DETROIT - A federal judge in Michigan on Dec. 21 granted State Farm Mutual Automobile Insurance Co.'s motion to reconsider and dismissed a health medical practices counterclaims for fraud, civil conspiracy and declaratory relief, finding that pursuant to the Michigan Supreme Court's ruling in Covenant Med. Ctr., Inc. v. State Farm Mut. Auto. Ins. Co., 500 Mich. 191, 895 N.W.2d 490, 505 (2017), State Farm is not required to pay claims for no-fault benefits submitted by health care providers (State Farm Mutual Automobile Insurance Company v. Universal Rehab Services Inc., et al., No. 15-10993, E.D. Mich., 2017 U.S. Dist. LEXIS 210318).
LOS ANGELES - A health insurer waived the right to deny coverage for vertebrate fusion surgery as experimental when it preauthorized the procedure, albeit with a different device, a federal judge in California held Dec. 12, entering judgment for the plaintiff on her Employee Retirement Income Security Act claims (Aubrey Cohorst v. Anthem Health Plans of Kentucky Inc., No. 16-7925, C.D. Calif., 2017 U.S. Dist. LEXIS 204362).
ST. LOUIS - The Eighth Circuit U.S. Court of Appeals on Dec. 6 reversed and remanded a district court's dismissal of a health care plan participant's claim seeking to recover premiums paid under the plan after determining that a restitutionary claim for premiums under the Employee Retirement Income Security Act may be available if there was a violation of the plan's terms (CeCelia Catherine Ibson v. United Healthcare Services Inc., No. 16-3260, 8th Cir., 2017 U.S. App. LEXIS 24608).
NEW YORK - A New York federal judge, in an order filed Dec. 1, declined preliminary approval of a class settlement worth up to $7,425,000 offered by Dave & Buster's Inc. to end claims that the nationwide restaurant/entertainment chain violated the Employee Retirement Income Security Act by reducing the hours of its work force in 2013 to avoid the costs associated with providing health insurance to its full-time employees in compliance with the Patient Protection and Affordable Care Act (ACA) (Maria De Lourdes Parra Marin v. Dave & Buster's, Inc., et al., No. 15-3608, S.D. N.Y.).
CAMDEN, N.J. - A federal judge in New Jersey on Dec. 1 refused to dismiss a lawsuit brought by the Government Employees Insurance Co. (GEICO) over an alleged fraudulent billing scheme by doctors at two orthopedic firms, finding that the insurer's claims under the Racketeer Influenced and Corrupt Organizations Act and the New Jersey Insurance Fraud Prevention Act (IFPA) are not subject to arbitration (Government Employees Insurance Company v. Regional Orthopedic Professional Association, et al., No. 17-1615, D. N.J., 2017 U.S. Dist. LEXIS 197599).
NEW ORLEANS - A Fifth Circuit U.S. Court of Appeals panel on Nov. 30 overturned a federal judge in Texas' ruling ordering a physician's assistant found guilty of conspiracy to commit insurance fraud to pay $4 million in restitution and forfeiture, holding that the man should be required to reimburse the government only for the proceeds he obtained from the scheme (United States of America v. Mansour Sanjar, et al., No. 15-20025, 5th Cir., 2017 U.S. App. LEXIS 24252).
SACRAMENTO, Calif. - A California federal judge on Nov. 16 remanded an insured's claim seeking coverage for almost $500,000 incurred for the transport of her daughter from a hospital in Mexico to a hospital in Seattle by air ambulance because the plan administrator did not consider all of the available information before denying the claim on the basis that the air transport was not for an emergency (Aviation West Charters LLC, d/b/a Angel Medflight v. UnitedHealthcare Insurance Co., No. 16-436, E.D. Calif., 2017 U.S. Dist. LEXIS 190114).
NEW ORLEANS - A Fifth Circuit U.S. Court of Appeals panel on Nov. 7 upheld convictions of a man and his son who were accused of health care fraud and paying kickbacks to obtain business for their partial hospitalization programs (PHPs), ruling that evidence presented by the government was sufficient to support the jury's verdict (United States of America v. Earnest Gibson III, et al., No. 15-20323, 5th Cir., 2017 U.S. Dist. LEXIS 22261).
RICHMOND, Va. - A Fourth Circuit U.S. Court of Appeals panel on Oct. 30 affirmed a federal judge in Virginia's decisions finding a couple guilty of conspiring to commit health care fraud and denying their post-trial motions for acquittal, holding that the judge properly addressed whether misrepresentations the defendants made to insurers were material (United States of America v. Beth Palin, et al., Nos. 16-4522, 16-4540, 4th Cir., 2017 U.S. App. LEXIS 21596).
BOISE, Idaho - A federal judge in Idaho on Oct. 27 ordered a dentist to pay $847,016 in restitution and forfeit $139,769.80 after pleading guilty to 24 counts of health care fraud (United States of America v. Cherie Renee Dillon, No. 16-cr-0037, D. Idaho, 2017 U.S. Dist. LEXIS 178810).
NEW ORLEANS - A federal judge in Louisiana on Oct. 13 sentenced a woman to one year and one day in prison and ordered her to pay $536,724 in restitution after she pleaded guilty to one count of health care fraud for misappropriating Medicaid funds received by a pediatric clinic where she worked for her to pay off unauthorized charges on a business credit card (United States of America v. Monica Sylvest, No. 17cr24, E.D. La.).
NEW YORK - After finding that an insurer did not improperly deny coverage for continued treatment of an insured's anorexia nervosa in violation of the Employee Retirement Income Security Act, the Second Circuit U.S. Court of Appeals on Oct. 2 affirmed a court's ruling that the insurer's decision to cease coverage was based on the substantial evidence (Elizabeth W. v. Empire Healthchoice Assurance Inc., et al., No. 16-3463, 2nd Cir., 2017 U.S. App. LEXIS 19099).
FRANKFORT, Ky. - A federal judge in Kentucky on Sept. 29 affirmed a jury's decision to convict two physicians who owned addiction clinics, as well as the partial owners of a laboratory that conducted screenings for urine drug tests of 17 counts of aiding and abetting one another to commit health care fraud, finding that the evidence was sufficient to support the verdict and that the jury's conclusion was not manifestly unjust (United States of America v. Robert L. Bertram, M.D., et al., No. 15-cr-14-GVFT-REW, E.D. Ky., 2017 U.S. Dist. LEXIS 160884).
SAN DIEGO - Allegations that an emergency health care provider touted its compassion toward those with gender dysphoria and then repeatedly referred to a transgender boy as female support his mother's Patient Protection and Affordable Care Act (ACA) and California unfair competition law claims, a federal judge in California held Sept. 27 (Katharine Prescott, et al. v. Rady Children's Hospital - San Diego, No. 16-2408, S.D. Calif., 2017 U.S. Dist. LEXIS 160259).
BILLINGS, Mont. - A Montana federal judge on Sept. 20 granted a disability claimant's motion for summary judgment after determining that Montana's mental health parity law requires the plan to provide the claimant with the same benefits for her mental illness as it would if her disability were physical (Theresa Sand-Smith v. Liberty Life Assurance Company of Boston, No. 17-0004, D. Mont., 2017 U.S. Dist. LEXIS 153217).
SHERMAN, Texas - A Texas federal judge on Sept. 19 refused to dismiss a plaintiff's breach of fiduciary claims arising out of a health care plan's denial of coverage for autism treatments because the fiduciary claims are not disguised benefits claims and the plaintiff alleged sufficient facts to support the breach of fiduciary claims (Amy Whitley, et al. v. Dr Pepper Snapple Group Health Plan, et al., No. 17-47, E.D. Texas, 2017 U.S. Dist. LEXIS 152417).
SAN FRANCISCO - In a motion seeking interlocutory review, an insurer argues that whether the Patient Protection and Affordable Care Act (ACA) requires an insurer to provide access to lactation services or merely forbids financial barriers to obtaining such services is exactly the type of question the Ninth Circuit U.S. Court of Appeals should address and, in an answer to the complaint filed Sept. 19 in a California federal court, the insurer says the plaintiffs' fail to state a claim under either the Employee Retirement Income Security Act (ERISA) and the ACA on which relief can be based (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 17-183, N.D. Calif.).
TRENTON, N.J. - A federal judge in New Jersey on Sept. 19 struck defenses submitted via email by three defendants accused by Government Insurance Co., GEICO Indemnity Co., GEICO General Insurance Co. and GEICO Casualty Co. (collectively GEICO) of submitting approximately $3.3 million in false insurance claims, ruling that emails to counsel are not the proper procedure for responding to a lawsuit (Government Employees Insurance Company, et al. v. Hamilton Health Care Center, P.C., et al., No. 17-0674, D. N.J., 2017 U.S. Dist. LEXIS 151772).
HOUSTON - A health plan beneficiary is owed full coverage for a gastric bypass surgery and a follow-up surgery and care required after she experienced complications, a Texas federal judge ruled Sept. 14, finding that the beneficiary's evidence that she has experienced nausea and vomiting placed her within the health plan's exception to its weight loss surgery exclusion (Karen A. Rittinger v. Health Alliance Life Insurance Company, et al., No. 16-639, S.D. Texas, 2017 U.S. Dist. LEXIS 149394).
NEWARK, N.J. - A firm of pediatric doctors can pursue allegations that a skilled nursing and rehabilitation facility violated the False Claims Act, the New Jersey False Claims Act (NJFCA) and the New York False Claims Act (NYFCA) for unlawfully billing Medicare and Medicaid as primary payers rather than a patient's private insurance company, a federal judge in New Jersey ruled Sept. 18, finding that the firm sufficiently stated claims under Federal Rule of Civil Procedure 12(b)(6) (United States of America v. Wanaque Convalescent Center, et al., No. 14-6651, D. N.J., 2017 U.S. Dist. LEXIS 150566).
NEW ORLEANS - A woman was properly convicted and sentenced to 140 months in prison for illegally billing Medicare more than $250,000 for medical equipment for beneficiaries that was not medically necessary, a Fifth Circuit U.S. Court of Appeals panel ruled Sept. 13, finding that she was deliberately ignorant of her scheme (United States of America v. Tracy Richardson Brown, No. 16-30933, 5th Cir.).
NEW ORLEANS - A Fifth Circuit U.S. Court of Appeals panel on Aug. 17 affirmed a jury's verdict convicting a man of committing health care fraud and paying and receiving kickbacks for approving patients for home health care when they did not need such treatment (United States v. Warren Dailey, No. 16-20517, 5th Cir., 2017 U.S. App. LEXIS 15595).
ST. LOUIS - A federal judge on Aug. 15 sentenced a podiatrist to 90 months in prison and ordered him to pay $6.9 million in restitution for fraudulently billing Medicare for services that were not rendered (United States v. Yev Gray, No. 15cr464, E.D. Mo.).
HOUSTON - A registered nurse who owned two home health care companies was found guilty on Aug. 10 by a federal jury in Texas of one count of conspiracy to commit health care fraud and four counts of health care fraud for her role in a $20 million Medicare fraud scheme (United States v. Evelyn Mokwuah, No. 16cr254, S.D. Texas).
GREENVILLE, Miss. - The U.S. Department of Justice announced Aug. 10 that a federal judge in Mississippi has sentenced a doctor to 39 months in prison and ordered him to pay $1.9 million in restitution to the Medicare program for referring patients to hospice care when such treatment was not necessary (United States v. Nathaniel Brown, No. 16cr74, N.D. Miss.).