an insurer must make its first payment.
August 25, 2023
Payment Evidence Saves Provider’s Compensation Case, Magistrate Judge Says

SAN ANTONIO — Uncontradicted evidence that providers were at times compensated at higher rates warrants denying summary judgment in all but a single case where there is no evidence that the insured is a member of one of the defendants’ plans, a federal magistrate judge in Texas said.
August 25, 2023
Medicare Drug Price Law Violates Constitution, Advocacy Group Says

AUSTIN, Texas — Price restrictions on Medicare drugs strip away various constitutional protections and will harm competition from biosimilars even when the caps are not applied to drugs with biosimilar competitors, an advocacy group tells a federal judge in Texas in an Aug. 24 amicus curiae brief.
August 24, 2023
Unspecified Deal Reported In ERISA Suit Against Insurer Over Drug Prices

NEW HAVEN, Conn. — Following the parties’ report of an unspecified settlement in a suit alleging that Cigna Health and Life Insurance Co. “had no right under its prescription drug plans to charge ‘spread’ and then ‘claw back’ the member copayment or deductible ‘overpayments,’” a Connecticut federal judge ordered the case administratively closed.
August 23, 2023
9th Circuit: Insureds’ Fiduciary Claims Survive, But Not ERISA Benefits Class

SAN FRANCISCO — Allegations that an insurer interpreted plan guidelines in a self-interested way, thus putting Employee Retirement Income Security Act insureds’ contractual benefits at risk, demonstrate a traceable injury for fiduciary claims, but because a benefits-based class included individuals whose denials were only partly based on the challenged guidelines, it was improperly certified, and to the extent that the ruling mandated that plans cover all treatments within the generally accepted standards of care, the judge erred, the Ninth Circuit U.S. Court of Appeals said Aug. 22 after panel rehearing.
August 21, 2023
Judge Won’t Reconsider Procedural Holding In ACA Reinsurance Row

WASHINGTON, D.C. — A U.S. Court of Federal Claims judge on Aug. 18 denied a reconsideration motion for her procedural holding that the plaintiffs in a lawsuit over the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA) had waived an argument.
August 18, 2023
In Partial Reversal, Panel Orders Reprocessing Of Residential Treatment Claims

DENVER — Partly reversing and remanding an Employee Retirement Income Security Act dispute over denial of claims for residential treatment for mental health and substance use, a 10th Circuit U.S. Court of Appeals panel ruled that a Utah federal court correctly found a violation of ERISA’s claims-processing requirements but applied “the wrong legal standard” in ordering a remedy.
August 17, 2023
Insurers Query Medical Coding Expert’s Role In Lab Testing Compensation Case

BRIDGEPORT, Conn. — A medical coding expert’s testimony lacks relevance in a case that turns on the medical necessity of labs’ drug testing, and the expert is not qualified to opine about internal codes used to deny claims, insurers tell a federal judge in Connecticut in seeking to exclude the opinions.
August 17, 2023
Insurer Seeks Distribution Of $100M To Subclass Member In ACA Risk-Corridor Row

WASHINGTON, D.C — An insolvent health insurer that sued the federal government alleging that the government failed to pay money owed under the Patient Protection and Affordable Care Act (ACA) for the ACA risk-corridor program filed a motion in a District of Columbia federal court seeking to distribute more than $100 million of a judgment entered for a subclass member.
August 16, 2023
Multiemployer Plan, Board File Own Suit Over ACA Reinsurance Contribution

WASHINGTON, D.C. — Saying their claim in a class action was rejected, a multiemployer health and welfare plan and its board have filed their own suit in the U.S. Court of Federal Claims against the government over the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA).
August 16, 2023
Texas HMO Isn’t Immune To Provider’s Compensation Suit, Split Appeals Court Says

HOUSTON — A nonprofit managed care organization that offers a variety of affordable and no-cost health insurance plans at least in part through the Patient Protection and Affordable Care Act marketplace is not entitled to common-law or government immunity from a medical provider’s suit alleging underpayment, a divided Texas appeals court said Aug. 15.
August 15, 2023
Parties Argue Tolling, Accrual Of Illegal Exaction Claim In ACA Reinsurance Cases

WASHINGTON, D.C. — In a U.S. Court of Federal Claims brief opposing dismissal, 10 group health plans alleging that the government illegally exacted contributions from them under the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA) argue that their claims are timely under “tolling principles that have long been applied by this Court.”
August 15, 2023
Insurer: Connecticut Supreme Court Should Reject Surprise Billing Questions

HARTFORD, Conn. — A dispute between two private parties provides a poor means to review an insurance department’s interpretation of the state’s surprise billing law, and the outcome of the case would likely not be determinative, an insurer tells the Connecticut Supreme Court in urging it to deny certified questions.
August 14, 2023
Amici Praise NSA, Urge Rejection Of Provider’s Attempt At Undoing Law

NEW YORK — The No Suprises Act (NSA) alleviates the devastating impact of surprise billing on families, and the Second Circuit U.S. Court of Appeals should reject a provider’s attempt to undo the law’s protections so it can sue patients, several health advocacy groups tell the court in an Aug. 12 amicus curiae brief.
August 14, 2023
No Surprises Act Air Ambulance Payment Calculation Proper, Judge Says

WASHINGTON, D.C. — Various government agencies’ explanations for rules dictating what constitutes the qualifying payment amount (QPA) for independent air ambulance services under the No Suprises Act (NSA) and how they treated those providers show that the decisions were not arbitrary and demonstrate the very type of analysis required by the Administrative Procedure Act (APA), a federal judge in the District of Columbia said in granting defendants’ motion for summary judgment.
August 11, 2023
Judge Won’t Reconsider Class Certification In Suit Over Alleged Cost-Shifting

ASHEVILLE, N.C. — Saying a health insurer and its subcontractor “do not contend that any new evidence or change in the law supports their motion,” a North Carolina federal judge declined to reconsider his order granting class certification in the Employee Retirement Income Security Act suit over an alleged cost-shifting scheme.
August 10, 2023
Asbestos Screener At Heart Of Libby, Mont., False Claims Verdict Files Bankruptcy

MISSOULA, Mont. — The Libby, Mont., asbestos disease screener hit with $5.8 million in damages and penalties for filing false claims under a special Patient Protection and Affordable Care Act (ACA) program created under Medicare has declared bankruptcy.
August 09, 2023
Insurer’s Motion To Stay Just Another Attempt At Delay, Providers Awarded Under NSA Say

AUSTIN, Texas — The No Surprises Act (NSA) cannot have left providers and courts powerless to enforce millions of dollars in independent dispute resolution (IDR) awards, and the court should deny a motion to stay discovery, which is just another attempt at delay by the insurer, air ambulance providers tell a federal judge in Texas in an Aug. 8 response.
August 09, 2023
Panel Says Hospital’s Fees Properly Listed, Affirms Dismissal Of UCL Suit

SAN DIEGO — A California appellate panel affirmed a trial court’s ruling striking a lawsuit accusing a group of medical service providers of violating California’s unfair competition law (UCL), finding that the providers complied with California regulations for disclosure of emergency room fees despite the plaintiffs’ allegation that he was unexpectedly billed $10,000 after three emergency room visits.
August 09, 2023
Connecticut Federal Judge Denies Class Certification In ERISA Suit Against Cigna

NEW HAVEN, Conn. — Denying certification of a nationwide class involving employer-sponsored health plans administered by Cigna Health and Life Insurance Co. and its subsidiaries and the use of third-party vendor CareCentrix, a Connecticut federal judge concluded that the plaintiffs didn’t establish commonality.