WASHINGTON, D.C. - Cost remains a barrier to obtaining medical insurance, with nearly one-third of uninsured but Patient Protection and Affordable Care Act (ACA)-eligible adults citing it as the reason they remain uninsured, according to a Henry J. Kaiser Family Foundation report issued Jan. 29.
DETROIT - A federal judge in Michigan on Jan. 27 denied a defendant's motion for acquittal and new trial, ruling that the government presented sufficient evidence to support the jury's finding that the man conspired to commit health care fraud (United States of America v. Vinod Patel, No. 11-20468-36, E.D. Mich.; 2015 U.S. Dist. LEXIS 8952).
SAN JOSE, Calif. - A federal judge in California on Jan. 26 remanded to state court a hospital's lawsuit seeking reimbursement for charges for treatment of a participant in a health plan governed by the Employee Retirement Income Security Act, holding that the hospital's state unfair competition law claims were not completely preempted by ERISA (Community Hospital of the Monterey Peninsula v. Blue Cross of California, et al., No. 14-CV-04552, N.D. Calif.; 2015 U.S. Dist. LEXIS 9248).
AKRON, Ohio - An Ohio federal judge on Jan. 26 dismissed a Medicare reimbursement dispute, finding that the plaintiffs failed to exhaust administrative remedies as required under the Medicare Act (Ohio State Chiropractic Association, et al. v. Humana Health Plan Inc., No. 14-2313, N.D. Ohio; 2015 U.S. Dist. LEXIS 8764).
NASHVILLE, Tenn. - A Tennessee federal judge on Jan. 23 dismissed a Medicare False Claims Act case, saying the plaintiff failed to plead the claims with the specificity required (Kathleen McFeeters v. Northwest Hospital, et al., No. 13-467, M.D. Tenn.; 2015 U.S. Dist. LEXIS 8523).
WASHINGTON, D.C. - The House of Representatives lacks standing to challenge implementation of the Patient Protection and Affordable Care Act (ACA)'s employer mandate in court, the U.S. Department of Health and Human Services (HHS) told a federal judge in the District of Columbia on Jan. 26 (United States House of Representatives v. Sylvia Mathews Burwell, et al., No. 14-1967, D. D.C.).
NEW YORK - A federal judge erred by finding that a health care provider settled its claims under the Employee Retirement Income Security Act for services rendered with a self-funded employee benefit plan based on the plan's "one-sided representation," the Second Circuit U.S. Court of Appeals ruled Jan. 21 in an unpublished order (Montefiore Medical Center v. Teamsters Local 272, et al., No. 13-4221-cv, 2nd Cir.; 2015 U.S. App. LEXIS 844).
NEW YORK - The Second Circuit U.S. Court of Appeals on Jan. 22 reversed the dismissal of a due process claim in a class action Medicare payment dispute, saying the lower court erred in concluding that the plaintiffs lacked a property interest in being treated as "inpatients." The court affirmed the dismissal of a claim brought under the Medicare Act (Lee Barrows, et al. v. Sylvia Matthews Burwell, secretary of Health and Human Services, No. 13-4179, 2nd Cir.; 2015 U.S. App. LEXIS 986).
WEST DES MOINES, Iowa - The Iowa insurance commissioner will liquidate CoOportunity Health Inc., a consumer-owned health insurance company started with $146 million in Patient Protection and Affordable Care Act (ACA) funds, it announced Jan. 23 (State of Iowa, et al. v. CoOpportunity Health Inc., No. N/A, Iowa Dist., Polk Co.).
WASHINGTON, D.C. - The U.S. Supreme Court on Jan. 26 denied a petition from the State of Oklahoma seeking a writ of certiorari before judgment in its challenge to the availability of subsidies in Patient Protection and Affordable Care Act (ACA) insurance exchanges (State of Oklahoma, ex rel. Scott Pruitt v. Sylvia Mathews Burwell, et al., No. 14-586, U.S. Sup.).
BOSTON - The presence of a few uninjured members in a class does not prevent certification, the First Circuit U.S. Court of Appeals ruled Jan. 21, affirming the certification of the class of indirect purchasers of Nexium in a pay-for-delay lawsuit over the heartburn drug (In re Nexium Antitrust Litigation, Astrazeneca AB, et al. v. United Food and Commercial Workers Unions and Employers Midwest Health Benefits Fund, et al., Nos. 14-1521 & 14-1522, 1st Cir.; 2015 U.S. App. LEXIS 968).
PRESCOTT, Ariz. - An Arizona federal judge on Jan. 16 dismissed a self-funded employee welfare benefit plan's subrogation lawsuit against the estate of a plan participant regarding settlement proceeds in an underlying wrongful death action because the participant's children did not incur health care expenses for which another party is responsible (MedCath Incorporated Employee Health Care Plan v. Dustin Stratton, et al., No. 14-08099, D. Ariz.; 2015 U.S. Dist. LEXIS 5514).
DETROIT - A doctor was sentenced to 15 months in prison and ordered to pay $1.3 million in restitution by a federal judge in Michigan on Jan. 14 for her role in a $2.1 million home health care fraud scheme, the U.S. Department of Justice announced (United States of America v. Paula Williamson, No. 13-cr-20347, E.D. Mich.).
HARTFORD, Conn. - An osteopathic physician on Jan. 16 pleaded guilty in Connecticut federal court to one count of committing health care fraud and agreed to pay the government $270,528 to resolve federal civil claims arising from his conduct (United States of America v. David Lester Johnston, No. 14-cr-00047, D. Conn.).
BALTIMORE - A pharmacy employee was sentenced by a federal judge in Maryland on Jan. 15 to 13 months in prison and ordered to pay $102,066.25 in restitution for his role in a scheme to defraud Medicare, Medicaid and the Federal Employees Health Benefits Program by submitting false prescriptions for refills, the U.S. Attorney's Office for the District of Maryland announced (United States of America v. Jigar Patel, No. 13-cr-00374, D. Md.).
PORTLAND, Ore. - Allegations by Oracle America Inc. that the State of Oregon infringed its copyrighted software were rejected Jan. 13 by an Oregon federal judge, on the basis of sovereign immunity (Oracle America Inc. v. The Oregon Health Insurance Exchange Corporation, et al., No. 14-1279, D. Ore.; 2015 U.S. Dist. LEXIS 3484.).
HOUSTON - Two physician owners of a mental health clinic were sentenced to 148 months and 120 months, respectively, in prison for their roles in a $97 million Medicare fraud scheme, according to docket entries entered Jan. 12 in Texas federal court (United States of America v. Mansour Sanjar, et al., No. 11-cr-00861, S.D. Texas).
TAMPA, Fla. - A Florida federal judge on Jan. 12 partially dismissed a complaint alleging that a health insurance company wrongfully declined to reimburse two health care providers for services, dismissing a fraud claim and granting the plaintiff leave to amend the complaint to assert claims under the Employee Retirement Income Security Act, but otherwise denied the motion (Tran Chiropractic Wellness Center Inc., et al. v. Aetna Inc., et al., No. 14-47, M.D. Fla.; 2015 U.S. Dist. LEXIS 3124).
WASHINGTON, D.C. - A home-care association with at least one member denied reimbursement from Medicare has standing to challenge Patient Protection and Affordable Care Act (ACA) rules and need not exhaust administrative remedies first given the unlikelihood of success, a District of Columbia federal judge held Jan. 6 (National Association for Home Care & Hospice Inc. v. Sylvia Mathews Burwell, secretary, U.S. Department of Health and Human Services, et al., No. 14-950, D. D.C.; 2015 U.S. Dist. LEXIS 477).
CARSON CITY, Nev. - Members of a health maintenance organization who seek medical monitoring for potential exposure to blood-borne diseases may maintain negligence claims against the HMO, the Nevada Supreme Court ruled Dec. 31, finding in a case of first impression under Nevada law that "a plaintiff may state a cause of action for negligence with medical monitoring as the remedy without asserting that he or she has suffered a present physical injury" (Susan Sadler, et al. v. PacifiCare of Nevada Inc., No. 62111, Nev. Sup.; 2014 Nev. LEXIS 133).
PHILADELPHIA - A panel of the Third Circuit U.S. Court of Appeals on Dec. 31 affirmed the sentence given to a radiologist who pleaded guilty to illegally paying physicians to refer their patients to his facility so he could obtain more reimbursement from Medicare and Medicaid (United States of America v. Ashokkumar Babaria, No. 14-2694, 3rd Cir.; 2014 U.S. App. LEXIS 24656).
BATON ROUGE, La. - In a Dec. 29 unpublished opinion, a Louisiana appeals court reversed a summary judgment opinion granting a permanent injunction to halt the termination of a health care clinic's Medicaid provider agreement, saying the plaintiff failed to meet its required prima facie showing of irreparable harm (Midtown Medical v. The Department of Health & Hospitals, et al., Nos. 2014 CA 0530 c/w 2014 CA 0531 c/w 2014 CA 0532, La. App., 1st Cir.; 2014 La. App. Unpub. LEXIS 792).
WASHINGTON, D.C. - A federal judge in the District of Columbia on Dec. 29 granted a preliminary injunction to enjoin the U.S. Department of Health and Human Services (HHS) from recouping any federal disproportionate-share hospital (DSH) funds provided to two pediatric teaching and research hospitals based on a state's noncompliance with a new Medicaid funding rule (Texas Children's Hospital, et al. v. Sylvia Burwell, secretary, United States Department of Health and Human Services, et al., No. 14-2060, D. D.C.; 2014 U.S. Dist. LEXIS 177644).
RICHMOND, Va. - A Fourth Circuit U.S. Court of Appeals panel on Dec. 19 upheld a jury's verdict finding a dermatologist guilty of 13 counts of health care fraud and affirmed a judge's sentencing of the defendant, holding that the evidence presented during the trial supported the jury's decision (United States of America v. Allen G. Saoud, No. 14-4288, 4th Cir.; 2014 U.S. App. LEXIS 24002).
SALT LAKE CITY - The government's loss of computer data from a women's health care clinic operated by a woman accused of defrauding Medicare by coaching illegal aliens to apply for benefits under the Baby Your Baby (BYB) program warrants the dismissal of her indictment, a federal judge in Utah ruled Dec. 12, ruling that the loss of the information prevents the defendant from defending herself (United States of America v. Larohnda Dennison, No. 13CR805DAK, D. Utah; 2014 U.S. Dist. LEXIS 173303).