MIAMI - A Florida federal judge on April 25 held that an external appeal upholding a plaintiff's denial of medical benefits is conclusive to the issue of medical necessity but said she would allow the plaintiff to conduct discovery as to whether the external reviewer had any conflict of interest that may have biased the decision (Alexandra H. v. Oxford Health Insurance Inc., et al., No. 11-23948, S.D. Fla.; 2014 U.S. Dist. LEXIS 57863).
LOS ANGELES - A divided California appeals court on April 23 reversed a trial court's decision in part and modified it to enjoin the California Department of Managed Health Care (DMHC) from upholding a plan's denial of applied behavioral analysis (ABA) therapy on the grounds that a Behavior Analyst Certification Board (BACB)-certified provider is not licensed. The court further held that even when a health plan is exempted from the ABA statute, the DMHC may not uphold a denial of coverage for ABA performed or supervised by therapists who are BACB certified on the basis the provider is not licensed (Consumer Watchdog, et al. v. Department of Managed Health Care, et al., No. B232338, Calif. App., 2nd Dist. Div. 3; 2014 Cal. App. LEXIS 352).
WASHINGTON, D.C. - The District of Columbia U.S. Circuit Court of Appeals on April 28 denied a petition seeking rehearing in a case challenging the Patient Protection and Affordable Care Act (ACA) individual mandate (Association of American Physicians & Surgeons Inc., et al. v. Kathleen G. Sebelius, et al., No. 13-5003, D.C. Cir.).
HOUSTON - A Texas federal judge on April 23 partially granted a health insurance company's motion to dismiss a reimbursement suit brought by a health care provider related to the payment of out-of-network services (Mid-Town Surgical Center v. Humana Health Plan of Texas Inc., No. 13-2620, S.D. Texas; 2014 U.S. Dist. LEXIS 56260).
DURHAM, Ore. - Oregon dumped its failed Patient Protection and Affordable Care Act (ACA) state exchange at an April 25 agency board meeting, with the governing body unanimously adopting a technology workgroup suggestion that the federal exchange provided the most reliable and least costly option going forward.
JEFFERSON CITY, Mo. - An insurance agents' group fails to demonstrate standing to intervene in a Patient Protection and Affordable Care Act (ACA) exchange regulation case or that the existing parties cannot adequately litigate the interest involved, a Missouri judge held April 24 (St. Louis Effort for Aids, et al. v. John Huff, director of the Missouri Department of Insurance, Financial Institutions and Professional Registration, No. 13-4246, W.D. Mo.).
DURHAM, Ore. - Oregon officials will vote April 25 on whether to abandon the state's failed health insurance exchange in favor of the federal Patient Protection and Affordable Care Act (ACA) exchange.
WASHINGTON, D.C. - No legal support exists for a man's claim that the Patient Protection and Affordable Care Act (ACA) exempts independent contractors of grant recipients from self-employment taxes, and the law is "devoid" of any language to that affect, a tax court judge held April 22 (Harris He Wang v. Commissioner of Internal Revenue, No. 4306-13S, U.S. Tax; 2014 Tax Ct. Summary LEXIS 42).
CINCINNATI - The Sixth Circuit U.S. Court of Appeals on April 22 upheld a Federal Trade Commission order requiring ProMedica Health System to divest St. Luke's Hospital to an FTC-approved buyer within 180 days, concluding that the FTC properly found that the acquisition was likely to substantially lessen competition and increase prices for general acute-care inpatient hospital services and inpatient obstetric services sold to commercial health plans in the Toledo, Ohio, area (ProMedica Health System, Inc. v. Federal Trade Commission, No. 12-3583, 6th Cir.; 2014 U.S. App. LEXIS 7500).
DENVER - A Colorado federal judge on April 17 enjoined Patient Protection and Affordable Care Act (ACA) regulations mandating that a group health plan provide post-fertilization contraceptive coverage (Dr. James C. Dobson and Family Talk v. Kathleen Sebelius, et al., No. 13-3326, D. Colo.; 2014 U.S. Dist. LEXIS 54585).
ALEXANDRIA, La. - A Louisiana federal judge on April 21 concurred with a magistrate judge's finding that a reimbursement dispute over the payment of health care benefits should be dismissed for failure of the plaintiff to exhaust administrative remedies (Sanat V. Sanghani, M.D. v. Aetna Life Insurance Co., No. 12-632, W.D. La.; 2014 U.S. Dist. LEXIS 55747).
SEATTLE - Two families who have had coverage for applied behavioral analysis (ABA) therapy to treat their children's autism spectrum disorders (ASD) denied filed a class action lawsuit in a Washington federal court against the plan and plan administrator on April 17 (C.S., et al. v. The Boeing Company Master Welfare Plan, et al., No. 14-574, W.D. Wash.).
ATLANTA - Less than half of the 221,604 Georgia residents who signed up for insurance through the Patient Protection and Affordable Care Act (ACA)'s federal exchange paid their premium by the close of enrollment, Georgia Insurance Commissioner Ralph Hudgens announced April 17.
NEWARK, N.J. - A New Jersey board-certified orthopedic surgeon and the company he owns on April 16 sued a patient's health insurer and employer in federal court for allegedly paying the wrong amount for out-of-network services provided to the patient (Professional Orthopedic Associates, et al. v. Horizon Blue Cross Blue Shield of New Jersey, et al., No. 14-2438, D. N.J.).
WASHINGTON, D.C. - A District of Columbia federal judge on April 17 remanded one hospital's Medicare payment dispute to a review board, but granted the defendant's summary judgment motion as to a second hospital's dispute, saying the review board did not have jurisdiction to hear the challenge to the plaintiff's disproportionate share hospital adjustment (Emanuel Medical Center Inc., et al. v. Kathleen Sebelius, secretary of the United States Department of Health and Human Services, No. 12-1962, D. D.C.; 2014 U.S. Dist. LEXIS 52969).
WASHINGTON, D.C. - While the government tries to downplay its impact, the contraceptive mandate imposes a substantial burden on religious organizations that cannot be avoided through the self-certification process, plaintiffs told the District of Columbia Circuit U.S. Court of Appeals on April 11 (Priests for Life, et al. v. U.S. Department of Health and Human Services, et al., No. 113-5368; Roman Catholic Archbishop of Washington, et al. v. Kathleen Sebelius, et al., No. 13-5371, D.C. Cir.).
SAN DIEGO - A California physician on April 15 sued his health care provider in federal court for allegedly under-reimbursing his neurosurgeon for two surgeries he underwent for back and leg pain (Michael Keller v. Aetna Health and Life Insurance Co., No. 14-895, S.D. Calif.).
NEWARK, N.J. - A New Jersey federal judge on April 14 denied a renewed motion to certify two classes in a reimbursement lawsuit filed against a health care insurer, a database company and the database's parent company (Darlery Franco v. Connecticut General Life Insurance Co., et al., No. 07-6039, D. N.J.; 2014 U.S. Dist. LEXIS 51138).
WASHINGTON, D.C. - U.S. Secretary of Health and Human Services Kathleen Sebelius formally resigned April 11, and President Obama nominated Sylvia Matthew Burwell, now director of the Office of Management and Budget, to succeed her, according to the White House.
WASHINGTON, D.C. - Patient Protection and Affordable Care Act (ACA) insurance provisions will cost $36 billion in 2014 and $1,383 billion for the period of 2015 through 2024, reductions of almost $5 billion less this year $104 billion long term, according to an April 14 analysis by the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT).
WASHINGTON, D.C. - A District of Columbia Circuit U.S. Court of Appeals panel on April 11 affirmed a district court's decision affirming an administrative ruling by the U.S. Department of Health and Human Services (HHS) denying depreciation reimbursement under the Medicare program to a Catholic health care system after a merger with two other Catholic-related hospitals, saying the merger was not a bona fide sale because the hospitals were not given proper consideration for their assets in exchange for their debts (Catholic Healthcare West v. Kathleen Sebelius, in her official capacity as Secretary of Health and Human Services, No. 13-5090, D.C. Cir.; 2014 U.S. App. LEXIS 6662).
CLEVELAND - An Ohio appeals court on April 10 reversed a summary judgment decision in favor of the defendant in a health insurance subrogation case, saying that the contract at issue was ambiguous and that the defendant did not show that its interpretation of the policy was the only reasonable interpretation (Philip Laboy, et al. v. Grange Indemnity Insurance Co., et al., No. 100116, Ohio App., 8th Dist.; 2014 Ohio App. LEXIS 1460).
SAN FRANCISCO - Noting that the issue was a matter of first impression in the circuit, the Ninth Circuit U.S. Court of Appeals on April 8 granted an emergency injunction pending appeal to halt the implementation of an Arizona law prohibiting the use of certain drugs to induce abortions (Planned Parenthood of Arizona Inc., et al. v. William Humble, director of the Arizona Department of Health Services, No. 14-15624, 9th Cir.).
CHICAGO - A Seventh Circuit U.S. Court of Appeals panel on Nov. 8 affirmed that a Medicaid nursing home provider was not entitled to a hearing to challenge deficiency findings under state and federal Medicaid regulations (Bryn Mawr Care Inc. v. Kathleen Sebelius, No. 12-3687, 7th Cir.; 2014 U.S. App. LEXIS 6451).
WASHINGTON, D.C. - A District of Columbia federal judge on April 3 granted an unopposed motion enjoining the government from applying the Patient Protection and Affordable Care Act (ACA) employer mandate (John F. Stewart, et al. v. Kathleen Sebelius, et al., No. 13-1879, D. D.C.).