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.).
HARRISBURG, Pa. - In an unpublished April 3 opinion, a panel of the Commonwealth Court of Pennsylvania affirmed a decision denying a hospital's challenge to the implementation of a new Medicaid payment system (Monongahela Valley Hospital Inc. v. Department of Public Welfare, No. 1110 C.D. 2013, Pa. Commw.; 2014 Pa. Commw. Unpub. LEXIS 202).
PHILADELPHIA - In holding that the Health and Human Services secretary had a rational basis for distinguishing between two types of patient days in determining Medicare reimbursement rates, a panel of the Third Circuit U.S. Court of Appeals on April 1 reversed a lower court's decision (Nazareth Hospital, et al. v. Secretary, U.S. Department of Health and Human Services, No. 13-2627, 3rd Cir.; 2014 U.S. App. LEXIS 6082).
NEW YORK - A federal district court erred in ruling that a health plan participant did not have standing under the Employee Retirement Income Security Act to challenge calculations of benefits for members who are eligible for Medicare, the Second Circuit U.S. Court of Appeals ruled April 4 in an unpublished opinion remanding the case to the trial court (Marianne Gates v. UnitedHealthGroup Incorporated, et al., No. 13-2114-cv, 2nd Cir.; 2014 U.S. App. LEXIS 6136).
WASHINGTON, D.C. - The U.S. House of Representative on April 3 passed legislation redefining a full-time employee for purposes of the Patient Protection and Affordable Care Act (ACA)'s employer mandate as an individual who works on average 40 hours per week.
HELENA, Mont. - The Montana Supreme Court on April 2 denied a petition challenging the constitutionality and legal sufficiency of a proposed ballot measure barring the use of state resources to administer the Patient Protection and Affordable Care Act (ACA) (Travis Hoffman, Melissa Smylie and Kim Abbott v. State of Montana, et al., No. 14-0146, Mont. Sup.; 2014 Mont. LEXIS 107).
ATLANTA - The provider of medical devices to health plan participants lacks standing to bring a reimbursement action against the plan insurer under the Employee Retirement Income Security Act because the provider did not demonstrate that it possessed valid written assignments of benefits from the participants or beneficiaries, the 11th Circuit U.S. Court of Appeals affirmed April 1 in an unpublished opinion (Medicomp, Inc. v. United Healthcare Insurance Co., et al., No. 13-13849, 11th Cir.; 2014 U.S. App. LEXIS 6041).
MUSKOGEE, Okla. - An Oklahoma federal magistrate judge on March 31 dismissed a defendant from a denial of benefits suit after finding that the health insurer did not have sufficient contacts with the state for the court to have jurisdiction over the defendant (Samuel Howard Logan Jr. v. Healthcare International Global Networks, et al., No. 13-1444, E.D. Okla.; 2014 U.S. Dist. LEXIS 44710).
NEWARK, N.J. - Although it was enacted in 2010, sections of the Patient Protection and Affordable Care Act (ACA) barring discrimination based on the licensing or certification of physicians became effective only after conduct alleged in two doctors' lawsuit, a New Jersey federal judge held March 31 (Neelendu Bose d/b/a High Crest, et al. v. Horizon Blue Cross Blue Shield of New Jersey, et al., No. 12-4671, D. N.J.; 2014 U.S. Dist. LEXIS 43244).
SEATTLE - In an unpublished opinion, a Washington appeals court on March 31 affirmed the denial of benefits for a patient seeking inpatient rehabilitation services, saying the health plan at issue clearly limited the amount it would pay for such services (Bruce Pleasant, et al. v. Regence Blue Shield, No. 69143-1-1, Wash. App., Div. 1; 2014 Wash. App. LEXIS 743).
WASHINGTON, D.C. - The secretary of the U.S. Department of Health and Human Service (HHS) did not provide adequate notice and opportunity to comment before promulgating a rule that changed how disproportionate-share hospitals (DSH) received payment through Medicare, a panel of the District of Columbia Circuit U.S. Court of Appeals affirmed April 1. However, the lower court erred in directing the secretary on how to recalculate the hospitals' reimbursements using an alternative methodology and should just have remanded after identifying the error, the court added (Allina Services, et al. v. Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, Nos. 13-5011, 13-5015, D.C. Cir.; 2014 U.S. App. LEXIS 5976).
CAMDEN, N.J. - A New Jersey federal judge on March 31 partially granted a plaintiff's motion to remand to state court a proposed class action case over liens asserted by a health insurer against proceeds from personal injury cases but said additional discovery was needed to determine whether an exception to the Class Action Fairness Act (CAFA) also supported remand (Michelle Roche v. Aetna Health Inc., et al., No. 13-3933, D. N.J.; 2014 U.S. Dist. LEXIS 43239).
CHICAGO - An Illinois federal judge on March 28 held that a chiropractic association was entitled to injunctive relief in its suit against a Blue Cross Blue Shield entity for failing to provide adequate notice and appeal notices prior to recouping money from previously paid claims (Pennsylvania Chiropractic Association, et al. v. Blue Cross Blue Shield Association, et al., No. 09-5619, N.D. Ill; 2014 U.S. Dist. LEXIS 41749).
BOSTON - A Massachusetts federal judge on March 26 denied the plaintiffs' motion for summary judgment in a health care reimbursement suit and partially granted the defendant's motion, leaving only one count involving 11 disputed claims to continue (Spinal Imaging Inc. v. Aetna Health Management, et al.; Radiology Diagnostics v. Aetna Health Management, et al., Nos. 09-11873, 12-11521, D. Mass.; 2014 U.S. Dist. LEXIS 40099).