KANSAS CITY, Kan. - A participant in a nongovernmental health need not exhaust tribal remedies prior to bringing a claim for recovery of health benefits under the Employee Retirement Income Security Act, a federal judge in Kansas ruled March 13 (Amy Coppe v. The Sac & Fox Casino Healthcare Plan, et al., No. 14-2598, D. Kan.; 2015 U.S. Dist. LEXIS 30992).
ALAMEDA, Calif. - An Alameda County, Calif., Superior Court judge on March 16 heard opening arguments in a class suit brought by members accusing Kaiser Foundation Health Plan Inc. of violating California Health and Safety Code Section 1367.63 by denying all requests for surgery to remove excess skin following bariatric surgery without first having a physician review each request (Wendy Gallimore, et al. v. Kaiser Foundation Health Plan, Inc., et al., No. RG12616206, Calif. Super., Alameda Co.).
OKLAHOMA CITY - Judicial economy is not served by considering a class certification motion in a Patient Protection and Affordable Care Act (ACA) challenge while appeals are pending, a federal judge held March 13 (The Catholic Benefits Association LCA; The Catholic Insurance Co. v. Sylvia M. Burwell, et al., No. 14-240, W.D. Okla.).
NEW ORLEANS - An out-of-network medical provider that implemented a discount program has standing as an assignee to sue the administrator of plans regulated by the Employee Retirement Income Security Act for underpayment of benefits, the Fifth Circuit U.S. Court of Appeals ruled March 10 (North Cypress Medical Center Operating Company, et al. v. Cigna Healthcare, et al., No. 12-20695, 5th Cir.; 2015 U.S. App. LEXIS 3711).
WASHINGTON, D.C. - Nearly 11.7 million consumers found insurance through Patient Protection and Affordable Care Act (ACA) marketplaces for 2015, the U.S. Department of Health and Human Services said March 10.
HELENA, Mont. - Expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA) appears dead in Montana after a 59-41 vote by a Montana House committee on March 10.
CINCINNATI - A group's advertising indicating that a politician voted for federally funded abortions cannot be considered untrue in light of the debate surrounding whether the Patient Protection and Affordable Care Act (ACA) actually permits such procedures, the Sixth Circuit U.S. Court of Appeals held March 6 (Susan B. Anthony List v. Steven Driehaus, No. 13-3238, 6th Cir.).
DALLAS - The Employee Retirement Income Security Act does not preempt the Texas Prompt Payment Act's (TPPA) mandatory payment deadlines, insofar as the deadlines apply to third-party administrators of self-funded health insurance plans, a federal judge in Texas ruled March 4 (Aetna Life Insurance Company v. Methodist Hospitals of Dallas, No. 3:14-cv-347-M, N.D. Texas; 2015 U.S. Dist. LEXIS 26455).
WASHINGTON, D.C. - The U.S. Supreme Court on March 9 vacated a Seventh Circuit U.S. Court of Appeals opinion that denied the University of Notre Dame an injunction in its challenge to the Patient Protection and Affordable Care Act (ACA) accommodation process and remanded the case for consideration in light of Burwell v. Hobby Lobby Stores, Inc. (University of Notre Dame v. Sylvia Burwell, et al., No. 14-392, U.S. Sup.).
WASHINGTON, D.C. - Both sides faced critical questioning from Justice Anthony Kennedy during oral arguments March 4 in the case challenging the availability of subsidies in the Patient Protection and Affordable Care Act (ACA) federal exchange (David King, et al. v. Sylvia Mathew Burwell, et al., No. 14-114, U.S. Sup.).
FORT WAYNE, Ind. - An Indiana federal judge on March 2 granted summary judgment in favor of a nursing facility in its suit against another nursing facility for breach of contract for the defendant's failure to pay for the transfer of Medicaid certification rights that the defendant had sought so it could increase the number of comprehensive care beds it could obtain reimbursement for by Medicaid (Lutheran Homes Inc. v. Lock Realty Corporation IX, No. 14-102, N.D. Ind.; 2015 U.S. Dist. LEXIS 24588).
CHICAGO - A trial judge did not err in instructing a jury on both institutional and professional negligence in a suit alleging that the death of an elderly woman was the result of negligence on the part of a nursing home and its staff, the Illinois Appellate Court for the First Judicial District ruled Feb. 27 (William M. Groeller Jr. v. The Evergreen Health Care Center LLC, No. 1-14-0932, Ill. App., 1st Jud. Dist.)
BOSTON - A New York operator of skilled nursing facilities has entered into an agreement with the United States to pay $3.5 million to resolve allegations concerning inflated Medicare claims for rehabilitation therapy, according to a March 2 news release issued by the U.S. Attorney Carmen M. Ortiz for the District of Massachusetts.
DENVER - A federal judge in Colorado on Feb. 25 declined to dismiss a suit in which the plaintiff accused his health insurance company of breach of contract for allegedly wrongfully informing him that the effective date of his coverage was later than it really was, causing the plaintiff to receive treatment for pancreatic cancer later than necessary (Kent Wilson v. Humana Health Plan Inc., No. 14-3259, D. Colo.; 2015 U.S. Dist. LEXIS 22672).
WASHINGTON, D.C. - The House of Representatives' role as controller of the purse strings gives it sufficient injury to challenge the administration's alleged misallocation of public funds related to the Patient Protection and Affordable Care Act (ACA), Republicans told a federal judge in the District of Columbia on Feb. 27 (United States House of Representatives v. Sylvia Mathews Burwell, et al., No. 14-1967, D. D.C.).
NEWARK, N.J. - A federal judge in New Jersey on Feb. 27 dismissed a health care reimbursement suit, saying that the plaintiff failed to follow administrative procedures for the Medicaid-related claims and that federal law preempted the common-law claims related to the Medicare-based claims (MHS LLC, D/B/A Meadowlands Hospital Medical Center v. Healthfirst Inc., et al., No. 13-6036, D. N.J.; 2015 U.S. Dist. LEXIS 23699).
CHICAGO - A divided Illinois appeals court on Feb. 27 reversed and vacated the judgment of a trial court granting the plaintiff's motion for summary judgment and class certification in a health care subrogation dispute, saying the plaintiff had no right to rely on the common fund doctrine to support her claims (Nelli Stefanski v. The City of Chicago, No. 1-13-2844, Ill. App., 1st Dist. 6th Div.; 2015 Ill. App. LEXIS 133).
CHICAGO - A federal judge in Illinois on Feb. 26 denied a man's motion to dismiss his insurance company's lawsuit accusing him of violating the Illinois Insurance Fraud Statute and stayed the case for the company to assert a portion of its allegations as a counterclaim to a separate suit brought by the defendant accusing the company of violating the Employee Retirement Income Security Act (Concert Health Plan Insurance Company v. James E. Killian, No. 14 C 4697, N.D. Ill.; 2015 U.S. Dist. LEXIS 23195).
NEW YORK - The federal government provided sufficient evidence to a jury that a female doctor was only a paper owner of a New York medical clinic who made material misrepresentations to insurance companies as part of a conspiracy to commit health care fraud, a federal judge in New York ruled Feb. 26 in denying the defendant's motion for acquittal or new trial (United States of America v. Tatyana Gabinskaya, No. 12-cr-171 JPO, S.D. N.Y.; 2015 U.S. Dist. LEXIS 23343).
WASHINGTON, D.C. - The U.S. Supreme Court on Feb. 23 declined to review a Second Circuit U.S. Court of Appeals ruling that the Employee Retirement Income Security Act does not preempt a New York state anti-subrogation law that prohibits insurers from obtaining reimbursement of medical benefits from participants' tort settlements (The Rawlings Company, et al. v. Megan Wurtz, et al., No. 14-487, U.S. Sup.).
WASHINGTON, D.C. - The U.S. Supreme Court on Feb. 23 let stand a Third Circuit U.S. Court of Appeals ruling that a multiemployer welfare benefits plan may seek reimbursement of health benefits paid on behalf of a plan participant who later received a third-party settlement because the plan language established an equitable lien by agreement (Bernard McLaughlin v. Board of Trustees of the National Elevator Industry Health Benefit Plan, No. 14-626, U.S. Sup.).
WASHINGTON, D.C. - The U.S. Supreme Court on Feb. 23 denied certiorari, leaving stand a Third Circuit U.S. Court of Appeals decision holding that the Medicare as a Secondary Payer Act (MSP Act) authorizes the government to seek reimbursement from a settlement a plaintiff receives from a tortfeasor because the funds came from a "primary plan" and that the plaintiff cannot invoke a New Jersey state law to avoid her reimbursement obligations (Cecelia A. Taransky v. Secretary of the U.S. Department of Health and Human Services, et al., No. 14-758, U.S. Sup.).
WASHINGTON, D.C. - The U.S. Supreme Court on Feb. 23 declined to grant certiorari, which left standing an agreement reached in In re Managed Care Litigation that bars several physicians and physician groups from bringing claims against WellPoint Inc. in In re WellPoint, Inc. Out-of-Network "UCR" Rates Litigation under the Racketeer Influenced and Corrupt Organizations Act and the Sherman Act but not from bringing certain claims under the Employee Retirement Income Security Act (Medical Association of Georgia, et al. v. Wellpoint Inc., No. 14-554, U.S. Sup.).
DENVER - A Colorado federal judge on Feb. 20 declined to dismiss antitrust claims in a suit alleging that health insurers conspired with hospitals to drive multiple ambulatory surgical centers out of business (Arapahoe Surgery Center, et al. v. CIGNA Healthcare Inc., et al., No. 13-3422, D. Colo.; 2015 U.S. Dist. LEXIS 20488).
MIAMI - A federal magistrate judge in Florida on Feb. 17 recommended accepting a home health care clinic owner's guilty plea in a $13 million Medicare fraud scheme, finding that the defendant was capable and competent in entering an informed plea (United States of America v. Alexander Lara, No. 15-cr-20029-KMM, S.D. Fla.).