NEW ORLEANS - A plan management agreement between Humana Health Plan and a health plan's administrator, which provided that Humana would supply subrogation and recovery services, did not vest Humana with discretionary authority sufficient to make Humana a fiduciary with standing to bring claims under the Employee Retirement Income Security Act, the Fifth Circuit U.S. Court of Appeals ruled 2-1 on May 11 (Humana Health Plan, Inc. v. Patrick Nguyen, No. 14-20358, 5th Cir.; 2015 U.S. App. LEXIS 7741).
ATLANTA - A federal district court judge did not err in dismissing a securities class action lawsuit because, despite having numerous opportunities to amend their complaint, the lead plaintiffs still failed to properly plead loss causation, a divided 11th Circuit U.S. Court of Appeals panel ruled May 11 (Miklen Sapssov, et al. v. Health Management Associates Inc., et al., No. 14-12838, 11th Cir.; 2015 U.S. App. LEXIS 7731).
NEW YORK - A federal judge in New York on May 12 sentenced a man who pleaded guilty to two counts of health care fraud for his role in a scheme involving the sale of secondhand prescription drugs to 48 months in prison and ordered him to pay $2.9 million in restitution (United States of America v. Bladimir Rigo, No. 13 cr. 897, S.D. N.Y.; 2015 U.S. Dist. LEXIS 62239).
NEW YORK - Nationwide restaurant/entertainment chain Dave & Buster's Inc. violated the Employee Retirement Income Security Act by reducing the hours of its work force in 2013 in order 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), an employee alleges in a class action complaint filed May 8 in federal court in New York (Maria De Lourdes Parra Marin v. Dave & Buster's, Inc., et al., No. 15 CV 3608, S.D. N.Y.).
RICHMOND, Va. - A federal judge in Virginia erred when granting three pretrial motions to exclude evidence filed by a dermatologist accused of health care fraud, a Fourth Circuit U.S. Court of Appeals panel ruled May 11, holding that the rulings restricted the latitude needed by the government to carry its burden of proof (United States of America v. Amir A. Bajoghli, No. 14-4798, 4th Cir.; 2015 U.S. App. LEXIS 7737).
PHILADELPHIA - The Third Circuit U.S. Court of Appeals ruled May 8 that the "catalyst theory" of recovery of attorney fees is available under the Employee Retirement Income Security Act and that judicial action is not required under that theory in order to establish some degree of success on the merits (Christopher Templin, et al. v. Independence Blue Cross, et al., No. 13-4493, 3rd Cir.; 2015 U.S. App. LEXIS 7624).
SAN DIEGO - The U.S. Department of Justice announced May 5 that five California-based ambulance companies have agreed to collectively pay more than $11.5 million to resolve allegations from the federal government and a whistle-blower that they paid illegal kickbacks to hospitals and skilled nursing facilities in exchange for the exclusive rights to Medicare patients (Kelvin Carlisle v. Pacific Ambulance, et al., No. 09-cv-02628, S.D. Calif.).
INDIANAPOLIS - Indiana's high court on April 22 reversed a lower court and found that certain alleged wrongful acts by a self-insured managed health organization are covered under a number of reinsurance agreements (WellPoint, Inc. [f/k/a Anthem, Inc.], et al. v. National Union Fire Insurance Company of Pittsburgh PA, et al., No. 49S05-1404-PL-244, Ind. Sup.; 2015 Ind. LEXIS 316).
WASHINGTON, D.C. - The U.S. Supreme Court on April 27 granted two Catholic groups' petition for certiorari and vacated a Sixth Circuit U.S. Court of Appeals ruling that the Patient Protection and Affordable Care Act's contraceptive mandate did not substantially burden religious beliefs. The court remanded the case for further consideration in light of Burwell v. Hobby Lobby Stores Inc. (573 U.S. __ ) (Michigan Catholic Conference, et al. v. Burwell, Sec. of H&HS, et al., No 14-701, U.S. Sup.).
WASHINGTON, D.C. - The U.S. Department of Justice (DOJ) announced April 21 that Citizens Medical Center, a county-owned hospital in Texas, agreed to pay $21.7 million to resolve allegations that it violated the False Claims Act (FCA) by overcompensating cardiologists for their services and paid bonuses to emergency room employees who improperly took into account the value of their cardiology referrals.
ST. LOUIS - The U.S. Attorney's Office for the Eastern District of Missouri on April 17 announced that a federal judge in Missouri sentenced a podiatrist to 12 months and one day in prison for his role in submitting false documents and reimbursement claims to Medicare.
CHICAGO - The U.S. Attorney's Office for the Northern District of Illinois announced that a federal judge in Illinois on April 17 sentenced the owner of two home health care companies who pleaded guilty to submitting more than $20 million in fraudulent bills to Medicare to 10 years in prison and ordered him to pay $23.3 million in restitution (United States of America v. Jacinto "John" Gabriel Jr., No. 11-cr-00054, N.D. Ill.).
TYLER, Texas - A federal judge in Texas on April 14 sentenced a doctor found guilty of conspiracy to commit health care fraud, seven counts of health care fraud and seven counts of aggravated identity theft to 135 months in prison and ordered him to pay $599,128.02 in restitution (United States of America v. Tariq Mahmood, No. 13-cr-00032, E.D. Texas).
WASHINGTON, D.C. - Two cardiovascular disease testing companies agreed to pay a combined $48.5 million to resolve claims brought by three whistle-blowers that the companies paid physicians illegal kickbacks and billed Medicare for unnecessary medical testing for patients, the U.S. Department of Justice announced April 9.
HELENA, Mont. - Montana Legislature on April 9 appeared to ready to enact legislation expanding Medicaid under the Patient Protection and Affordable Care Act (ACA) after a newly introduced bill survived four failed motions for a second reading and two motions to re-refer the legislation to the House Appropriations.
JEFFERSON CITY, Mo. - A judge properly enjoined portions of a Missouri law governing the conduct of advisers employed to help people navigate the Patient Protection and Affordable Care Act (ACA) exchange, an Eighth Circuit U.S. Court of Appeals panel held April 10 in partially affirming (St. Louis Effort for Aids, et al. v. John Huff, director of the Missouri Department of Insurance, Financial Institutions and Professional Registration, No. 14-1520, 8th Cir.).
SAN DIEGO - One of the owners of an alleged Medicare billing mill in El Centro, Calif., was sentenced by a federal judge in California on April 6 to 30 months in prison and ordered to pay $964,011 in restitution (United States of America v. Gevorg "George" Kupelian, No. 14-cr-3419-BAS, S.D. Calif.).
SAN FRANCISCO - A federal judge in California on April 7 denied United Behavioral Health's (UBH) motion to dismiss a putative class action alleging that the insurer denied claims for mental illness and substance abuse-related outpatient treatment in violation of the Employee Retirement Income Security Act (Gary Alexander, et al. v. United Behavioral Health, No. 14-cv-05337, N.D. Calif.; 2015 U.S. Dist. LEXIS 46046).
SAN LUIS OBISPO, Calif. - A resident of a California care facility for the elderly filed a class complaint against the owners and operators on April 6 in California state court, alleging negligent business practices and staffing assignments based on the number of residents rather than the needs of the residents (Doreen Trombley, et al. v. Westpac Investments, Inc., et al., No. 15CV7010, Calif. Super., San Luis Obispo Co.).
WASHINGTON, D.C. - The Medicare statute precludes a hospital's challenge to reimbursement calculations made under the amended rules of the Patient Protection and Affordable Care Act (ACA), a federal judge in the District of Columbia held March 31 (Florida Health Sciences Center Inc., d/b/a Tampa General Hospital v. Secretary U.S. Department of Health and Human Services, No. 14-0791, D. D.C.; 2015 U.S. Dist. LEXIS 42650).
WASHINGTON, D.C. - A federal judge should ignore "alarmist" rhetoric and instead find that House of Representatives members lack standing to challenge how the government spends Patient Protection and Affordable Care Act (ACA) funds, the government argues in a March 31 brief (United States House of Representatives v. Sylvia Mathews Burwell, et al., No. 14-1967, D. D.C.).
WASHINGTON, D.C. - The Supreme Court on March 30 declined a challenge to the Patient Protection and Affordable Care Act (ACA) alleging that the individual mandate impermissibly required disclosure of confidential personal information (Nick Coons, et al. v. Jacob L. Lew, et al., No. 14-525, U.S. Sup.).
TAMPA, Fla. - A jury in the U.S. District Court for the Middle District of Florida on March 25 found a couple guilty of operating a sham clinic for the purpose of committing health care fraud (United States of America v. Mario Fuertes, et al., No. 14-cr-00092, M.D. Fla.).
WASHINGTON, D.C. - An elected official cannot demonstrate injury from the Patient Protection and Affordable Care Act (ACA)'s transitional policy allowing states to decide whether to impose minimum insurance requirements, and his establishment clause claims would not remedy any alleged injury, the government told the District of Columbia Circuit U.S. Court of Appeals on March 20 (Jeffrey Cutler v. United States Department of Health and Human Services, et al., No. 14-5183, D.C. Cir.).
CHEYENNE, Wyo. - An Indian tribe waived its objections to the Patient Protection and Affordable Care Act (ACA)'s large employer mandate by not raising them during the rulemaking process, and its action runs afoul of the Anti-Injunction Act's (AIA) bar on tax challenges taxes, the government told a federal judge on March 19 (Northern Arapaho Tribe, et al. v. Sylvia Burwell, et al., No. 14-247, D. Wyo.; 2015 U.S. Dist. LEXIS 30480).