Plan Failed To Provide Full And Fair Review Of Benefit Denial, 5th Circuit Holds

    NEW ORLEANS - A health benefits plan that changed its basis for denying coverage on administrative appeal did not substantially comply with procedures for reviewing denial-of-benefits decisions set out in Employee Retirement Income Security Act, the Fifth Circuit U.S. Court of Appeals ruled Jan. 8, in remanding to the federal district court for remand to the plan for a full and fair review (Lucas Rossi v. Precision Drilling Oilfield Services Corporation Employee Benefits Plan, No. 11-50861, 5th Cir.; 2013 U.S. App. 702).

    Ex-Orthofix Manager Sentenced To 5 Months Of House Arrest For Health Care Fraud

    BOSTON - A former manager for medical device maker Orthofix Inc. was sentenced Jan. 9 to five months of home confinement and ordered pay and forfeit $44,000 for defrauding Medicare by falsifying medical records (United States of America v. Derrick R.D. Field, No. 12-cr-10057, D. Mass.).

    Federal Judge Rules On Motions In Abortion Health Insurance Coverage Case

    KANSAS CITY, Kan. - A federal judge in Kansas on Jan. 7 denied summary judgment in favor of the plaintiff and partially granted summary judgment in favor of the defendant in a case challenging a state law prohibiting insurance companies from offering comprehensive health insurance plans that cover abortion, unless the abortion is required to prevent the death of the mother (American Civil Liberties Union of Kansas and Western Missouri v. Sandy Praeger, Kansas insurance commissioner, No. 11-2462, D. Kan.; 2013 U.S. Dist. LEXIS 1711).

    5th Circuit: Third-Party Administrator Abused Discretion In Denying Claims

    NEW ORLEANS - A third-party administrator (TPA) can be liable for improperly denying benefits under Employee Retirement Income Security Act Section 502(a)(1)(B), and a TPA abused its discretion in denying a medical provider reimbursement by misinterpreting the plans' definition of "skilled nursing facilities $(SNFs$)," the Fifth Circuit U.S. Court of Appeals affirmed Jan. 4 (LifeCare Management Services LLC v. Insurance Management Administrators Incorporated, et al., No. 11-10733, 11th Cir.; 2013 U.S. App. LEXIS 239).

    U.S. Supreme Court Denies Certiorari In Denial Of Medicare Coverage Case

    WASHINGTON, D.C. - The U.S. Supreme Court on Jan. 7 denied a petition for writ of certiorari sought by the trustee for the bankruptcy estate of a durable medical equipment manufacturer, leaving in place a lower court decision finding that coverage denials for the equipment were not arbitrary and capricious under Medicare (Monique D. Almy, Chapter 7 Trustee for the bankruptcy estate of BioniCare Medical Technologies Inc. v. Kathleen Sebelius, Secretary of Health and Human Services, No. 12-356, U.S. Sup.).

    Supreme Court Declines To Hear Beneficiaries' Quest To Disclaim Medicare Benefits

    WASHINGTON, D.C. - The U.S. Supreme Court on Jan. 7 denied a petition for writ of certiorari brought by three Medicare beneficiaries challenging the dismissal of their suit seeking to formally disclaim their entitlement to Medicare Part A - hospital insurance (Brian Hall, et al. v. Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, et al., No. 12-262, U.S. Sup.).

    D.C. Circuit Affirms Price Cap On Prescriptions For Military Members

    WASHINGTON, D.C. - A panel of the District of Columbia U.S. Circuit Court of Appeals on Jan. 4 affirmed that the secretary of defense reasonably interpreted a federal regulation aimed at curbing the cost of prescription drugs for military families to impose involuntary price caps on prescription drugs and to impose retroactive rebate liability on pharmaceutical manufacturers (Coalition for Common Sense in Government Procurement v. United States of America, et al., No. 11-5350, D.C. Cir.; 2013 U.S. App. LEXIS 216).

    Prompt-Payment Statute Is Preempted As To Self-Funded Plans, Federal Judge Rules

    ATLANTA - The Employee Retirement Income Security Act preempts Georgia's statute requiring self-funded employer health insurance plans governed by ERISA to pay or deny benefit claims within a specified time frame, a federal judge in Georgia ruled Dec. 31 in granting a preliminary injunction prohibiting enforcement of the provision (American's Health Insurance Plans v. Hudgens, No. 1:12-cv-2978, N.D. Ga.; 2012 U.S. Dist. LEXIS 182922).

    Small-Employer Exception Applies In COBRA Case, 4th Circuit Rules

    RICHMOND, Va. - A purchase option that was in effect for four months of the relevant calendar year did not require that the two companies be considered a single employer for purposes of continuation health care coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), the Fourth Circuit U.S. Court of Appeals ruled Dec. 28 in an unpublished opinion (Conn Feamster, et al. v. Mountain State Blue Cross & Blue Shield, Incorporated, et al., No. 11-2256, 4th Cir.; 2012 U.S. App. LEXIS 26628).

    HHS Must Pay Interest To Hospitals To Correct Medicare Payments, Judge Says

    WASHINGTON, D.C. - A District of Columbia federal judge on Dec. 31 ordered the U.S. Department of Health and Human Services (HHS) to recalculate Medicare and Medicaid payments to disproportionate share hospitals (DSH) for services furnished to low-income patients and added that the agency must pay interest to the DSH providers if further reimbursement is forthcoming (Alegent Health -Immanual Medical Center et al. v. Kathleen Sebelius, et al., Nos. 11-139 and 11-1932, D. D.C.; 2012 U.S. Dist. LEXIS 182943).

    Restraining Order Prohibiting Implementation Of Birth Control Mandate Granted

    DETROIT - A Michigan federal judge on Dec. 30 granted a temporary restraining order to halt the implementation of a mandate contained in the Patient Protection and Affordable Care Act (PPACA) related to the provision of birth control against the owner of a property management company and the company (Thomas Monaghan, et al. v. Kathleen Sebelius, et al., No. 12-15448, E.D. Mich.; 2012 U.S. Dist. LEXIS 182857).

    Missouri Federal Judge's Order Halts Implementation Of Birth Control Mandate

    HANNIBAL, Mo. - A Missouri federal judge on Dec. 31 granted plaintiffs a temporary restraining order and preliminary injunction to halt the implementation of a mandate contained in the Patient Protection and Affordable Care Act (PPACA) related to the provision of birth control (Sharpe Holdings Inc., et al. v. United States Department of Health and Human Services, et al., No. 12-92, E.D. Mo.; 2012 U.S. Dist. LEXIS 182942).

    Indiana Federal Judge Denies Preliminary Injunction In Birth Control Mandate Case

    NEW ALBANY, Ind. - An Indiana federal judge on Dec. 27 denied the plaintiffs' motion for a preliminary injunction to halt the implementation of a mandate contained in the Patient Protection and Affordable Care Act (PPACA) related to the provision of birth control (Grote Industries, et al. v. Kathleen Sebelius, et al., No. 12-134, S.D. Ind.; 2012 U.S. Dist. LEXIS 181965).

    Supreme Court Denies Injunction Pending Appellate Review Of Birth Control Issue

    WASHINGTON, D.C. - In an in-chambers order, the U.S. Supreme Court on Dec. 26 denied a request for an injunction pending appellate review of a lower court's decision rejecting a preliminary injunction to halt the implementation of a mandate contained in the Patient Protection and Affordable Care Act (PPACA) related to the provision of birth control (Hobby Lobby Stores Inc., et al. v. Kathleen Sebelius, et al., No. 12A644, U.S. Sup.; 2012 U.S. LEXIS 9594).

    Preliminary Injunctions Over Medicaid Reimbursement Reductions Vacated

    SAN FRANCISCO - A Ninth Circuit U.S. Court of Appeals panel on Dec. 13 reversed a district court's decisions and vacated preliminary injunctions prohibiting the implementation of Medicaid reimbursement reductions in California (Managed Pharmacy Care, et al. v. Kathleen Sebelius, et al., Nos. 12-55067, 12-55068, 12-55103, 12-55315, 12-55331, 12-55332, 12-55334, 12-55335, 12-55550, 12-55554, 9th Cir.; 2012 U.S. App. LEXIS 25478).

    California Federal Judge Finds Claims Not Preempted, Remands Health Insurance Case

    SAN FRANCISCO - A California federal judge on Dec. 12 found that the Employee Retirement Income Security Act did not preempt claims brought in a health insurance payment dispute and remanded the case to state court (Board of Trustees of Alameda County Medical Center v. Costco Employees Benefit Program, No. 12-4609, N.D. Calif.; 2012 U.S. Dist. LEXIS 176195).

    Illinois Federal Judge Denies Preliminary Injunction In Contraception Mandate Suit

    EAST ST. LOUIS, Ill. - An Illinois federal judge on Dec. 14 denied a motion for preliminary injunction in a case brought by the owners of a secular, for-profit construction business who are seeking to stop the implementation of a "contraception mandate" contained in the Patient Protection and Affordable Care Act (PPACA) (Cyril B. Korte, et al. v. U.S. Department of Health and Human Services, et al., No. 12-1072, S.D. Ill.; 2012 U.S. Dist. LEXIS 177101).

    Antitrust Suits Against Blue Cross Blue Shield Are Centralized In MDL

    WASHINGTON, D.C. - The U.S. Judicial Panel on Multidistrict Litigation on Dec. 12 centralized in the U.S. District Court for the Northern District of Alabama litigation alleging that the licensing agreements between Blue Cross Blue Shield Association (BCBSA) and its 38 licensees divide and allocate health insurance markets throughout the United States in violation of Sections 1 and 2 of the Sherman Act and various state laws (In re: Blue Cross Blue Shield Antitrust Litigation, MDL No. 2406, JPMDL).

    Preliminary Approval Of Settlement In Out-Of-Network Reimbursement MDL Sought

    NEWARK, N.J. - Parties involved in a multidistrict litigation case in which defendants are accused of manipulating the rates for which they reimburse out-of-network medical providers filed a joint motion on Dec. 7 asking a New Jersey federal judge to preliminarily approve a settlement valued up to $120 million (In re: Aetna UCR Litigation, MDL No. 2020, Master File No. 07-3541, D. N.J.).

    Arizona Federal Judge Affirms Denial Of Drug Coverage Under Medicare Part D

    PHOENIX - An Arizona federal court judge on Dec. 11 affirmed a health plan's denial of a prescription drug, agreeing that the drug is not covered under Medicare Part D (Penny Rickhoff v. United States Secretary for the Department of Health and Human Services, No. 11-2189, D. Ariz.; 2012 U.S. Dist. LEXIS 175206).

    N.J. Federal Judge Rules On Dismissal Motions In Denial Of Health Benefits Case

    TRENTON, N.J. - A New Jersey federal judge on Dec. 5 partially granted motions to dismiss brought by a health insurance company and a peer review assessment company in a wrongful denial of benefits suit and allowed the plaintiff to amend a portion of her complaint (Linda S. Skelcy v UnitedHealth Group Inc., et al.,  No. 12-1014, D. N.J.; 2012 U.S. Dist. LEXIS 172922).

    N.J. Federal Judge Dismisses Claims Administrator, Says Not Proper Defendant

    NEWARK, N.J. - A New Jersey federal judge on Dec. 6 dismissed claims against a claims administrator in a health care reimbursement suit, saying the defendant is not a fiduciary and, therefore, not a proper defendant (Montvale Surgical Center v. Horizon Blue Cross Blue Shield of New Jersey, et al.,  No. 12-2478, D. N.J.; 2012 U.S. Dist. LEXIS 173337).

    5th Circuit: Challenge To Medicare Calculation For Low-Income Patients Denied

    NEW ORLEANS - The Fifth Circuit U.S. Court of Appeals on Dec. 6 affirmed a trial court order denying health care providers' challenge of how the U.S. Department of Health and Human Services (HHS) determines whether a hospital qualifies for, and the amount of, payment for serving a "disproportionate number of low-income patients." The court determined that the U.S. Congress specifically meant to leave out patients who qualify for Medicare Part A and Medicaid but do not qualify for Supplemental Security Income (SSI) when calculating the extra payments (Memorial Hospital at Gulfport, et al., v. Kathleen Sebelius, as Secretary of the United States Department of Health and Human Services, et al.,  No. 12-60333, 5th Cir.; 2012 U.S. App. LEXIS 25040).

    Missouri Appeals Court Affirms Denial Of Medicaid Benefits To Legal Alien

    KANSAS CITY, Mo. - The Western District Missouri Court of Appeals, Division Two, on Dec. 4 affirmed a trial court ruling denying Medicaid coverage for kidney dialysis treatment to a "legal alien." The appeals court concluded that while a legal alien may receive Medicaid benefits after living in the country for five years or more, or for seeking emergency treatment, the plaintiff had resided in the United States for only three years and her condition was not considered an emergency under state and federal law (Bertha Cruz v. Mo. Department of Social Services,  No. WD74667, Mo. App., Western Dist., Div. 2; 2012 Mo. App. LEXIS 1537).

    Unsettled Case Law Leads 7th Circuit To Uphold Award In ERISA Dispute

    CHICAGO - Citing the previously unsettled state of case law regarding the production of insurers' internal documents and a lack of bad faith in an insurer's handling requests for such documents, a Seventh Circuit U.S. Court of Appeals panel on Nov. 28 upheld a lower court's ruling that had limited an insured's damages against her health plan provider (Sharon Mondry v. American Family Mutual Insurance Co, et al.,   No. 10-3490 and 11-1750, 7th Cir.; 2012 U.S. App. LEXIS 24476).