4th Circuit Affirms Health Care Fraud Conviction Against Doctor

    RICHMOND, Va. - The Fourth Circuit U.S. Court of Appeals on April 23 affirmed a federal jury conviction of a Maryland cardiologist for health care fraud, saying there was sufficient evidence that he willfully made false statements and submitted fraudulent bills to Medicare, Medicaid and private insurers for medically unnecessary cardiac stent procedures (United States of America v. John R. McLean, No. 11-5130, 4th Cir.; 2013 U.S. App. LEXIS 8160).

    6th Circuit Affirms Decision In Medicaid Payment Dispute

    CINCINNATI - A Sixth Circuit U.S. Court of Appeals panel on April 22 affirmed that the U.S. Department of Health and Human Services secretary's decision to omit waiver-expansion population patients from the Medicaid fraction provision in the disproportionate share hospital (DSH) adjustment calculation was based on a permissible construction of the DSH statute (Adventist Health System/Sunbelt Inc. v. Kathleen Sebelius, No. 11-5990, 6th Cir.; 2013 U.S. App. LEXIS 7907).

    FTC Seeks Expedited Remand In Hospital Merger Case

    ATLANTA - The Federal Trade Commission on April 18 asked the 11th Circuit U.S. Court of Appeals to issue an expedited order remanding its challenge to the merger between Georgia hospitals following the U.S. Supreme Court's recent ruling that the state-action doctrine does not immunize the merger from antitrust scrutiny (Federal Trade Commission v. Phoebe Putney Health System, Inc., et al., No. 11-12906, 11th Cir.).

    Ark. Federal Judge Declines To Dismiss Wrongful Rescission Of Health Policy Suit

    JONESBORO, Ark. - An Arkansas federal judge on April 18 denied a health insurer's motion to dismiss a wrongful rescission of a health insurance policy, saying the plaintiff pleaded a plausible claim for breach of contract (William Masterson v. Starr Indemnity & Liability Co., No. 13-79, E.D. Ark.; 2013 U.S. Dist. LEXIS 55641).

    9th Circuit: Medicare Does Not Allow Insurer To Recover Survivor's Benefits

    SAN FRANCISCO - A Ninth Circuit U.S. Court of Appeals panel on April 19 affirmed that a private Medicare Advantage Organization (MAO) plan cannot sue a plan participant's survivors for reimbursement of expenses paid out of the proceeds of an automobile insurance policy (Guillermina Parra, et al. v. PacifiCare of Arizona Inc., No.11-16069, 9th Cir.; 2013 U.S. App. LEXIS 7861).

    New York Federal Judge Dismisses Copay Dispute For Lack Of Standing

    NEW YORK - A New York federal judge on April 19 dismissed a health care copayment dispute, finding that the plaintiff lacked standing to bring her claims (Marianne Gates v. United Healthcare Insurance Co., et al., No. 11-3487, S.D. N.Y.; 2013 U.S. Dist. LEXIS 56619).

    Texas Supreme Court: Providers Cannot Assert Pay Violation Against HMO

    AUSTIN, Texas - The Texas Supreme Court on April 19 held that health care providers could not assert a prompt-pay violation against a health maintenance organization because it had contracts only with the HMO's network and not the HMO (Christus Health Gulf Coast, et al. v. Aetna Inc., et al., No. 11-483, Texas Sup.; 2013 Tex. LEXIS 296).

    Mich. Appeals Court Affirms, Reverses Class Order In Reimbursement Suit

    DETROIT - A Michigan appeals panel on April 18 partially affirmed and partially reversed class certification in a suit alleging that a health insurer failed to properly reimburse chiropractors (Michigan Association of Chiropractors, et al. v. Blue Cross Blue Shield, No. 304763, Mich. App.; 2013 Mich. App. LEXIS 721).

    Michigan Appeals Court Modifies Class Definitions In Reimbursement Dispute

    DETROIT - A Michigan appeals panel on April 18 partially affirmed and partially reversed class certification of five classes in a suit alleging that a health insurer failed to properly reimburse chiropractors (Michigan Association of Chiropractors, et al. v. Blue Care Network of Michigan Inc., No. 304783, Mich. App.; 2013 Mich. App. LEXIS 724).

    Oklahoma Federal Judge Declines To Dismiss Prescription Drug Payment Suit

    OKLAHOMA CITY - An Oklahoma federal judge on April 18 denied a motion to dismiss a breach of contract claim related to the payment for prescription drugs, saying that the court had personal jurisdiction over the out-of-state defendants and that the plaintiff sufficiently supported its claims (Pharmacy Providers of Oklahoma Inc. v. Q Pharmacy Inc., et al., No. 12-1405, W.D. Okla.; 2013 U.S. Dist. LEXIS 55567).

    Pa. Federal Judge Grants Preliminary Injunction In Birth Control Mandate Case

    PITTSBURGH - A Pennsylvania federal judge on April 19 granted a motion for a preliminary injunction in a case brought by a private, nonprofit college, two for-profit entities and the owners of those entities who are challenging the "birth control" mandate contained in the Patient Protection and Affordable Care Act (PPACA) (Geneva College, et al. v. Kathleen Sebelius, et al., No. 12-207, W.D. Pa.; 2013 U.S. Dist. LEXIS 56087).

    Federal Judge Dismisses 4 Defendants In Payment Dispute; 7 Defendants Remain

    NEWARK, N.J. - A New Jersey federal judge on April 17 dismissed claims against four health care payers in a reimbursement dispute, saying that either the defendants were not subject to the Employee Retirement Income Security Act or were not proper parties; he left claims against seven other defendants, saying that the plaintiff exhausted administrative remedies before filing suit (Sportscare of America v. Multiplan Inc., et al., No. 10-4414, D. N.J.; 2013 U.S. Dist. LEXIS 54947).

    Va. Provider Must Repay Medicaid For Services By Unqualified Workers

    RICHMOND, Va. - The Virginia Court of Appeals on April 16 affirmed a trial court order granting summary judgment to the Virginia Department of Medical Assistance Services (DMAS) ordering the Family Redirection Institute Inc. (FRI) to reimburse the state Medicaid program for payments made to FRI for services by unqualified mental health care professionals (Family at Redirection Institute Inc. v. Commonwealth of Virginia Department of Medical Assistance Services, No. 1274-12-2, Va. App.; 2013 Va. App. LEXIS 116).

    Louisiana Federal Judge Affirms Denial Of Benefits, Says Plan Excluded Coverage

    LAFAYETTE, La. - A Louisiana federal judge on April 11 granted summary judgment in favor of a health insurance company in a wrongful denial of benefits case, agreeing with the insurer that the plan excluded coverage for bariatric surgery and complications arising from the surgery (Amy Macip v. Louisiana Service & Indemnity Co., No. 10-1678, W.D. La.; 2013 U.S. Dist. LEXIS 53342).

    High Court: Plan Terms Govern ERISA Reimbursement Action Based On Equitable Lien

    WASHINGTON, D.C. - The U.S. Supreme Court on April 16 ruled that a health plan administrator's claim for reimbursement against a plan participant under Employee Retirement Income Security Act Section 502(a)(3) based on an equitable lien by agreement is governed by the terms of the plan and is not subject to equitable limitations (U.S. Airways, Inc. v. James McCutchen, et al., No. 11-1285, U.S. Sup.).

    Illinois Federal Judge Dismisses Medicare Suit For Lack Of Jurisdiction

    CHICAGO - An Illinois federal judge on April 12 granted a defense motion to dismiss a Medicare dispute for lack of jurisdiction (Columbus Park Nursing and Rehabilitation Center v. Kathleen Sebelius, No. 10-4317, N.D. Ill.; 2013 U.S. Dist. LEXIS 52774).

    Wisconsin Federal Judge: Plaintiff Failed To Join Proper Party In Health Care Case

    GREEN BAY, Wis. - A Wisconsin federal judge on April 10 held that a plaintiff in a health care payment determination case failed to join the beneficiary as a necessary party to the action (VHC Inc. as trustee for SBV Health Plan v. University of Wisconsin Hospitals and Clinics, No. 13-92, E.D. Wis.; 2013 U.S. Dist. LEXIS 51635).

    Supreme Court Denies Certiorari; Provider Can Sue For Avandia-Related Expenses

    WASHINGTON, D.C. - The U.S. Supreme Court on April 15 denied a petition for writ of certiorari filed by GlaxoSmithKine PLC (GSK), leaving stand a decision allowing a Medicare Advantage provider to seek reimbursement from GSK under Medicare law for the costs of treating insurance customers who were injured by GSK's Avandia diabetes drug (GlaxoSmithKline, et al. v. Humana Medical Plans, et al., No. 12-690, U.S. Sup.).

    Plan Administrator Didn't Breach Fiduciary Duties In Mental Health Parity Case

    SEATTLE - A health plan administrator did not breach its fiduciary duties under the Employee Retirement Income Security Act by failing to modify its coverage certificates to reflect a court order that it provide mental health treatment because the administrator informed its members of the changes to its coverages of neurodevelopmental therapy mandated by the court's order, a federal judge in Washington ruled April 8 (Z.D., et al. v. Group Health Cooperative, et al., No. 2:11-cv-01119, W.D. Wash.; 2013 U.S. Dist. LEXIS 50402).

    Medicare Qui Tam Action Dismissed; Claims Barred By Public Disclosure

    NASHVILLE, Tenn. - A Tennessee federal judge on April 5 dismissed a qui tam action brought by a state resident who accused local medical clinics of offering illegal inducements to Medicare beneficiaries to secure patronage, saying that the relator obtained his information from public records (United States of America, ex rel. Marc Osheroff v. HealthSpring Inc., et al., No. 10-1015, M.D. Tenn.; 2013 U.S. Dist. LEXIS 49526).

    Oklahoma Federal Judge Remands Medicare Reimbursement Dispute

    OKLAHOMA CITY - An Oklahoma federal judge remanded to the U.S. Department of Health and Human Services a Medicare reimbursement case, finding that an appeals board erred in determining that a contractor administering the program established the reimbursement codes at issue (Oklahoma Procure Management v. Kathleen Sebelius, secretary of the United States department of Health and Human Services, No. 12-680, W.D. Okla.; 2013 U.S. Dist. LEXIS 48829).

    N.D. Supreme Court Affirms Medical Providers Not Liable For Lawsuit Expenses

    BISMARCK, N.D. - The North Dakota Supreme Court on April 4 affirmed summary judgment in favor of health care providers in a suit in which plaintiffs were seeking reimbursement for expenses and liabilities incurred in pursuing a federal court action to get health insurance companies to pay for medical services provided by the hospitals (Arthur M. Hayden, et al. v. Medcenter One Inc., et al., No. 20120337, N.D. Sup.; 2013 N.D. LEXIS 47).

    9th Circuit Affirms, Reverses Decision In Medicaid Payment Calculation Case

    SAN FRANCISCO - A Ninth Circuit U.S. Court of Appeals panel on April 4 affirmed in part and reversed in part the dismissal of two federally funded health care clinics' actions alleging that the California Department of Health Care Services incorrectly calculated payments for Medicaid-covered pharmacy services provided to "dual-eligible" Medicare beneficiaries who also receive Medicaid (North East Medical Services Inc., et al. v. State of California, et al., Nos. 11-16795, 11-16796, 9th Cir.; 2013 U.S. App. LEXIS 6808).

    Louisiana Federal Judge Grants Remand In Health Care Reimbursement Dispute

    LAFAYETTE, La. - A Louisiana federal judge on April 4 granted a motion to remand in a class action health care reimbursement case, saying that one of the defendants was not fraudulently joined and that the plaintiffs met an exception to the Class Action Fairness Act (CAFA) (Opelousas General Trust Authority v. Multiplan Inc., et al., No. 12-1830, W.D. La.; 2013 U.S. Dist. LEXIS 49824).

    New York Federal Judge Allows False Claims Suit To Proceed Against Americare

    BROOKLYN, N.Y. - A federal judge in the U.S. District Court for the Eastern District of New York on April 3 partially granted a motion to dismiss a federal and New York state False Claims Act (FCA) suit against Americare Inc. and partially denied the motion, saying that the plaintiff was able to sufficiently assert that the corporate defendants may have altered medical records to justify unnecessary home health services under Medicare (United States of America, ex rel. Patricia Mooney, v. Americare Inc., et al., No. 06cv1806, E.D. N.Y.; 2013 U.S. Dist. LEXIS 48398).