CONCORD, N.H. - A federal judge in New Hampshire on Sept. 27 denied a motion to dismiss a health care provider challenge to the New Hampshire Department of Health and Human Services' (NHDHHS) methodology for implementing certain Medicaid reimbursement rate reductions. The judge explained that the U.S. Department of Health and Human Services is better suited to determine whether the methodology is consistent with federal statutory provisions that impose rate reductions (Dartmouth Hitchcock Clinic, et al., v. Nicholas Toumpas, Commissioner, N.H. Dept. of Health and Human Services, No. 11cv358, 2012 U.S. Dist. LEXIS 138888).
CHICAGO - The Seventh Circuit U.S. Court of Appeals on Sept. 26 affirmed a federal trial court order granting a class of Medicaid plaintiffs from Indiana preliminary injunctive relief in their challenge of the state's cap on "medically necessary" dental care under the state's Medicaid program. The Seventh Circuit concluded that Indiana's Family and Social Services Administration must not attach "arbitrary" caps to medically necessary dental care under federal and state law (Sandra M. Bontrager, et al., v. Indiana Family and Social Services Administration, et al., No. 11-3710, 7th Cir.; 2012 U.S. App. LEXIS 20157).
PHOENIX - A federal judge in the U.S. District Court for the District of Arizona on Sept. 24 denied the state's motion to dismiss a Medicaid class action challenging copayments charged to a certain segment of the state's Medicaid population. The federal judge rejected the State of Arizona's argument that the class plaintiffs' claims are barred by res judicata (Flint Wood, et al., v. Thomas Betlach, Director of the Arizona Health Care Cost Containment System, et al., No. 3:12cv08098, D. Ariz.; 2012 U.S. Dist. 135926).
WASHINGTON, D.C. - A federal judge on Sept. 19 denied a motion for summary judgment against the U.S. Department of Health and Human Services (HHS) challenging a department order by Secretary of Health and Human Services Kathleen Sebelius that denied the plaintiff hospitals' request to special status as a "new" hospital for purposes of reimbursement under the Medicare statute (Select Specialty Hospital - South Dallas, et al., v. Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services, No. 09-2008, D. D.C., 2012 U.S. Dist. LEXIS 134795).
COLUMBUS, Ohio - The 10th District Ohio Court of Appeals in Franklin County on Sept. 18 affirmed the state's grant of a certificate of need (CON) to a state nursing home company to relocate licensed nursing home beds from Stark County, Ohio, to a new nursing facility in Summit County. The appeals court determined that the CON met the requirements under the state Medicaid statute and protected access to so-called Medicaid-beds in the community (In re: Altercare of Stow Rehabilitation Center, No. 12AP-29, Ohio App., 10th Dist., Franklin Co.; 2012 Ohio App. LEXIS 3728).
SAN JUAN, Puerto Rico - Humana Health of Puerto Rico Inc., a health insurer, sufficiently alleged that eight physicians violated federal and state antitrust laws by price-fixing, a federal judge in Puerto Rico ruled Sept. 17 in denying the physicians' motion to dismiss (Humana Health of Puerto Rico, Inc. v. Juan L. Vilaro, et al., No. 12-1445, D. Puerto Rico). Subscribers may view the opinion available within the full article.
WASHINGTON, D.C. - A judge in the U.S. District Court for the District of Columbia on Sept. 17 granted a motion for summary judgment filed by U.S. Secretary for Health and Human Services (HHS) Kathleen Sebelius seeking to dismiss a challenge to the secretary's authority to reduce hospital-specific rates to rural and sole community hospitals under the Medicare program (Adirondack Medical Center, et al., v. Kathleen Sebelius, Secretary, Dept. of Health and Human Services, No. 11-1671, consolidated with 12-457, D. D.C.; 2012 U.S. Dist. LEXIS 131858).
BOSTON - The Massachusetts Supreme Judicial Court on Sept. 14 affirmed that the secretary of the Executive Office of Health and Human Services did not violate her obligation to reimburse hospitals and a managed care organization for the reasonable costs of providing medical services to state Medicaid recipients in the MassHealth program (Boston Medical Center Corp., et al. v. Secretary of the Executive Office of Health and Human Services, et al., No. SJC -11139, Mass. Sup.; 2012 Mass. LEXIS 837).
SAN JOSE, Calif. - A California federal judge on Sept. 14 dismissed a reimbursement suit, saying that a health care provider failed to plead facts sufficient to support its allegation that an insurer had agreed to pay 60 percent of costs related to surgery performed by an out-of-network provider, but allowed the plaintiff to amend its complaint (Bay Area Surgical Management v. Principal Life Insurance Co., No. 12-1140, N.D. Calif.; 2012 U.S. Dist. LEXIS 131639).
LAFAYETTE, La. - A Louisiana federal judge on Sept. 12 denied the plaintiffs' motion for summary judgment in a wrongful denial of health benefits suit, denied one defendant's summary judgment motion and partially granted another defendant's motion (Garry Toups, et al. v. Moreno Group LLC, et al., No. 11-1559, W. D. La.; 2012 U.S. Dist. LEXIS 130906).
ST. LOUIS - An Eighth Circuit U.S. Court of Appeals panel on Sept. 12 affirmed that payments a provider receives from a "pool" of Medicaid reimbursement checks reduces the provider's Medicare costs actually incurred (Kindred Hospitals East v. Kathleen Sebelius, No. 11-3555, 8th Cir.; 2012 U.S. App. LEXIS 19116).
WASHINGTON, D.C. - The District of Columbia U.S. Court of Appeals on Sept. 11 agreed to expedite the appeal of the dismissal of a religious college's case alleging that the Patient Protection and Affordable Care Act (PPACA), 111 P.L. 148, mandate requiring all health plans to provide preventive services for free, including those for birth control, violates their religious rights (Wheaton College v. Kathleen Sebelius, et al., No. 12-5273, D.C. Cir.). View related prior history, 2012 U.S. Dist. LEXIS 120187.
DETROIT - Blue Cross Blue Shield of Michigan engaged in self-dealing in violation of the Employee Retirement Income Security Act, 29 U.S.C.S. § 1001 et seq., by charging self-insured welfare plans and their sponsors an administrative fee and unilaterally determining the amount of the fee, a federal judge in Michigan ruled Sept. 7 in granting summary judgment against Blue Cross on prohibited transaction claims (Borroughs Corporation, et al, v. Blue Cross Blue Shield of Michigan, Nos. 11-12565, 11-12557, E.D. Mich.; 2012 U.S. Dist. LEXIS 127587).
ST. LOUIS - A welfare benefit plan may not enforce its subrogation provision as an implied contract or in equity under the Employee Retirement Income Security Act, 29 U.S.C.S. § 1001 et seq., against a law firm that acknowledged the validity of the provision during its representation of a plan beneficiary in a civil lawsuit but that did not agree to be bound by the provision, the Eighth Circuit U.S. Court of Appeals affirmed Sept. 7 (Treasurer, Trustees of Drury Industries, Inc. Health Care Plan and Trust v. Sean Goding, et al.,, No. 11-2885, 8th Cir.; 2012 U.S. App. LEXIS 18815).
BOSTON - A First Circuit U.S. Court of Appeals panel on Sept. 7 affirmed the dismissal of a Medicare fee reimbursement suit, saying that the health maintenance organization defendants could compensate the plaintiff doctors in a manner of their choosing and that no antitrust violations occurred (Carlos P. Gonzalez-Maldonado, et al. v. MMM Healthcare Inc., et al., No. 11-1880, 1st. Cir.; 2012 U.S. App. LEXIS 18913).
CINCINNATI - In considering an issue of first impression regarding the admissibility of functional magnetic resonance imaging (fMRI) lie detection testing, a Sixth Circuit U.S. Court of Appeals panel on Sept. 7 affirmed the conviction of an owner of two companies providing follow-up psychiatric care to nursing home patients in Tennessee and Mississippi for Medicare fraud, saying the lower court did not err in excluding the evidence because the technology has not been examined in a "real world" setting (United States of America v. Lorne Allan Semrua, No. 11-5396, 6th Cir.; 1012 U.S. App. LEXIS 18824).
DETROIT - The Employee Retirement Income Security Act, 29 U.S.C.S. § 1001 et seq., does not preempt the Michigan Health Insurance Claims Assessment Act, which imposes an assessment of 1 percent on the value of all claims paid by every carrier or third-party administrator for medical services that are rendered in Michigan to a resident of the state, including ERISA plans, a federal judge in Michigan ruled Aug. 31 (Self-Insurance Institute of America, Inc. v. Rick Snyder et al., No. 11-15602, E.D. Mich.; 2012 U.S. Dist. LEXIS 124405).
PHOENIX - An Arizona federal judge on Aug. 31 dismissed several claims from a case challenging the Patient Protection and Affordable Care Act (PPACA), 111 P.L. 148 ordered supplemental briefing regarding other claims, saying the plaintiffs had not had an opportunity to address questions of whether the act denies them a substantive due process right or conflicts with state law when construed as a tax (Nick Coons, et al. v. Timothy Geithner, et al., 10-1714, D. Ariz.).
HONOLULU - A Hawaii federal judge on Aug. 31 declined to remand a dispute over the rescission of a health care insurance policy to state court, saying the Employee Retirement Income Security Act preempted several of the claims (Robert Poffenbarger, et al. V. Hawaii Management Alliance Association, et al., No. 12-172, D. Hawaii; 2012 U.S. Dist. LEXIS 124416).
NEWARK, N.J. - A New Jersey federal judge in an unpublished decision on Aug. 30 granted summary judgment in favor of the defendant in a health insurance reimbursement dispute, saying that the plaintiff did not meet the definition of a facility entitled to reimbursement for facility fees under the defendant's policies (Pain & Surgery Ambulatory Center v. Connecticut General Life Insurance Co., No. 11-5209, D. N.J.; 2012 U.S. Dist. LEXIS 124589).
WASHINGTON, D.C. - A District of Columbia federal judge on Aug. 24 dismissed a challenge brought by a religious college that alleges that the Patient Protection and Affordable Care Act (PPACA), 111 P.L. 148 mandate requiring all health plans to provide preventive services for free, including those for birth control, violates their religious rights, saying the plaintiff lacks standing (Wheaton College v. Kathleen Sebelius, et al., No. 12-1169, D. D.C.; 2012 U.S. Dist. LEXIS 120187).
NEW ORLEANS - A Louisiana federal judge on Aug. 24 affirmed that the operator of an inpatient rehabilitation facility had received Medicare overpayments after an audit of claims submitted for payment (United Medical Healthcare Inc. v. Department of Health and Human Services, No. 10-4158, E.D. La.; 2012 U.S. Dist. LEXIS 12046).
CINCINNATI - A Sixth Circuit U.S. Court of Appeals panel in an Aug. 23 unpublished opinion affirmed that the determination of the amount of Medicare reimbursements made to psychiatric hospitals was compelled by the Medicare statute (Michigan Department of Community Health, et al. v. Secretary of Health and Human Services, et al., No. 11-1905, 6th Cir.; 2012 U.S. App. LEXIS 18014).
OMAHA, Neb. - A Nebraska federal judge on Aug. 22 granted partial summary judgment to the defendant in a wrongful denial of benefits case, saying that the plaintiffs' claims were preempted by federal law, but permitted the plaintiffs leave to amend the complaint (Christopher Stalp, et al., v. Excellus Health Plan Inc., No. 11-226, D. Neb.; 2012 U.S. Dist. LEXIS 118540).
PHOENIX - An Arizona federal judge on Aug. 23 dismissed two of three claims from a wrongful denial of benefits suit, holding that the plaintiffs failed to state a claim under the Employee Retirement Income Security Act, 29 U.S.C.S. § 1001 et seq., for one of the claims and that another claim was duplicative of the remaining claim (Michael LaSpina, et al. v. Anthem Blue Cross Life & Health Ins. Co., et al., No. 12-707, D. Ariz.; 2012 U.S. Dist. LEXIS 119410).