RALEIGH, N.C. - A federal judge in North Carolina on May 29 partially granted and partially denied a motion for summary judgment seeking a reversal of a final Medicare reimbursement decision by U.S. Health and Human Services Secretary Kathleen Sebelius, finding that Sebelius' decision to deny reimbursement for some evaluation and management (E/M) services was not arbitrary or capricious. The judge, however, found that claims for at least one beneficiary should have been paid using the standards HHS uses for evaluating claims (Ibikunle Ojebuoboh, M.D., v. Kathleen Sebelius, No. 4:11cv00017, E.D. N.C., Eastern Div.; 2012 U.S. Dist. LEXIS 73821).
NEW ORLEANS - A judge in the U.S. District Court for the Eastern District of Louisiana on May 29 granted a motion to dismiss claims alleging violations of the Americans with Disabilities Act (ADA) and the federal Rehabilitation Act against the Louisiana Department of Health and Hospitals (DHH), the Office for Citizens with Developmental Disabilities (OCDD) and the Easter Seals of Louisiana, regarding the denial of payment for the medical care of a developmentally disabled child (James Edward Boyle, et al., v. Bruce Greenstein, et al., No. 2:11cv03192, E.D. La.; 2012 U.S. Dist. LEXIS 73670).
SPRINGFIELD, Ill. - An Illinois federal judge on May 25 granted a plaintiff's request for a temporary restraining order that requires that she be provided with medical treatment at a residential facility under Medicaid until the court can rule on a motion for preliminary injunction (S.B., by and through her father, W.B. v. Julie Hamos, in her official capacity as Director of the Illinois Department of Healthcare and Family Services, No. 12-3077, C.D. Ill.; 2012 U.S. Dist. LEXIS 73088).
TAMPA, Fla. - A Florida federal judge on May 25 denied a health plan's motion for attorney fees in a denial of benefits case, saying the defendant showed no bad faith on the part of the plaintiff or the plaintiff's attorneys (Kristy Schwade v. Total Plastics Inc., No. 10-2436, M.D. Fla.; 2012 U.S. Dist. LEXIS 73203).
TALLAHASSEE, Fla. - The First District Florida Court of Appeal on May 23 reversed a state agency's determination that a Medicaid waiver program beneficiary should receive a lower level of home-based benefits than he requires. The appeals court concluded that Florida Agency for Persons with Disabilities erred in its interpretation of the rules regarding assignment of disabled persons into state-designed benefit tiers (T.S. v. Agency for Persons with Disabilities, No. 1D11-5563, Fla. App., 1st Dist.; 2012 Fla. App. LEXIS 8108).
NEW ORLEANS - A judge in the U.S. District Court for the Eastern District of Louisiana on May 21 denied a motion for partial summary judgment by the U.S. Department of Health and Human Services (DHHS) and the Centers for Medicare and Medicaid Services (CMS) seeking to recover a portion of a medical malpractice settlement the family of a Medicare beneficiary received for services covered under Medicare (Kristen B. Sorrell, et al. v. Lakeview Regional Medical Center, et al., No. 11-3084, E.D. La.; 2012 U.S. Dist. LEXIS 70519).
JACKSON, Tenn. - The Tennessee Court of Appeals at Jackson on May 16 affirmed a trial court order denying Medicaid benefits to a Qualified Medicare Beneficiary (QMB), saying the beneficiary's financial resources exceeded the $4,000 limit set by state law (Alene S. Neal v. The State of Tennessee, Department of Human Services, No. W2011-01123-COA-R3-CV, Tenn. App., at Jackson; 2012 Tenn. App. LEXIS 312).
PHILADELPHIA - The Third Circuit U.S. Court of Appeals on May 16 affirmed a trial court order denying the appeal of a podiatrist seeking reimbursement for services she rendered to Medicare patients, agreeing with the trial court that the podiatrist failed to fully exhaust the administrative remedies available to her and, thus, that the trial court lacked jurisdiction to hear the claims (Karen E. Tucker v. Secretary of Health and Human Services, No. 11-3350, 3rd Cir.; 2012 U.S. App. LEXIS 9838).
WASHINGTON, D.C. - The District of Columbia Circuit U.S. Court of Appeals on May 14 affirmed a trial court order granting summary judgment to U.S. Secretary of Health and Human Services Kathleen Sebelius, upholding her decision to deny reimbursement to Baptist Memorial Hospital for its disproportionate share hospital (DSH) payment for costs attributed to inpatient days for patients covered under a state "expansion" Medicaid program, explaining that the hospital's appeal of the reimbursement denial was too vague (Baptist Memorial Hospital Inc. v. Kathleen Sebelius, Secretary of Health & Human Services, et al., No. 11-5112, D.C. Cir.; 2012 U.S. App. LEXIS 9723).
HONOLULU - A divided Hawaii Supreme Court on May 11 held that a health maintenance organization cannot appeal the denial of a Medicaid contract awarded by the Department of Human Services (DHS) for the State of Hawaii under a state statute pertaining to procurement contracts but can obtain judicial review of the administrative denial of such matters under the declaratory judgment statute (AlohaCare v. Department Of Human Services, State of Hawaii, No. SCWC-29630, Hawaii Sup.; 2012 Haw. LEXIS 152).
BALTIMORE - A federal judge in the U.S. District Court for the District of Maryland on May 9 granted a U.S. Department of Health and Human Services (HHS) motion to dismiss a physicians' group's challenge to the way the department and the Centers for Medicare and Medicaid Services (CMS) calculate the physician fee schedule (PFS). The judge concluded that the U.S. Congress has barred administrative and judicial review of the fee schedule under 42 U.S. Code Section 1395w-4(i)(1)(B) (Paul Fischer, M.D., et al. v. Donald Berwick, M.D., et al., No. WMN-11-2191, D. Md.; 2012 U.S. Dist. LEXIS 65034).
DALLAS - A Texas federal judge on May 7 declined to dismiss a reimbursement suit brought by a provider of mobile cardiopulmonary diagnostic tests against a health insurer, saying the plaintiff pleaded sufficient allegations to support its causes of action (Team Healthcare/Diagnostic Corp. v. BlueCross and Blue Shield, No. 10-1441, N.D. Texas; 2012 U.S. Dist. LEXIS 63760).
NEWARK, N.J. - A Florida federal judge on May 8 declined to dismiss counterclaims brought by an insurance company against chiropractors in a billing dispute and also affirmed a magistrate judge's decision to deny the plaintiffs' request to file a second amended complaint to address their post-auditing practice claims (Association of New Jersey Chiropractors, et al. v. Aetna Inc., No. 09-3761, D. N.J.). Subscribers may view the opinion available within the full update.
DENVER - A Christian university on May 3 filed a brief in Colorado federal court opposing dismissal of its first amended complaint in a case that alleges that the mandate contained in the Patient Protection and Affordable Care Act (PPACA) requiring that all health plans provide "preventative services" for free, including those for birth control, violates the rights of religious organizations (Colorado Christian University v. Kathleen Sebelius, No. 11-3350, D. Colo., No. 11-3350). Subscribers may view the opposition brief available within the full update.
COLUMBUS, Ga. - Following a bench trial, a Georgia federal magistrate judge held May 4 that a plaintiff's breach of fiduciary duty claim in a suit alleging violations of the Consolidated Omnibus Budget Reconciliation Act (COBRA) was time-barred and that even if the claim was not time-barred, the plaintiff had failed to show that the defendants were fiduciaries who owed him any duties (Homer Ira Lockhart v. Southern Health Plan Inc., et al., No. 04-0006, M.D. Ga.; 2012 U.S. Dist. LEXIS 63265).
SCRANTON, Pa. - Participants in their employer's health plan failed to demonstrate that the insurer violated the Employee Retirement Income Security Act by terminating the insurance contract because the employer breached the contract's underwriting requirements, a federal judge ruled May 3 in granting the insurer summary judgment (New Life Homecare, Inc., et al. v. Blue Cross of Northeastern Pennsylvania, et al., No. 3:06-2485, M.D. Pa.; 2012 U.S. Dist. LEXIS 61959).
PHILADELPHIA - A hospital lacked standing as a participant or a beneficiary to bring a claim for benefits under Employee Retirement Income Security Act Section 502(a); therefore, the hospital's breach of contract claim against the sponsor and third-party claims administrator of a medical plan for failure to pay for medical services rendered on behalf of a plan participant were not completely preempted, a federal judge in Pennsylvania ruled May 2 in remanding the case to state court (Tenet Health System Philadelphia, Inc. v. Diversified Administration Corporation, et al., No. 07-4948, E.D. Pa.; 2012 U.S. Dist. LEXIS 61395).
SAN JUAN, Puerto Rico - A Puerto Rico federal judge on May 2 declined to set aside an earlier opinion that left only a breach of contract claim in a class action reimbursement suit, saying that the plaintiffs provided no evidence in support of the relief requested (College of Dental Surgeons of Puerto Rico v. Triple S Management Inc., No. 09-1209, D. Puerto Rico; 2012 U.S. Dist. LEXIS 61462).
PITTSBURGH - A federal judge in Pennsylvania on April 25 ruled that pharmacies and pharmacy trade groups challenging the consummated $29 billion merger of pharmaceutical benefit management companies Express Scripts Inc. (ESI) and Medco Health Solutions Inc. were not entitled to a preliminary injunction because they failed to establish the likelihood of immediate, irreparable harm that could be alleviated by the issuance of a preliminary injunction (National Association of Chain Drug Stores, et al. v. Express Scripts, Inc., et al., No. 2:12-cv-00395-CB, W.D. Pa.; 2012 U.S. Dist. LEXIS 57884).
LOS ANGELES - A California appeals court on April 26 in an unpublished opinion affirmed that plaintiffs suing a hospital for breach of contract involving health insurance payments failed to allege any factual basis for recoverable damages (Clinton B. Eull III, et al. v. Providence Little Company of Mary, No. B227903, Calif. App., 2nd Dist., Div. 3; 2012 Cal. App. Unpub. LEXIS 3161).
TACOMA, Wash. - A Washington federal judge on April 25 denied a motion for preliminary injunction in a case in which Medicaid managed care organization (MCO) providers are seeking to stop the state's Medicaid administrator from entering into contracts with new MCOs (Columbia United Providers Inc., et al. v. State of Washington, Health Care Authority, No. C12-5174BHS, W.D. Wash.; 2012 U.S. Dist. LEXIS 58105).-->
SAN FRANCISCO - The First District California Court of Appeal, Division Two, on April 24 affirmed a trial court ruling sustaining defendant Health Net Inc.'s demurrers in a Medicare Part D, prescription drug benefit, denial of benefits cause of action. The appeals court agreed with the lower court that the negligence claims against the insurance company are subject to administrative exhaustion and that the state fraud and unfair trade practices claims are preempted by the federal Medicare Act (Jordan Rosenberg v. Health Net Inc., No. A131756, Calif. App., 1st Dist., Div. 2; 2012 Cal. App. Unpub. LEXIS 3087).
NEWARK, N.J. - In an unpublished opinion, a New Jersey federal judge on April 24 dismissed a putative class action case against a health insurer, saying the plaintiff failed to state a cause of action because the actions taken by the defendant in seeking repayment of money for services provided failed to implicate the Employment Retirement Income Security Act (ERISA), 29 U.S.C.S. § 1001 et seq. (TR13 Enterprises v. Aetna Inc., et al., No. 11-3021, D. N.J.; 2012 U.S. Dist. LEXIS 57158).
PHILADELPHIA - The Third Circuit U.S. Court of Appeals on April 20 affirmed the denial of attorney fees and costs in a Medicare overpayment dispute between the U.S. Department of Health and Human Services and a Medicare provider. The appellate court concluded that the trial court properly denied the fees sought under the Equal Access to Justice Act (EAJA) but further concluded that the trial court incorrectly determined that the proceedings were not adversarial as required under the EAJA (John D. Handron v. Secretary Department of Health and Human Services, et al., No. 10-1021, 3rd Cir.; 2012 U.S. App. LEXIS 8015).
DETROIT - A Michigan federal judge on April 18 dismissed a claim for breach of settlement agreement from a wrongful denial of benefits suit, saying that the Employment Retirement Income Security Act (ERISA), 29 USCS § 1001 et seq. preempted the claim (Paul Goldman v. BCBSM Foundation, No. 11-14043, E.D. Mich.; 2012 U.S. Dist. LEXIS 54469).