WASHINGTON, D.C. - The Patient Protection and Affordable Care Act (ACA)'s structure suggests the availability of tax subsidies in the federal exchange, and Congress could not have intended the state insurance market "death spirals" likely to result from barring such subsidies, a divided U.S. Supreme Court held June 25 (David King, et al. v. Sylvia Mathew Burwell, et al., No. 14-114, U.S. Sup.).
WASHINGTON, D.C. - The U.S. Department of Justice announced June 16 that a Florida-based skilled nursing facility, its former president and executive director and its subsidiaries have agreed to pay $17 million to resolve allegations that it violated the False Claims Act (FCA) and Anti-Kickback Statute by improperly paying doctors for their referrals of Medicare patients to the defendants' facilities (United States of America, ex. rel. Stephen M. Beaujon v. Hebrew Homes Health Network Inc., et al., No. 12-cv-20951, S.D. Fla.).
WASHINGTON, D.C. - The U.S. Department of Justice on June 15 announced that Children's National Medical Center Inc., Children's Hospital and its affiliated entities (collectively CNMC) agreed to pay $12.9 million to resolve allegations in a False Claims Act (FCA) lawsuit that they submitted false cost reports to the U.S. Department of Health and Human Services (HHS) and Medicare programs in the District of Columbia and Virginia (United States of America, ex rel. James A. Roark Sr. v. Children's Hospital, et al., No. 14-cv-616, D. D.C.).
JACKSONVILLE, Fla. - The federal government filed an intervener complaint in Florida federal court on June 12 in a False Claims Act (FCA) and Anti-Kickback Statute lawsuit brought against an ambulance service company accused of engaging in a 10-year scheme in which it fraudulently billed Medicare for services that were medically unnecessary (United States of America v. Liberty Ambulance Services Inc., No. 15-cv-, M.D. Fla.).
BOSTON - A First Circuit U.S. Court of Appeals panel on June 10 affirmed the conviction and sentencing of man found guilty for his role in a scheme of fraudulently billing Medicare for durable medical equipment (DME), finding that the judge presiding over the case did not err in any of his evidentiary rulings and used the proper guidelines when determining his sentence (United States of America v. Blessing Sydney Iwuala, No. 13-2497, 1st Cir.; 2015 U.S. App. LEXIS 9685).
WASHINGTON, D.C. - The U.S. Supreme Court on June 8 denied the State of Maine's petition challenging mandatory continued Medicaid coverage for older children under the Patient Protection and Affordable Care Act's maintenance of effort requirements, according to the docket (Mary C. Mayhew, in her capacity as Secretary of the Maine Department of Health and Human Services v. Sylvia M. Burwell, et al., No. 14-992, U.S. Sup.).
WASHINGTON, D.C. - The U.S. Supreme Court on May 26 declined to review the Eighth Circuit U.S. Court of Appeals ruling that a shareholder-owner's state law claims related to improper cancellation of her health care coverage were preempted by the Employee Retirement Income Security Act (CeCelia Catherine Ibson v. United Healthcare Services, Inc., No. 14-1119, U.S. Sup.).
MEMPHIS, Tenn. - A Tennessee federal judge on May 18 declined to strike or exclude testimony of three experts for a couple alleging medical malpractice in the death of their 11-year-old son but ruled that testimony by a fourth expert for the plaintiffs should be excluded from trial based on state law geographic requirements and the relevancy of the testimony (Thomas G. Hensley, et al. v. Methodist Healthcare Memphis Hospitals, et al., No. 2:13-cv-02436, W.D. Tenn.; 2015 U.S. Dist. LEXIS 64518).
CHICAGO - Notre Dame is not entitled to a preliminary injunction while it challenges the opt-out provision of the Patient Protection and Affordable Care Act (ACA)'s contraceptive mandate, a divided Seventh Circuit U.S. Court of Appeals held May 19 (University of Notre Dame v. Kathleen Sebelius, et al., No. 13-3853, 7th Cir.).
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.).