COLUMBIA, S.C. - The government is improperly withholding payments from, and setting off debts owed by, a failed South Carolina Patient Protection and Affordable Care Act (ACA) co-operative insurer, illegally placing its own interests before those of policyholders and others entitled to priority, the insurer's liquidator allege in an April 12 federal complaint filed in South Carolina (Raymond G. Farmer, et al. v. The United States of America, et al., No. 17-956, D. S.C.).
SEATTLE - A Washington federal judge on April 10 issued an order granting final approval of a settlement under which the Washington State Health Care Authority (WHCA) has agreed to provide coverage for direct-acting antiviral medications for the treatment of hepatitis C (HCV) for Medicaid enrollees who claimed that they were previously denied the drugs due to the cost (B.E., et al. v. Dorothy F. Teeter, No. 16-227, W.D. Wash.).
GREENSBORO, N.C. - An insurer received mixed results in its challenge to claims that it failed to properly compensate the developer of a colorectal cancer screening test, with a federal judge in North Carolina dismissing some of the claims on March 27 but largely allowing Employee Retirement Income Security Act claims to proceed (Exact Sciences Corp. and Exact Sciences Laboratories LLC v. Blue Cross and Blue Shield of North Carolina, No. 16-125, M.D. N.C., 2017 U.S. Dist. LEXIS 44679).
CHICAGO - A federal judge in Illinois dismissed without prejudice claims from a man that his former employer falsely billed Medicare, Medicaid and other private insurers for endovascular laser therapy (EVLT) procedures that were not medically necessary or done with reused laser fibers, finding that the allegations were not made with the required level of specificity to support his False Claims Act (FCA) allegations (United States of America, ex rel. Constantine Zverev, et al. v. USA Vein Clinics of Chicago, LLC, et al., No. 12 CV 8004, N.D. Ill., 2017 U.S. Dist. LEXIS 43807).
BIRMINGHAM, Ala. - A man's Employee Retirement Income Security Act (ERISA) suit impermissibly seeks equitable relief in the face of other available remedies, a federal magistrate judge in Alabama held March 23 (Jeffrey Woodruff v. Blue Cross and Blue Shield of Alabama, et al., 2017 U.S. Dist. LEXIS 41921).
SAN FRANCISCO - Health care centers designated to receive direct payment from a health plan administrator for medical services cannot file suit in federal court under the Employee Retirement Income Security Act because they lack both direct statutory authority and derivative authority through assignment under ERISA's civil enforcement provisions, a Ninth Circuit U.S. Court of Appeals panel held March 22 (DB Healthcare, LLC, et al. v. Blue Cross Blue Shield of Arizona, Inc., No. 14-16518, Advanced Women's Health Center, Inc. v. Anthem Blue Cross Life and Health Insurance Company, No. 14-16612, 9th Cir., 2017 U.S. App. LEXIS 5082).
SAN FRANCISCO - The variety of contracts at issue and evidence that at least some of the contracted pharmacy benefit managers (PBMs) understood that a pharmacy's usual and customary rate did not include the rate offered for generic drugs in its membership program defeat a motion for class certification of insured purchasers of generic drugs, a federal judge in California held March 21 (Christopher Corcoran, et al. v. CVS Health, et al., No. 15-3504, N.D. Calif., 2017 U.S. Dist. LEXIS 40783).
NEWARK, N.J. - Three drug makers and the three largest pharmacy benefit managers have engaged in a pricing scheme to drive up the cost of diabetes insulin - by more than 150 percent in the last five years - in violation of the Racketeer Influenced and Corrupt Organizations Act, the Employee Retirement Income Security Act of 1974, the Sherman Act and numerous state laws, four consumers and Type 1 Diabetes Defense Foundation allege in a March 17 class complaint filed in the U.S. District Court for the District of New Jersey (Julia Boss, et al. v. CVS Health Corporation, et al., No. 17-1823, D. N.J.).
ST. LOUIS - An insolvent insurer's suit against the government over its handling of the Patient Protection and Affordable Care Act (ACA) risk corridor and how it offset debts properly belongs before the U.S. Court of Federal Claims, a federal judge in Iowa said March 17 in finding that she lacked jurisdiction and entering judgment (Nick Gerhart, et al. v. United States Department of Health and Human Services, et al., No. 16-151, S.D. Iowa, 2017 U.S. Dist. LEXIS 37620).
RICHMOND, Va. - A federal judge in Virginia erred in finding that a physical therapist assistant's retaliation claim against his employer should be dismissed, finding that they were not subject to the False Claims Act's (FCA) first-to-file rule, a Fourth Circuit Court of Appeals ruled March 16, but affirmed the dismissal of his qui tam claims under the statute (United States of America, ex rel. Patrick Gerard Carson v. Manor Care, Inc., a./k/a Manor Care, Inc., et al., No. 16-1035, 4th Cir., 2017 U.S. App. LEXIS 4617).
DETROIT - A federal judge in Michigan on March 6 denied a motion to dismiss filed by defendants accused by State Farm Mutual Automobile Insurance Co. of submitting false bills under Michigan's No-Fault Automobile Insurance Act for services that were either medically unnecessary or never provided, ruling that the defendants' arguments lacked merit (State Farm Mutual Automobile Insurance Company v. Elite Health Centers, Inc., et al., No. 16-13040, E.D. Mich., 2017 U.S. Dist. LEXIS 30826).
HOUSTON - A man who posed as a physician as part of a $1.3 million Medicare fraud scheme was found guilty on counts of conspiracy to commit health care fraud, health care fraud and conspiracy to pay health care kickbacks by a federal jury in Texas on March 3 (United States of America v. Nkiru Ibeabuchi, et al., No. 16-cr-114, S.D. Texas).
MIAMI - An administrator of a home health agency was sentenced to 126 months in prison by a federal judge in Florida on Feb. 24, after the defendant was found guilty for his role in a $2.5 million Medicare fraud scheme (United States of America v. Raciel Leon, et al., No. 16cr20476, S.D. Fla.).
McALLEN, Texas - U.S. Attorney Kenneth Magidson on Feb. 24 announced that the owner of a durable medical equipment (DME) company was found guilty by a federal jury in the Southern District of Texas for conspiracy to commit health care fraud, health care fraud, paying illegal kickbacks and other charges in connection with a $2.5 million scheme involving the submission of fraudulent bills to Texas Medicaid.
NEW YORK - A federal magistrate judge in New York on Feb. 22 recommended that a judge enter default judgment against defendants accused by the Government Employees Insurance Company (GEICO) and other insurers of fraud and unjust enrichment for submitting bills from clinics that were not owned by physicians and order them to pay $2.7 million in damages (Government Employees Insurance Co., et al. v. parkway medical Care, P.C., et al., No. 15 Civ. 3670, E.D. N.Y., 2017 U.S. Dist. LEXIS 24994).
NEWARK, N.J. - Remand of an insurance breach of contract and bad faith lawsuit to state court is proper because a third-party's claims are not preempted by the Employee Retirement Income Security Act (ERISA), a federal magistrate judge in New Jersey ruled Feb. 17 (North Jersey Brain & Spine Center v. Aetna Life Insurance Co., et al., No. 16-1544, D. N.J., 2017 U.S. Dist. LEXIS 22710).
NEW YORK - A federal magistrate judge in New York on Feb. 13 recommended that a federal judge enter default judgment against a doctor and the clinics he owned for common-law fraud and violation of the Racketeer Influenced and Corrupt Organizations Act for his role involving the submission of fraudulent bills and kickbacks for referring patients to doctors for medical procedures that were not necessary (Government Employee Insurance Company v. Roger Jacques, M.D., et al., No. 14 Civ. 5299, E.D. N.Y., 2017 U.S. Dist. LEXIS 20195).
ORLANDO, Fla. - Judgment was entered in favor of insurers on Feb. 15, one day after a Florida federal judge found that there is no further coverage owed to insureds for lawsuits alleging that they have intentionally engaged in wrongful antitrust and monopolizing conduct in an effort to dominate the health care service industry (Health First Inc., et al. v. Capitol Specialty Insurance Corporation, et al., No. 15-718, M.D. Fla., 2017 U.S. Dist. LEXIS 20320).
SHREVEPORT, La. - A federal jury in Louisiana on Feb. 10 found a mental health care facility administrator guilty of organizing a kickback scheme that resulted in the submission of $6.7 million in fraudulent bills to Medicare, the U.S. Attorney's Office announced (United States of America v. Tom McCardell, No. 16-cr-212, W.D. La.).
TRENTON, N.J. - A New Jersey judge on Feb. 3 ordered a Patient Protection and Affordable Care Act (ACA) consumer-operated and oriented plan insurer's liquidation and appointed the state's insurance commissioner as liquidator (In the Matter of Freelancers Consumer Operated and Oriented Program of New Jersey d/b/a Health Republic Insurance of New Jersey, No. MCR-C-000063-16, N.J. Super., Mercer Co., Chanc. Div.).
TOLEDO, Ohio - A trial court judge did not err when allowing a jury to hear evidence about an administrative hearing that concluded that a man should be terminated from his job for representing that he was married to obtain insurance benefits for his ex-wife because presentation of the information did not result in "a manifest miscarriage of justice," an Ohio appeals court panel ruled Jan. 20 in affirming the man's sentence and conviction (State of Ohio v. Marvin Arnold, No L-15-1126, Ohio App., 6th Dist.; 2017 Ohio App. LEIS 227).
DALLAS - A Texas federal judge on Jan. 13 dismissed claims alleging gender identity discrimination under Section 1557 of the Patient Protection and Affordable Care Act (ACA) against an insurer and an employer because the plaintiff failed to cite any controlling precedent that recognizes a cause of action under Section 1557 for gender identity discrimination (Charlize Marie Baker v. Aetna Life Insurance Co., et al., No. 15-3679, N.D. Texas; 2017 U.S. Dist. LEXIS 5665).
NEW YORK - A federal judge in New York, who was ordered by the Second Circuit U.S. Court of Appeals to provide more detailed findings on the intended loss of an insurance fraud scheme that involved the redistribution of drugs originally provided to HIV and AIDS patients, on Jan. 17 affirmed his earlier decision that the scheme resulted in $2.9 million in losses to Medicare, finding that a ledger found at the man's apartment detailed the prices and quantities of the drugs (United States of America v. Bladimir Rigo, No. 13 CR 897, S.D. N.Y.; 2017 U.S. Dist. LEXIS 6228).
OAKLAND, Calif. - A California woman on Jan. 13 filed a class action complaint in federal court alleging that she and other women have been wrongfully denied access to and coverage for a vital women's preventive service - breastfeeding support, supplies and counseling - for which coverage is mandated by the Patient Protection and Affordable Care Act (ACA) (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 4:17-cv-00183, N.D. Calif.).
CHICAGO - An Illinois federal judge on Jan. 12 denied a plaintiff's motion to remand after determining that her state law claims arising out of the disclosure of medical records without consent are preempted by the Employment Retirement Income Security Act (Jane Doe v. Aetna Inc., et al., No. 16-8390, N.D. Ill.; 2017 U.S. Dist. LEXIS 4866).