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

Mealey's Health Care / ACA

November 09, 2023
Insurer Says Costa Rica Air Transport Wasn’t Medically Necessary

LOS ANGELES — Because there was no emergency and two insureds were transported from a hospital where they were in stable condition, the services were not medically necessary and the claims for payment properly denied, an insurer told a California appeals court.
November 09, 2023
Judge Dismisses Hospital’s ACA Cost-Sharing Case, Grants Leave To Amend

SACRAMENTO, Calif. — The Patient Protection and Affordable Care Act (ACA) does not appear to preclude a health plan from not contracting with any hospitals and thus the cap on in-network out-of-pocket costs does not apply to a hospital’s attempt to recover $400,000 in uncompensated care, a federal judge in California said while granting leave to amend.
November 09, 2023
2nd Circuit: Attorney Can Sue For Insureds, But Claims Ultimately Fail

NEW YORK — Attorney in fact status permits a lawsuit on behalf of a provider’s patients, but the breach of contract and other claims at the heart of the case alleging insufficient compensation for applied behavioral analysis therapy fail because the compensation complies with plan language and there is no evidence of conduct that would support an implied covenant of good faith and fair dealing claim, a panel of the Second Circuit U.S. Court of Appeals said in a Nov. 8 amended summary order affirming dismissal.
November 07, 2023
Air Transports Won’t Amend Complaints After No Surprises Act Dismissals

FORT MYERS, Fla. — Two emergency air transport companies said they believe in the sufficiency of their allegations and intend to stand on their complaints after a federal judge in Florida dismissed their actions alleging that two insurance plans misrepresented information during the No Surprises Act (NSA) arbitration process and naming the arbitrator as a defendant.
November 03, 2023
Final Settlement OK Sought Amid Attorney Fee Fight In ERISA Surgery Coverage Row

SAN FRANCISCO — With a separate and opposed attorney fee request pending, the plaintiff who sued a health plan and related entities over denial of coverage for a specialized form of liposuction to treat lipedema asked a California federal court for final approval of a class settlement that had a long road to preliminary approval.
November 02, 2023
California Supreme Court Grants Review In 3rd Suit Over Nondisclosure Of ER Fees

SAN FRANCISCO — The California Supreme Court on Nov. 1 granted an uninsured emergency room patient’s petition for review of his putative class suit accusing a group of medical service providers of violating California’s unfair competition law (UCL) by failing to directly disclose to him that he would be billed more than $10,000 for three emergency room visits.
October 26, 2023
Insurer’s Summary Judgment Motion Granted In Residential Treatment Case

NEW YORK — A federal judge in New York granted insurers’ motion for summary judgment on an Employee Retirement Income Security Act claim to recover benefits for residential treatment services and denied as moot a father and son’s cross-motion on the same claim, ruling that insurers provided substantial evidence to support their denials for coverage.
October 25, 2023
Fee Award Denied In Dismissed ‘Impossible To Adjudicate’ COVID-19 Testing Row

NEWARK, N.J. — Following dismissal with prejudice of a medical practice’s Employee Retirement Income Security Act suit over payment for COVID-19 tests, a New Jersey federal magistrate judge on Oct. 24 denied an insurer’s request for attorney fees and costs.
October 25, 2023
Judge: Bankruptcy Stays Attorney Fees Motion In Asbestos Diagnosis Case

MISSOULA, Mont. — Because a railway’s motion for attorney fees in the wake of its successful pursuit of a False Claims Act case came before the Patient Protection and Affordable Care Act (ACA) asbestos program provider’s bankruptcy, the request constitutes a claim against the debtor and falls under the U.S. Bankruptcy Code’s automatic stay, a federal judge in Montana said.
October 24, 2023
Partial Dismissal Recommended In Insurance Case For Mental Health Treatment

AUSTIN, Texas — A federal magistrate judge in Texas recommended partly granting a motion to dismiss filed by the parent company of an insurer on the ground that a high school student alleging that the insurer misrepresented policy provisions to deny covering her mental health treatment focused her complaint on facts that give rise to the need for coverage and not on alleged misrepresentation of the insurance policy itself.
October 24, 2023
Judge Stays Emergency Care Case Involving Claims Data File Production Dispute

TEXARKANA, Texas — A federal judge in Texas on Oct. 23 granted a joint motion to stay pending mediation, putting on hold a motion seeking reconsideration of a ruling ordering the production of data files created during the health care claims process, which the insurer warned would require 1.4 million man hours.
October 24, 2023
Texas Court Won’t Rehear Question On Health District’s Immunity From Suit

HOUSTON — A Texas appeals court on Oct. 24 declined rehearing en banc of its split decision finding that a statutorily created hospital district’s nonprofit health maintenance organization lacked the ability to claim immunity from a medical provider’s lawsuit as a unit of local government.
October 20, 2023
En Banc Review Denied To COVID-19 Test Provider Seeking Reimbursement From Insurer

SAN FRANCISCO — The Ninth Circuit U.S. Court of Appeals denied a petition for rehearing en banc sought by a COVID-19 test provider after a panel of the court affirmed the judgment of a California federal court dismissing five complaints brought by the provider seeking reimbursement from an insurer for COVID testing services under the Coronavirus Aid, Relief and Economic Security (CARES) Act.
October 20, 2023
Judge Denies Injunction In UCL Health Care Data Case Against Google

SAN JOSE, Calif. — Plaintiffs’ privacy and California unfair competition law (UCL) claims appear to turn on whether Google LLC simply acquires health information as a vendor or actually uses that data in some fashion, a federal judge said while concluding that the balance of hardships weighs against granting a motion for a preliminary injunction. In their complaint, the plaintiffs allege that Google’s own artificial intelligence suggested that Google’s collection of health data might run afoul of various laws.
October 19, 2023
9th Circuit Affirms Ruling For Fair Housing Advocate In Suit Against Nursing Home

SAN FRANCISCO — The Ninth Circuit U.S. Court of Appeals affirmed a district court’s ruling in favor of a nonprofit that advocates to stop housing discrimination under the federal Fair Housing Act (FHA) and Arizona Fair Housing Act, finding that the nonprofit had standing to sue and seek injunctive relief against a nursing home that allegedly refused to provide an American Sign Language (ASL) interpreter to a fictitious prospective resident and that “[t]he punitive damages award was not constitutionally excessive.”
October 18, 2023
Plaintiffs File Notice Of Appeal Regarding Rulings In ACA Reinsurance Row

WASHINGTON, D.C. — Two plaintiffs in a lawsuit over the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA) have filed a notice that they are appealing rulings against them that were issued in the U.S. Court of Federal Claims.
October 16, 2023
Supreme Court Grants Certiorari In 2nd Challenge To Chevron Deference

WASHINGTON, D.C. — The U.S. Supreme Court on Oct. 13 granted a petition for a writ of certiorari in a second case challenging the doctrine of Chevron deference and ordered that it be briefed on a schedule allowing argument “in tandem” with a pending case pertaining to the same issue, both of which involve challenges to regulations that require fishing vessels to pay federal monitors.
October 16, 2023
Hospitals Must Disclose ER Fees To Patients, California Supreme Court Told

SAN FRANCISCO — A patient tells the California Supreme Court in an opening brief on the merits that it should find that California’s unfair competition law (UCL) and Consumers Legal Remedies Act (CLRA) require a hospital to disclose emergency room visitation fees to patients, an issue on which a “split of authority” exists among California appellate courts.
October 13, 2023
Amici, Government Defend ACA Preventive Care Mandate To 5th Circuit

NEW ORLEANS — A women’s advocacy group warns in an amicus curiae brief about the impact of removing insurance coverage for preventive care while federal defendants tell the Fifth Circuit U.S. Court of Appeals that the individuals responsible for formulating what constitutes preventive care under the Patient Protection and Affordable Care Act (ACA) are inferior officers subject to sufficient control by the Department of Health and Human Services (HHS) to survive a constitutional challenge.
October 13, 2023
Providers: Insurer Avoids NSA Arbitration Through ‘Absurd’ Claim Processing

FLAGSTAFF, Ariz. — Arizona’s largest commercial health insurance company uses the No Surprises Act as both “a sword and a shield” by processing out-of-network claims as in-network claims based on decades-old contracts with individual physicians rather than the medical practice doing the billing in an effort to short circuit the law’s arbitration process, medical providers allege in an Oct. 12 federal lawsuit.
October 13, 2023
FDA Forms Committee With Eye On Digital Health, AI Technologies

WASHINGTON, D.C. — The Food and Drug Administration on Oct. 11 announced the formation of an advisory committee investigating digital health technologies such as artificial intelligence (AI) and related advancements.
October 12, 2023
Connecticut High Court Accepts Surprise Billing Certified Questions

HARTFORD, Conn. — The Connecticut Supreme Court accepted three certified questions, agreeing to resolve issues involving the interplay of the state’s Surprise Billing Law and insurance statutes.
October 12, 2023
Judge: Insurer’s Website Plan Details Can’t Support Hospitals’ Compensation Case

TRENTON, N.J. — References to how an insurer’s website portrays its plans’ out-of-network compensation do not sufficiently allege that hospitals were entitled to additional compensation under the Employee Retirement Income Security Act, and nothing in Patient Protection and Affordable Care Act (ACA) regulations precludes balance billing, a federal judge in New Jersey said in dismissing a case.
October 11, 2023
10th Circuit Won’t Rehear ERISA Case Where Panel Ordered Claim Reprocessing

DENVER — A ruling directing remand for claim reprocessing in an Employee Retirement Income Security Act case involving coverage of residential treatment for mental health and substance use will stand, with a 10th Circuit U.S. Court of Appeals panel issuing an Oct. 10 order denying insureds’ petition for panel or en banc rehearing.
October 10, 2023
4th Circuit Denies Rehearing In ERISA Case Involving Equitable Remedy Question

RICHMOND, Va. — The Fourth Circuit U.S. Court of Appeals has denied a petition for panel or en banc rehearing of an Employee Retirement Income Security Act case over denial of a heart transplant in which a panel partly vacated dismissal, focusing on the question of when monetary relief is equitable and splitting on an issue involving interpretation of a 2016 U.S. Supreme Court decision.