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

Mealey's Health Care / ACA

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.
November 28, 2023
2nd Circuit: Hospital’s Use Of Daughter As Interpreter Didn’t Violate ACA

NEW YORK — A district court properly concluded that a hospital staff’s interactions with two individuals could be interpreted as a request that a deaf woman’s daughter serve as her interpreter and that the provider did not violate the Patient Protection and Affordable Care Act (ACA) in doing so, a panel of the Second Circuit U.S. Court of Appeals said.
November 28, 2023
Aging, Health Care Amici Throw Support Behind Medicare Drug Negotiation Law

WILMINGTON, Del. — In a trio of amicus curiae briefs, health care and aging experts and advocates told a federal judge in Delaware that a recently enacted Medicare drug negotiation program falls within well-established powers to regulate prices the program and others within the government pay and will help reign in the “unsustainable increase in prescription drug prices.”
November 28, 2023
10th Circuit Revives ERISA Claim For Violation Of Parity Act In Coverage Row

DENVER — Reversing and remanding dismissal of a 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 ruled in part that the insureds “plausibly alleged a disparity between the treatment limitations applied to benefits for mental health or substance abuse care compared to those applied to benefits for medical or surgical care.”
November 27, 2023
Judge Orders Insurer To Fully Compensate Man For Proton Beam Therapy

ALEXANDRIA, La. — An insurer found liable for proton beam therapy (PBT) treatments a man paid for out of pocket after being denied coverage may not retroactively try to compensate him at in-network rates, a federal judge in Louisiana said in granting a motion to enforce judgment and ordering the insurer to fully compensate him after the Fifth Circuit U.S. Court of Appeals affirmed the award.
November 20, 2023
Judge Grants But Reduces By 70% Attorney Fees, Costs In ACA Discrimination Case

CENTRAL ISLIP, N.Y. — Because a hospital’s own offer of judgment in a Patient Protection and Affordable Care Act (ACA) discrimination case contemplates attorney fees and costs in a case where a woman recovered nominal damages, its “quarrel lies with their own drafting,” but a federal judge in New York said the problematic request for fees and costs required a 70% reduction.
November 16, 2023
2 Estates’ Class Suit Accuses UnitedHealth Of Care Denial By AI

MINNEAPOLIS — An insurer illegally employs artificial intelligence (AI) to deny elderly insureds medically necessary care based on a model that the insurer knows “has a 90% error rate,” two estates allege in a class complaint filed in a federal court in Minnesota.
November 15, 2023
HIV/AIDS Sufferers Defend ACA Discrimination, UCL Claims In Drug Case

SAN FRANCISCO — Defendants didn’t need a court ruling to know that restricting access to HIV/AIDS drugs would discriminate against those suffering from the disease in violation of the Patient Protection and Affordable Care Act (ACA), while the California unfair competition law (UCL) permits recovery of unlawful profits accrued through unfair means, plaintiffs tell a federal judge in California in a Nov. 14 memorandum opposing dismissal.
November 14, 2023
Class Suit: CVS Job Applicant AI Screening Tool Is Illegal Lie Detector Test

BOSTON — CVS Health Corp. and CVS Pharmacy Inc. use an artificial intelligence-based facial and vocal scanning program during the hiring process, drawing conclusions about applicants’ enthusiasm and potential culture fit in what amounts to a lie detector test given in violation of Massachusetts law, plaintiffs allege in a federal class action.
November 13, 2023
Lipedema Sufferers Keep Insurance Class, Can’t Secure Summary Judgment

SAN FRANCISCO — Recent precedent does not require decertifying an Employee Retirement Income Security Act class action seeking reprocessing of lipedema sufferers’ liposuction coverage claims, but because a dispute remains over whether the insurer categorically denied coverage, summary judgment for the insureds is also inappropriate, a federal judge in California said.
November 13, 2023
Government, Class Report Agreement To Settle 1 Appeal In ACA Reinsurance Row

WASHINGTON, D.C. — Parties in an appeal concerning a $185,230,024.42 judgment against the government have told the Federal Circuit U.S. Court of Appeals that they “have agreed to settle this matter,” with a settlement framework approved by both sides in the litigation over the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA).
November 10, 2023
Chambers: Medicare Pricing Law Dresses Up Unconstitutional Coercion As Voluntary

DAYTON, Ohio — The Medicare price-negotiation law dresses itself up as a voluntary scheme when in reality it imposes “unprecedented and unconstitutional” price controls and hands nearly unchecked powers to the federal government, four chambers of commerce plaintiffs argue in a motion for summary judgment in Ohio federal court.