INDIANAPOLIS - Res judicata and U.S. Supreme Court precedent require judgment in favor of the federal government in a state's and school district's attack on the Patient Protection and Affordable Care Act (ACA) employer mandate, a federal judge in Indiana held Feb. 14 (Indiana, et al. v. Internal Revenue Service, et al., NO. 13-1612, S.D. Ind., 2018 U.S. Dist. LEXIS 24863).
SACRAMENTO, Calif. - Lawyers took deposition comments from a medical claims reviewer out of context to create trial and media leverage, Aetna Inc. says in a Feb. 14 response to an announcement that California would investigate the insurer's claims processing.
NEW YORK - A surgeon who was found guilty of one count of health care fraud, three counts of making false statements related to health care matters and two counts of money laundering was sentenced by a federal judge in New York on Feb. 7 to 196 months in prison and ordered to pay $7.2 million in restitution (United States of America v. Syed I. Ahmed, No. 17cr277, E.D. Mich.).
BOWLING GREEN, Ky. - A doctor pleaded guilty on Feb. 5 in Kentucky federal court to intentionally distributing and dispensing controlled substances outside the course of professional practice and submitting fraudulent bills to Medicare and Medicaid and agreed to serve eight years in prison (United States of America v. Charles F. Gott, No. 15cr13, W.D. Ky.).
TRENTON, N.J. - A medical provider has a valid assignment of Employee Retirement Income Security Act benefits, and it is too early in its litigation against an insurer to determine if its claims seek duplicative recovery, a federal judge in New Jersey held Feb. 2 (University Spine Center v. Anthem Blue Cross Life & Health Ins. Co., No. 17-8711, D. N.J., 2018 U.S. Dist. LEXIS 17537).
ATLANTA - A hospital's general references to Employee Retirement Income Security Act plans is not sufficiently specific to put a health care insurer on notice of the claims against it, and requiring at least a summary of the number of plans in question would not hamper judicial efficiency, a federal judge in Georgia held Jan. 30 in dismissing the case (Polk Medical Center Inc. v. Blue Cross and Blue Shield of Georgia Inc., et al., No. 17-3692, N.D. Ga., 2018 U.S. Dist. LEXIS 14461).
ATLANTA - An 11th Circuit U.S. Court of Appeals panel on Jan. 23 refused to vacate a couple's convictions and sentences for a $12 million insurance fraud scheme that involved their clinics overcharging Universal Health Care Insurance Co. for treatment of patients with HIV, finding that the judge did not err when admitting evidence and calculating the amount of loss sustained by the insurer (United States of America v. Gladys Fuertes, et al., No. 15-12928, 11th Cir., 2018 U.S. App. LEXIS 1900).
CHICAGO - A federal judge in Illinois did not err when sentencing a home health care office manager and billing specialist following their convictions for health care fraud and conspiracy to commit health care fraud, a Seventh Circuit U.S. Court of Appeals panel ruled Jan. 19, holding that the reasoning behind the sentences was correct (United States of America v. Rick E. Brown, et al., Nos. 15-3117, 15-3261, 7th Cir., 2017 U.S. App. LEXIS 1284).
BAY CITY, Mich. - A Michigan Indian tribe that won an $8.4 million award for Blue Cross Blue Shield's charging of hidden administrative fees for the tribe's employee benefit program had its request for attorney fees drastically reduced Jan. 17 by a federal judge, who slashed the fees by 75 percent because the tribe won only one of its four causes of action (Saginaw Chippewa Indian Tribe of Michigan, et al. v. Blue Cross Blue Shield of Michigan, No. 1:16-cv-10317, E.D. Mich., 2018 U.S. Dist. LEXIS 7005).
PHILADELPHIA - A federal judge in Pennsylvania on Jan. 12 denied a motion to remand filed by Aetna Inc. and Aetna Health Management LLC, finding that their attempt to provide service to a defendant doctor accused of conspiring to submit claims for an opioid-based pain medication for cancer patients was improper because the complaint was not sent to a location with a person who could accept service on his behalf (Aetna Inc., et al. v. Insys Therapeutics Inc., et al., No. 17-4812, E.D. Pa., 2018 U.S. Dist. LEXIS 6943).
PHILADELPHIA - Aetna Inc. and related entities (Aetna, collectively) have agreed to pay $17,161,200 to settle privacy claims by more than 13,400 class members whose HIV status was revealed by the insurer through an indiscreet mailing, according to a motion for preliminary approval of a class action settlement filed Jan. 16 (Andrew Beckett, et al. v. Aetna, Inc., et al., No. 17-3864, E.D. Pa.).
WASHINGTON, D.C. - Neither pregnancy counseling centers challenging a law requiring that they disclose the availability of abortion services nor the state of California advances the correct standard for analyzing the case, and the law at the heart the case partially fails when properly evaluated, the United States tells the U.S. Supreme Court in a Jan. 16 brief (NIFLA, et al. v. Xavier Becerra, et al., No. 16-1140, U.S. Sup.).
PHILADELPHIA - A Third Circuit U.S. Court of Appeals panel on Jan. 10 reversed a federal judge in New Jersey's ruling that allowed the Government Employees Insurance Co. (GEICO) to withhold payment on $2.1 million in pending personal injury protection (PIP) claims submitted by a neurology and rehabilitation facility, holding that under the New Jersey Automobile Insurance Cost Reduction Act, the dispute is subject to arbitration (Government Employees Insurance Co. v. Tri County Neurology & Rehab LLC, No. 17-2113, 3rd Cir., 2018 U.S. App. LEXIS 617).
NEW YORK - A New York federal judge on Jan. 5 dismissed Employee Retirement Income Security Act and Racketeer Influenced and Corrupt Organizations Act class claims against the largest pharmacy benefits manager (PBM) and a health insurance provider over prescription pricing, but gave the plaintiffs 21 days to file a third amended complaint (In re Express Scripts/Anthem ERISA Litigation, No. 16-3399, S.D. N.Y., 2018 U.S. Dist. LEXIS 3081).
SAN FRANCISCO - Insureds create standards for lactation support services the Patient Protection and Affordable Care Act (ACA) does not impose in an attempt to save their suit, an insurance group told a California federal judge on Jan. 5 in support of its motion for summary judgment (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 17-183, N.D. Calif.).
BOSTON - A gynecologist accused of wrongfully providing a pharmaceutical drug sales representative access to patients' confidential health information cannot have access to instructions provided to two grand juries, a federal magistrate judge in Massachusetts ruled Jan. 3, holding that the information could not support her claim for vindictive prosecution (United States of America v. Rita Luthra, No. 15-cr-30032, D. Mass., 2018 U.S. Dist. LEXIS 604).
SAN FRANCISCO - A religious order has sufficient interests in the outcome of a suit challenging rules broadening the exemptions to the Patient Protection and Affordable Care Act (ACA) contraceptive mandate to permit intervention into the case, a federal judge in California held Dec. 29 (California, et al. v. Don J. Wright, et al., No. 17-5783, N.D. Calif., 2017 U.S. Dist. LEXIS 213352).
DETROIT - A federal judge in Michigan on Dec. 21 granted State Farm Mutual Automobile Insurance Co.'s motion to reconsider and dismissed a health medical practices counterclaims for fraud, civil conspiracy and declaratory relief, finding that pursuant to the Michigan Supreme Court's ruling in Covenant Med. Ctr., Inc. v. State Farm Mut. Auto. Ins. Co., 500 Mich. 191, 895 N.W.2d 490, 505 (2017), State Farm is not required to pay claims for no-fault benefits submitted by health care providers (State Farm Mutual Automobile Insurance Company v. Universal Rehab Services Inc., et al., No. 15-10993, E.D. Mich., 2017 U.S. Dist. LEXIS 210318).
LOS ANGELES - A health insurer waived the right to deny coverage for vertebrate fusion surgery as experimental when it preauthorized the procedure, albeit with a different device, a federal judge in California held Dec. 12, entering judgment for the plaintiff on her Employee Retirement Income Security Act claims (Aubrey Cohorst v. Anthem Health Plans of Kentucky Inc., No. 16-7925, C.D. Calif., 2017 U.S. Dist. LEXIS 204362).
ST. LOUIS - The Eighth Circuit U.S. Court of Appeals on Dec. 6 reversed and remanded a district court's dismissal of a health care plan participant's claim seeking to recover premiums paid under the plan after determining that a restitutionary claim for premiums under the Employee Retirement Income Security Act may be available if there was a violation of the plan's terms (CeCelia Catherine Ibson v. United Healthcare Services Inc., No. 16-3260, 8th Cir., 2017 U.S. App. LEXIS 24608).
NEW YORK - A New York federal judge, in an order filed Dec. 1, declined preliminary approval of a class settlement worth up to $7,425,000 offered by Dave & Buster's Inc. to end claims that the nationwide restaurant/entertainment chain violated the Employee Retirement Income Security Act by reducing the hours of its work force in 2013 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) (Maria De Lourdes Parra Marin v. Dave & Buster's, Inc., et al., No. 15-3608, S.D. N.Y.).
CAMDEN, N.J. - A federal judge in New Jersey on Dec. 1 refused to dismiss a lawsuit brought by the Government Employees Insurance Co. (GEICO) over an alleged fraudulent billing scheme by doctors at two orthopedic firms, finding that the insurer's claims under the Racketeer Influenced and Corrupt Organizations Act and the New Jersey Insurance Fraud Prevention Act (IFPA) are not subject to arbitration (Government Employees Insurance Company v. Regional Orthopedic Professional Association, et al., No. 17-1615, D. N.J., 2017 U.S. Dist. LEXIS 197599).
NEW ORLEANS - A Fifth Circuit U.S. Court of Appeals panel on Nov. 30 overturned a federal judge in Texas' ruling ordering a physician's assistant found guilty of conspiracy to commit insurance fraud to pay $4 million in restitution and forfeiture, holding that the man should be required to reimburse the government only for the proceeds he obtained from the scheme (United States of America v. Mansour Sanjar, et al., No. 15-20025, 5th Cir., 2017 U.S. App. LEXIS 24252).
SACRAMENTO, Calif. - A California federal judge on Nov. 16 remanded an insured's claim seeking coverage for almost $500,000 incurred for the transport of her daughter from a hospital in Mexico to a hospital in Seattle by air ambulance because the plan administrator did not consider all of the available information before denying the claim on the basis that the air transport was not for an emergency (Aviation West Charters LLC, d/b/a Angel Medflight v. UnitedHealthcare Insurance Co., No. 16-436, E.D. Calif., 2017 U.S. Dist. LEXIS 190114).
NEW ORLEANS - A Fifth Circuit U.S. Court of Appeals panel on Nov. 7 upheld convictions of a man and his son who were accused of health care fraud and paying kickbacks to obtain business for their partial hospitalization programs (PHPs), ruling that evidence presented by the government was sufficient to support the jury's verdict (United States of America v. Earnest Gibson III, et al., No. 15-20323, 5th Cir., 2017 U.S. Dist. LEXIS 22261).