LexisNexis® Legal Newsroom
    New York Federal Judge Dismisses Copay Dispute For Lack Of Standing

    NEW YORK - A New York federal judge on April 19 dismissed a health care copayment dispute, finding that the plaintiff lacked standing to bring her claims (Marianne Gates v. United Healthcare Insurance Co., et al., No. 11-3487, S.D. N.Y.; 2013 U.S. Dist. LEXIS 56619).

    Texas Supreme Court: Providers Cannot Assert Pay Violation Against HMO

    AUSTIN, Texas - The Texas Supreme Court on April 19 held that health care providers could not assert a prompt-pay violation against a health maintenance organization because it had contracts only with the HMO's network and not the HMO (Christus Health Gulf Coast, et al. v. Aetna Inc., et al., No. 11-483, Texas Sup.; 2013 Tex. LEXIS 296).

    Mich. Appeals Court Affirms, Reverses Class Order In Reimbursement Suit

    DETROIT - A Michigan appeals panel on April 18 partially affirmed and partially reversed class certification in a suit alleging that a health insurer failed to properly reimburse chiropractors (Michigan Association of Chiropractors, et al. v. Blue Cross Blue Shield, No. 304763, Mich. App.; 2013 Mich. App. LEXIS 721).

    Michigan Appeals Court Modifies Class Definitions In Reimbursement Dispute

    DETROIT - A Michigan appeals panel on April 18 partially affirmed and partially reversed class certification of five classes in a suit alleging that a health insurer failed to properly reimburse chiropractors (Michigan Association of Chiropractors, et al. v. Blue Care Network of Michigan Inc., No. 304783, Mich. App.; 2013 Mich. App. LEXIS 724).

    Oklahoma Federal Judge Declines To Dismiss Prescription Drug Payment Suit

    OKLAHOMA CITY - An Oklahoma federal judge on April 18 denied a motion to dismiss a breach of contract claim related to the payment for prescription drugs, saying that the court had personal jurisdiction over the out-of-state defendants and that the plaintiff sufficiently supported its claims (Pharmacy Providers of Oklahoma Inc. v. Q Pharmacy Inc., et al., No. 12-1405, W.D. Okla.; 2013 U.S. Dist. LEXIS 55567).

    Pa. Federal Judge Grants Preliminary Injunction In Birth Control Mandate Case

    PITTSBURGH - A Pennsylvania federal judge on April 19 granted a motion for a preliminary injunction in a case brought by a private, nonprofit college, two for-profit entities and the owners of those entities who are challenging the "birth control" mandate contained in the Patient Protection and Affordable Care Act (PPACA) (Geneva College, et al. v. Kathleen Sebelius, et al., No. 12-207, W.D. Pa.; 2013 U.S. Dist. LEXIS 56087).

    Federal Judge Dismisses 4 Defendants In Payment Dispute; 7 Defendants Remain

    NEWARK, N.J. - A New Jersey federal judge on April 17 dismissed claims against four health care payers in a reimbursement dispute, saying that either the defendants were not subject to the Employee Retirement Income Security Act or were not proper parties; he left claims against seven other defendants, saying that the plaintiff exhausted administrative remedies before filing suit (Sportscare of America v. Multiplan Inc., et al., No. 10-4414, D. N.J.; 2013 U.S. Dist. LEXIS 54947).

    Va. Provider Must Repay Medicaid For Services By Unqualified Workers

    RICHMOND, Va. - The Virginia Court of Appeals on April 16 affirmed a trial court order granting summary judgment to the Virginia Department of Medical Assistance Services (DMAS) ordering the Family Redirection Institute Inc. (FRI) to reimburse the state Medicaid program for payments made to FRI for services by unqualified mental health care professionals (Family at Redirection Institute Inc. v. Commonwealth of Virginia Department of Medical Assistance Services, No. 1274-12-2, Va. App.; 2013 Va. App. LEXIS 116).

    Louisiana Federal Judge Affirms Denial Of Benefits, Says Plan Excluded Coverage

    LAFAYETTE, La. - A Louisiana federal judge on April 11 granted summary judgment in favor of a health insurance company in a wrongful denial of benefits case, agreeing with the insurer that the plan excluded coverage for bariatric surgery and complications arising from the surgery (Amy Macip v. Louisiana Service & Indemnity Co., No. 10-1678, W.D. La.; 2013 U.S. Dist. LEXIS 53342).

    High Court: Plan Terms Govern ERISA Reimbursement Action Based On Equitable Lien

    WASHINGTON, D.C. - The U.S. Supreme Court on April 16 ruled that a health plan administrator's claim for reimbursement against a plan participant under Employee Retirement Income Security Act Section 502(a)(3) based on an equitable lien by agreement is governed by the terms of the plan and is not subject to equitable limitations (U.S. Airways, Inc. v. James McCutchen, et al., No. 11-1285, U.S. Sup.).

    Illinois Federal Judge Dismisses Medicare Suit For Lack Of Jurisdiction

    CHICAGO - An Illinois federal judge on April 12 granted a defense motion to dismiss a Medicare dispute for lack of jurisdiction (Columbus Park Nursing and Rehabilitation Center v. Kathleen Sebelius, No. 10-4317, N.D. Ill.; 2013 U.S. Dist. LEXIS 52774).

    Wisconsin Federal Judge: Plaintiff Failed To Join Proper Party In Health Care Case

    GREEN BAY, Wis. - A Wisconsin federal judge on April 10 held that a plaintiff in a health care payment determination case failed to join the beneficiary as a necessary party to the action (VHC Inc. as trustee for SBV Health Plan v. University of Wisconsin Hospitals and Clinics, No. 13-92, E.D. Wis.; 2013 U.S. Dist. LEXIS 51635).

    Supreme Court Denies Certiorari; Provider Can Sue For Avandia-Related Expenses

    WASHINGTON, D.C. - The U.S. Supreme Court on April 15 denied a petition for writ of certiorari filed by GlaxoSmithKine PLC (GSK), leaving stand a decision allowing a Medicare Advantage provider to seek reimbursement from GSK under Medicare law for the costs of treating insurance customers who were injured by GSK's Avandia diabetes drug (GlaxoSmithKline, et al. v. Humana Medical Plans, et al., No. 12-690, U.S. Sup.).

    Plan Administrator Didn't Breach Fiduciary Duties In Mental Health Parity Case

    SEATTLE - A health plan administrator did not breach its fiduciary duties under the Employee Retirement Income Security Act by failing to modify its coverage certificates to reflect a court order that it provide mental health treatment because the administrator informed its members of the changes to its coverages of neurodevelopmental therapy mandated by the court's order, a federal judge in Washington ruled April 8 (Z.D., et al. v. Group Health Cooperative, et al., No. 2:11-cv-01119, W.D. Wash.; 2013 U.S. Dist. LEXIS 50402).

    Medicare Qui Tam Action Dismissed; Claims Barred By Public Disclosure

    NASHVILLE, Tenn. - A Tennessee federal judge on April 5 dismissed a qui tam action brought by a state resident who accused local medical clinics of offering illegal inducements to Medicare beneficiaries to secure patronage, saying that the relator obtained his information from public records (United States of America, ex rel. Marc Osheroff v. HealthSpring Inc., et al., No. 10-1015, M.D. Tenn.; 2013 U.S. Dist. LEXIS 49526).

    Oklahoma Federal Judge Remands Medicare Reimbursement Dispute

    OKLAHOMA CITY - An Oklahoma federal judge remanded to the U.S. Department of Health and Human Services a Medicare reimbursement case, finding that an appeals board erred in determining that a contractor administering the program established the reimbursement codes at issue (Oklahoma Procure Management v. Kathleen Sebelius, secretary of the United States department of Health and Human Services, No. 12-680, W.D. Okla.; 2013 U.S. Dist. LEXIS 48829).

    N.D. Supreme Court Affirms Medical Providers Not Liable For Lawsuit Expenses

    BISMARCK, N.D. - The North Dakota Supreme Court on April 4 affirmed summary judgment in favor of health care providers in a suit in which plaintiffs were seeking reimbursement for expenses and liabilities incurred in pursuing a federal court action to get health insurance companies to pay for medical services provided by the hospitals (Arthur M. Hayden, et al. v. Medcenter One Inc., et al., No. 20120337, N.D. Sup.; 2013 N.D. LEXIS 47).

    9th Circuit Affirms, Reverses Decision In Medicaid Payment Calculation Case

    SAN FRANCISCO - A Ninth Circuit U.S. Court of Appeals panel on April 4 affirmed in part and reversed in part the dismissal of two federally funded health care clinics' actions alleging that the California Department of Health Care Services incorrectly calculated payments for Medicaid-covered pharmacy services provided to "dual-eligible" Medicare beneficiaries who also receive Medicaid (North East Medical Services Inc., et al. v. State of California, et al., Nos. 11-16795, 11-16796, 9th Cir.; 2013 U.S. App. LEXIS 6808).

    Louisiana Federal Judge Grants Remand In Health Care Reimbursement Dispute

    LAFAYETTE, La. - A Louisiana federal judge on April 4 granted a motion to remand in a class action health care reimbursement case, saying that one of the defendants was not fraudulently joined and that the plaintiffs met an exception to the Class Action Fairness Act (CAFA) (Opelousas General Trust Authority v. Multiplan Inc., et al., No. 12-1830, W.D. La.; 2013 U.S. Dist. LEXIS 49824).

    New York Federal Judge Allows False Claims Suit To Proceed Against Americare

    BROOKLYN, N.Y. - A federal judge in the U.S. District Court for the Eastern District of New York on April 3 partially granted a motion to dismiss a federal and New York state False Claims Act (FCA) suit against Americare Inc. and partially denied the motion, saying that the plaintiff was able to sufficiently assert that the corporate defendants may have altered medical records to justify unnecessary home health services under Medicare (United States of America, ex rel. Patricia Mooney, v. Americare Inc., et al., No. 06cv1806, E.D. N.Y.; 2013 U.S. Dist. LEXIS 48398).

    Kentucky Federal Judge Allows Amendment To Add Defendant In Medicaid Waiver Case

    LEXINGTON, Ky. - A Kentucky federal judge on March 28 allowed plaintiffs to amend a complaint to add a defendant in a Medicaid waiver dispute (Appalachian Regional Healthcare, et al. v. Coventry Health and Life Insurance Co., et al., No. 12-114, E.D. Ky.; 2013 U.S. Dist. LEXIS 44394).

    Federal Appeals Court Grants Injunction Pending Appeal In Birth Control Suit

    WASHINGTON, D.C. - In reconsidering a previous decision, a District of Columbia Circuit U.S. Court of Appeals panel on March 29 granted a motion for injunction pending appeal in a case in which a secular, for-profit food company and the company owners are challenging the implementation of a mandate contained in the Patient Protection and Affordable Care Act (PPACA) aimed at providing free preventive services to women, including those for birth control (Francis A. Gilardi, et al. v. United States Department of Health and Human Services, et al., No. 13-5069, D.C. Cir.).

    Florida Federal Judge Dismisses Challenge To Birth Control Mandate

    FORT MYERS, Fla. - A Florida federal judge on March 29 denied a motion to dismiss a challenge to the birth control mandate contained in the Patient Protection and Affordable Care Act, saying that the plaintiff's claims were not ripe (Ave Maria University v. Kathleen Sebelius, et al., No. 12-88, M.D. Fla.; 2013 U.S. Dist. LEXIS 45685).

    Michigan Federal Judge Denies Temporary Injunction In Birth Control Suit

    DETROIT - A Michigan federal judge on March 22 denied an emergency motion for a temporary injunction brought by a natural foods company and its owner, who are seeking to halt the implementation of the "birth control mandate" contained in the Patient Protection and Affordable Care Act (PPACA) (Eden Foods Inc., et al. v. Kathleen Sebelius, et al., No. 13-11229, E. D. Mich.; 2013 U.S. Dist. LEXIS 40768).

    California Appeals Court Finds No Showing Of Unlawful Conduct In Premium Case

    LOS ANGELES - In an unpublished opinion, a California appeals panel on March 21 affirmed summary judgment in favor of a health insurer in a premium dispute case, saying there was no showing that the defendant engaged in any unlawful conduct (Richard Feder v. Blue Cross of California, No. B239534, Calif. App., 2nd Dist., Div. 8; 2013 Cal. App. Unpub. LEXIS 2076).