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

Mealey's Health Care / ACA

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.
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.