Mealey's Health Care / ACA
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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.
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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.
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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.
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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).
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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.
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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.”
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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August 07, 2023
Magistrate Judge Finds Plaintiffs Can’t Link Premiums To ACA Network Size Claims
EL PASO, Texas — The plaintiffs’ own expert testified about the multitude of factors affecting health insurance premiums, and the plaintiffs never sufficiently explain how allegedly overinflated network provider lists would increase Patient Protection and Affordable Care Act marketplace plan premiums, a federal magistrate judge in Texas said Aug. 4 in recommending the court admit an expert on damages but deny a motion for class certification.
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August 04, 2023
Federal Judge Vacates No Surprises Act Fee, Batching Rules
TYLER, Texas — New rules increasing the No Suprises Act (NSA) fee and imposing restrictions on how independent dispute resolution (IDR) claims can be batched are substantive and required a notice and comment period, a federal judge in Texas said Aug. 3 in vacating the rules but declining to refund fees providers already paid.
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August 03, 2023
10th Circuit Won’t Rehear ERISA Residential Care Admission Opinion Case
DENVER — The 10th Circuit U.S. Court of Appeals declined rehearing and en banc rehearing, leaving in place a ruling finding that in denying coverage, an Employee Retirement Income Security Act health insurer failed to properly grapple with treating physicians’ opinions about a woman’s need for care at a long-term residential treatment facility.
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August 03, 2023
6th Circuit: ACA Shared Responsibility Payment Is A Tax For Bankruptcy Purposes
CINCINNATI — The Patient Protection and Affordable Care Act (ACA) shared responsibility payment acts as a tax and permits priority debtor status for the Internal Revenue Service under federal bankruptcy law, a Sixth Circuit U.S. Court of Appeals panel said in affirming a bankruptcy appellate panel’s ruling.
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August 02, 2023
Judge Won’t Reconsider ERISA Preemption Ruling In Medical Payment Case
NEW YORK — A federal judge in New York denied a medical provider reconsideration, saying there is no evidence that the original ruling finding the case preempted by the Employee Retirement Income Security Act overlooked any facts or law.
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August 01, 2023
Judge Denies Reconsideration In Light Of Amended No Surprises Act Complaint
BROOKLYN, N.Y. — A federal judge in New York denied as moot a motion for reconsideration in light of a provider’s amended complaint alleging that the government’s failure to employ sufficient arbitration entities and resulting delay in resolution violates the No Surprises Act (NSA).
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July 31, 2023
Judge Permits Amendment In ACA Discrimination Case Involving HIV Drug Shipping
SAN FRANCISCO — Because it does not appear that an effort to amend a class complaint would be overly prejudicial or futile, the plaintiffs can amend an action alleging that an insurer discriminated against those with AIDS by requiring HIV drugs to be purchased through mail order, a federal judge in California said July 28.
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July 28, 2023
California Appeals Court: Interactions Didn’t Create Provider-Insurer Contract
SAN DIEGO — There is no evidence that an insurer’s past payments or benefit discussions with a provider created a contract or promise to pay a specific level of reimbursement, a California appeals court said in affirming summary judgment on July 27.
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July 27, 2023
Court To Hear Arguments On Medical Reimbursement Claim Splitting Ruling
LOS ANGELES — A California appeals court set oral arguments for September in a case challenging rulings granting a demurrer, staying a case and imposing sanctions for improper claim splitting in a medical reimbursement action involving claims under the California unfair competition law (UCL).
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July 27, 2023
Proton Beam Cancer Treatment Class Receives Preliminary Class Settlement Approval
PHILADELPHIA — A federal judge in Pennsylvania granted an unopposed motion for preliminary approval of a settlement in a case alleging that an insurer breached its fiduciary duty under the Employee Retirement Income Security Act by denying coverage for proton beam therapy (PBT).
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July 27, 2023
ACA, Other Discrimination Claims Head To Trial After Surviving Summary Judgment
NEW YORK — Patient Protection and Affordable Care Act (ACA) and other discrimination claims are going to trial after a federal judge in New York on July 26 said questions remain as to whether a medical provider honored a deaf individual’s request for an interpreter and whether it provided an effective means of communication in the alternative.