LexisNexis® Legal Newsroom
    Mealey's Health Law - Pennsylvania Federal Judge: ERISA Controls Breach Of Contract, Fiduciary Duty Claims

    PHILADELPHIA - A Pennsylvania federal judge in an opinion filed Nov. 18 denied a plaintiff's motion to remand a case alleging improper denial of claims under an Employee Retirement Income Security Act-qualified health plan to state court, saying that claims for breach of contract and breach of fiduciary duty are properly brought under ERISA (Eric A. Shore P.C. v. Independence Blue Cross, et al., No. 16-5224, E.D. Pa.; 2016 U.S. Dist. LEXIS 160022).

    Mealey's Health Law - Former Pharmacy Owner Convicted For Role In $700,000 Medicare Fraud Scheme

    MIAMI - A former pharmacy owner was convicted by a federal jury in Florida on Nov. 16 of three counts of health care fraud for his role in a scheme in which he fraudulently billed Medicare $700,000 for prescription drugs that were never dispensed (United States of America v. Andres Alfonso, No. 16-cr-20567, S.D. Fla.).

    Mealey's Health Law - Home Health Agency Owner Convicted For Role In $13M Medicare Fraud Scheme

    HOUSTON - A federal jury in Texas on Nov. 10 convicted the co-owner of a home health agency for her role in a $13 million Medicare fraud scheme that operated from February 2006 to June 2015 (United States of America v. Ebong Tilong, et al., No. 15-cr-591, S.D. Texas).

    Mealey's Health Law - DOJ: Co-Owner Of Home Health Care Agency Sentenced To 96 Months In Prison

    ANN ARBOR, Mich. - The U.S. Department of Justice (DOJ) announced Nov. 7 that the co-owner of a Detroit-area home health care agency has been sentenced by a federal judge in Michigan to 96 months in prison and ordered to pay $38 million in restitution after being found guilty for his role in a $33 million Medicare fraud scheme (United States of America v. Zafar Mehmood, et al., No. 12-cr-20042, E.D. Mich.).

    Mealey's Health Law - Class Claims Insurer Misrepresents Quality Of Replacement Plans

    LOS ANGELES - Anthem Blue Cross promises Patient Protection and Affordable Care Act (ACA) exchange customers re-enrollment in a similar plans when cancellations occur, while in reality providing far inferior plans with no out-of-network coverage, according to a class action lawsuit filed Oct. 31 in California court, alleging violation of the state unfair competition law (UCL) (Paul Simon, et al. v. Blue Cross of California, d/b/a Anthem Blue Cross; and DOES 1-100, inclusive, No. BC639205, Calif. Super., Los Angeles Co.).

    Mealey's Health Law - High Court Won't Review Reversal Of Benefits Ruling For Moen Inc. Retirees

    WASHINGTON, D.C. - The U.S. Supreme Court on Oct. 31 denied a petition for writ of certiorari asking it to review a divided Sixth Circuit U.S. Court of Appeals panel decision that reversed a district court's ruling in favor of a class of retirees from Moen Inc. who argued that their collective bargaining agreements guaranteed them health care benefits for life (John L. Gallo, et al. v. Moen Incorporated, No. 16-222, U.S. Sup.).

    Mealey's Health Law - Federal Judge: Tribe's ERISA Claim Over 'Hidden' Plan Fees Can Proceed

    BAY CITY, Mich. - A Michigan federal judge on Oct. 27 stood by his dismissal of an Indian tribe's claim that its health care plan administrator breached its fiduciary duty under the Employee Retirement Income Security Act by failing to pay Medicare-like rates (MLRs) for certain health services but agreed with the parties that the tribe can still proceed with an ERISA claim based on the allegation that the administrator had a practice of hiding certain access fees (Saginaw Chippewa Indian Tribe of Michigan, et al. v. Blue Cross Blue Shield of Michigan, No. 16-cv-10317, E.D. Mich.; 2016 U.S. Dist. LEXIS 148615).

    Mealey's Health Law - 5th Circuit Panel Upholds 97-Month Sentence For Health Care Fraud

    NEW ORLEANS - A federal judge in Texas did not err when sentencing the "prime mover" of a Medicare fraud scheme to 97 months in prison by applying the 2009 U.S. Sentencing Guidelines Manual, a Fifth Circuit U.S. Court of Appeals panel ruled Oct. 26, holding that one of the charges against the defendant involved conduct that occurred after the guidelines amended the term "victim" to include a person whose identity was unlawfully used (United States of America v. Edgar Shakbazyan, No. 15-20426, 5th Cir.).

    Mealey's Health Law - Texas Federal Judge Lets ERISA Claim Stand In Action Against Employer

    DALLAS - A Texas federal judge on Oct. 24 partially denied a motion to dismiss for failure to state a claim in an action in which a man says he was illegally fired by his employer so it could stop paying for his medical expenses under its medical insurance plan, finding that he has sufficiently alleged facts that would support a claim under Employee Retirement Income Security Act Section 510 (Steve Wesley Culver, et al. v. United Commerce Centers Inc., et al., No. 3:16-cv-01055, N.D. Texas; 2016 U.S. Dist. LEXIS 146939).

    Mealey's Health Law - 7th Circuit Panel Finds Suit Against Insurers Not Allowed By Section 502(a)(3)

    CHICAGO - Joining its sister circuits, a Seventh Circuit U.S. Court of Appeals panel on Oct. 24 held that a health plan trustee's suit against insurers to recoup amounts it paid for the beneficiaries' medical care seeks legal relief, not equitable relief, and as such is not authorized by Employee Retirement Income Security Act Section 502(a)(3) (Central States, Southeast and Southwest Areas Health and Welfare Fund, et al. v. American International Group Inc., et al., No. 15-2237, 7th Cir.; 2016 U.S. App. LEXIS 19165).

    Mealey's Health Law - DOJ: Skilled Nursing Company, Owner, To Pay $145M To Settle Billing Suit

    WASHINGTON, D.C. - The U.S. Department of Justice (DOJ) announced Oct. 24 that a skilled nursing facility and its 83-year-old owner have agreed to pay $145 million to resolve allegations that they submitted fraudulent bills to Medicare and TRICARE, which provides health benefits for U.S. Armed Forces personnel (United States of America v. Life Care Centers of America Inc., et al., No. 16-113, E.D Tenn.).

    Mealey's Health Law - Skilled Nursing Facility, Director To Pay $2.5M Over Inflated Medicare Claims

    BOSTON - The U.S. Department of Justice (DOJ) announced Oct. 13 that a Massachusetts-based skilled nursing facility and its director of long-term care have agreed to pay $2.5 million to resolve allegations that they submitted inflated claims to Medicare.

    Mealey's Health Law - Reconsideration Of Class Certification Denied In Suits Over Denial Of Care

    SAN FRANCISCO - A California federal magistrate judge on Oct. 12 denied a motion filed by United Behavioral Health (UBH) to either reconsider his Sept. 19 certification of a class of insureds accusing UBH of wrongly denying coverage of mental health and substance abuse treatment to thousands or certify the order for interlocutory appeal (David Wit, et al. v. United Behavioral Health, No. 14-2346, Gary Alexander, et al. v. United Behavioral Health, No. 14-5337, N.D. Calif.; 2016 U.S. Dist. LEXIS 141441).

    Mealey's Health Law - High Court Denies Review Of Ruling On Standing To Sue Insurer Under ERISA

    WASHINGTON, D.C. - The U.S. Supreme Court on Oct. 11 denied a petition for writ of certiorari asking it to consider whether a party that is not an Employee Retirement Income Security Act plan participant, an ERISA beneficiary or a health care provider has standing to sue an insurer under ERISA for benefits (Gables Insurance Recovery Inc., as assignee of South Miami Chiropractic LLC, v. Blue Cross and Blue Shield of Florida Inc., No. 16-64, U.S. Sup.).

    Mealey's Health Law - New Jersey Magistrate Denies Insurance Department Motion To Quash Subpoena

    NEWARK, N.J. - A New Jersey federal magistrate judge on Sept. 30 denied the New Jersey Department of Banking and Insurance's motion to quash a subpoena related to the denial of a woman's mental health treatments, saying a confidentiality provision in the state Health Care Quality Act is preempted by the Employee Retirement Income Security Act (Rachel B. v. Horizon Blue Cross Blue Shield of New Jersey, No. 14-cv-01153, D. N.J.; 2016 U.S. Dist. LEXIS 135547).

    Mealey's Health Law - Top Court Declines Review In Case Involving ACA-ERISA Appeal Interplay

    WASHINGTON, D.C. - The U.S. Supreme Court on Oct. 3 declined to review a woman's case involving, among other issues, the proper way to handle external benefit denial appeal after the Patient Protection and Affordable Care Act (ACA)'s amendments to the Employee Retirement Income Security Act (S.M. v. Oxford Health Plans [NY] Inc., et al., No. 15-1540, U.S. Sup.).

    Mealey's Health Law - DOJ: Hospital Chain To Pay $32.7M To Resolve False Billing Claims

    HOUSTON - The U.S. Department of Justice (DOJ) announced Sept. 28 that Vibra Healthcare LLC (Vibra), a Mechanicsburg, Pa.-based national hospital chain, has agreed to pay $32.7 million to resolve claims that it violated the False Claims Act (FCA) when billing Medicare for medically unnecessary services (United States of America, ex rel. Daniel v. Vibra Healthcare LLC, No. 10-5099, S.D. Texas).

    Mealey's Health Law - Judge Says Health Care Provider's Attempt To Amend Complaint 'Futile'

    CHATTANOOGA, Tenn. - A Tennessee federal judge on Sept. 27 ruled that a health care provider's attempt to file an amended complaint against BlueCross BlueShield of Tennessee Inc. (BCBST) for alleged violations of the Employee Retirement Income Security Act was "futile" and accepted a magistrate judge's report and recommendation that the action should be dismissed because the plaintiff lacked standing to bring its ERISA claims (Apple Corporate Wellness Inc. v. BlueCross BlueShield of Tennessee Inc., No. 1:15-cv-324, E.D. Tenn.; 2016 U.S. Dist. LEXIS 131929).

    Mealey's Health Law - Judge Bars ACA Testimony; Jury Awards Defense Verdict In Medical Negligence Case

    HARRISBURG, Pa. - A federal jury in Pennsylvania on Aug. 19 found no negligence in a doctor's failure to properly diagnose and treat a woman's herpes zoster virus after a judge ruled that the jury would not hear testimony regarding the potential availability of Patient Protection and Affordable Care Act (ACA) benefits (Tami Bernheisel v. Martin Mikaya, M.D., Memorial Hospital Inc., et al., No. 13-1496, M.D. Pa.).

    Mealey's Health Law - Alaska Federal Judge: Lab Claims Preempted By ERISA, FEHBA

    ANCHORAGE, Alaska - An Alaska federal judge on Aug. 16 ruled that Alaska's Prompt Pay Statute, requiring insurers to pay benefit claims within 30 days, is preempted by the Employee Retirement Income Security Act for claims related to employee benefit plans and the Federal Employees Health Benefits Act (FEHBA) for claims related to federal worker benefit plans (John D. Zipperer Jr. v. Premera Blue Cross Blue Shield of Alaska, No. 3:15-CV-00208, D. Alaska; 2016 U.S. Dist. LEXIS 109531).

    Mealey's Health Law - Judge Dismisses Tribe's ERISA Claim Against Blue Cross Blue Shield

    BAY CITY, Mich. - An Indian tribe's claim that its health care plan administrator violated the Employee Retirement Income Security Act fails because the tribe cannot establish that the administrator had a fiduciary duty under ERISA to ensure payment of Medicare-like rates (MLRs) for certain health services, a Michigan federal judge ruled Aug. 3 in dismissing the claim (Saginaw Chippewa Indian Tribe of Michigan, et al. v. Blue Cross Blue Shield of Michigan, No. 16-cv-10317, E.D. Mich.; 2016 U.S. Dist. LEXIS 101610).

    Mealey's Health Law - Judge Places ACA Health Care Marketplace Co-Op Into Rehabilitation

    CHICAGO - An Illinois judge on July 14 placed a Patient Protection and Affordable Care Act (ACA) health care marketplace co-op into rehabilitation because, according to the state's acting director of insurance, the insurer will suffer a $68 million loss due to the actions of Congress and the Centers for Medicare & Medicaid Services, which would place the insurer in a hazardous position (People of the State of Illinois, ex rel. Anne Melissa Dowling, Acting Director of Insurance of the State of Illinois v. Land of Lincoln Mutual Health Insurance Company, No. 2016CH09210, Ill. Cir., Cook Co., Chanc. Div.).

    Mealey's Health Law - Durable Medical Equipment Provider Sentenced For Medicare Fraud Scheme

    TAMPA, Fla - The owner of a company that provided durable medical equipment was sentenced by a federal judge in Florida on June 13 to 37 months in prison and ordered to pay $$918,402 in restitution for his role in a $2.5 million Medicare fraud scheme (United States of America v. Ubert G. Rodriguez, No. 13cr372, M.D. Fla.).

    Mealey's Health Law - Spouse Lacks Standing To Assert Claims In ERISA Suit, 3rd Circuit Rules

    PHILADELPHIA- A spouse lacks standing to assert a claim under the Employee Retirement Income Security Act against his spouse's former employer regarding an alleged failure to timely send notice for health insurance coverage because the spouse was not a beneficiary or participant in the plan, the Third Circuit U.S. Court of Appeals affirmed June 13 in an unpublished opinion (John Sacchi v. Katheryn J. Luciani, et al., No. 15-1453, 3rd Cir.; 2016 U.S. App. LEXIS 10651).

    Mealey's Health Law - Federal Judge: Tribe Sufficiently States ERISA Claims Against Blue Cross

    DETROIT - Claims by a Native American tribe that Blue Cross Blue Shield of Michigan violated the Employee Retirement Income Security Act (ERISA) by overbilling the tribe for services rendered as third-party administrator for tribal members' health care claims survived a motion to dismiss April 27 when a federal judge in Michigan found that the tribe alleged sufficient facts to establish a right to relief on its ERISA claims (Little River Band of Ottawa Indians, et al. v. Blue Cross Blue Shield of Michigan, No. 15-13708, E.D. Mich.; 2016 U.S. Dist. LEXIS 55866).