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

Mealey's Health Care / ACA

September 18, 2023
Insurer Isn’t Honoring No Surprises Act Arbitration Payment Duty, Provider Says

OAKLAND, N.J. — Despite a No Surprises Act (NSA) arbitration award against it, a 30-day payment mandate and repeated attempts to collect on that debt, an insurer has yet to make any payment, a provider says in a complaint filed in New Jersey federal court.
September 15, 2023
California High Court Won’t Review UCL Mental Health Coverage Ruling

SACRAMENTO, Calif. — The California Supreme Court denied a petition for review after a lower court published its opinion finding that two insureds adequately alleged standing under the California unfair competition law (UCL) and that the way the insurer handles mental health care results in shortages of that care.
September 15, 2023
Texas HMO Wants Rehearing Over Question On Immunity From Provider’s Suit

HOUSTON — An appellate ruling finding that a statutorily created hospital district’s nonprofit health maintenance organization was not a unit of local government and therefore not entitled to statutory immunity glosses over complicated issues and ignores Texas Supreme Court precedent and the very purpose for such organizations, an insurer told a Texas appeals court in seeking rehearing and rehearing en banc on Sept. 14.
September 15, 2023
Certified Class: Insurer Used Single Experimental Treatment For Blanket Denials

UTICA, N.Y. — A federal judge in New York on Sept. 14 certified a class of insureds who claim that United Behavioral Health violated the Employee Retirement Income Security Act by issuing blanket denials for residential treatments when it considered even a single aspect of the facility’s treatment experimental.
September 14, 2023
Enforceability Of ACA, Parity Act Argued Before Washington High Court

TACOMA, Wash. — A family denied coverage for their daughter’s residential treatments told the Washington Supreme Court during Sept. 14 oral arguments that a health plan explicitly incorporated federal and state parity law and that the Patient Protection and Affordable Care Act (ACA) can form a breach of contract claim; but in response, the insurer told the court that regulatory agencies are the proper venue to correct insurer behavior and that not every claim denial is an act of bad faith.
September 14, 2023
Parties In ERISA Case With Large Class Denied Permission For Interlocutory Appeal

RICHMOND, Va. — Bids by a health insurer and subcontractor for permission to file interlocutory appeals to the Fourth Circuit U.S. Court of Appeals over a class certification order in a suit concerning an alleged cost-shifting scheme were denied without explanation in a Sept. 13 order.
September 13, 2023
Judge Affirms No Surprises Act Award, Says No Written Explanation Necessary

TRENTON, N.J. — The No Surprises Act (NSA) imposes no written explanation requirement on arbitrators, and the record contains no evidence the arbitrator in this case relied on since-vacated rules, a federal judge in New Jersey said in confirming an arbitration award in favor of an insurer.
September 13, 2023
Split 4th Circuit Panel Partly Remands ERISA Case In Equitable Remedy Ruling

RICHMOND, Va. — Partly vacating dismissal of an Employee Retirement Income Security Act case over denial of a heart transplant, a Fourth Circuit U.S. Court of Appeals panel focused on the question of when monetary relief is equitable, splitting on an issue involving interpretation of a 2016 U.S. Supreme Court decision.
September 12, 2023
California Court Revives Portion Of Air Transport Case Against School District

FRESNO, Calif. — While questions remain about whether a school health plan is its own legal entity or a public one, those questions keep alive claims that it underpaid for emergency air transport, while the school district’s argument about its discretionary power ignores that the contract is with its insured and not the third-party provider, a panel of a California appeals court said Sept. 11 in reversing judgment for the district.
September 11, 2023
9th Circuit Panel Affirms That CARES Act Does Not Provide Private Right Of Action

SAN FRANCISCO — A panel of the Ninth Circuit U.S. Court of Appeals affirmed the judgment of a California federal court dismissing five complaints brought by a COVID-19 test provider seeking reimbursement from an insurer for COVID testing services, agreeing with the lower court that the Coronavirus Aid, Relief and Economic Security (CARES) Act does not provide a private right of action to diagnostic testing providers.
September 08, 2023
2nd Class Action Targets Cigna’s Alleged Use Of AI In Denying Claims

NEW HAVEN, Conn. — Health insurer Cigna Health and Life Insurance Co. denies claims en masse using artificial intelligence (AI) knowing that most insureds will either forgo care or not spend the time on an appeal, plaintiffs allege in a putative class action filed in Connecticut federal court.
September 08, 2023
Insureds Seek Rehearing Of Case Where 10th Circuit Ordered Claim Reprocessing

DENVER — Arguing that it is “time to bring an end to the extra-statutory practice of remanding [Employee Retirement Income Security Act] benefit cases,” insureds are seeking rehearing of a 10th Circuit U.S. Court of Appeals panel ruling that ordered reprocessing of claims for residential treatment for mental health and substance use.
September 08, 2023
DOL Sues Big TPA Over Emergency, Drug Screening Claim Adjudication

MADISON, Wis. — Alleging that the third-party administrator (TPA) of more than 2,100 self-funded employee welfare benefit plans is a named and functional fiduciary in regard to the challenged conduct, Acting U.S. Department of Labor Secretary Julie A. Su filed an Employee Retirement Income Security Act suit over adverse benefit determinations regarding hospital emergency services claims and urinary drug screening claims.
September 07, 2023
Parties In ERISA Case With Large Class Dispute Bid For Interlocutory Appeal

RICHMOND, Va. — Arguing that a health insurer and subcontractor “advance the same arguments that have already been rejected four times in this case,” the respondent in a suit concerning an alleged cost-shifting scheme urged the Fourth Circuit U.S. Court of Appeals to deny the bids for permission to file interlocutory appeals over a class certification order.
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.