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.).
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.).
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spouse was not a beneficiary or participant in the plan, the Third Circuit U.S. Court of Appeals affirmed June 13 in an unpublished opinion (John Sacchi v. Katheryn J. Luciani, et al., No. 15-1453, 3rd Cir.; 2016 U.S. App.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).
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).
WASHINGTON, D.C. - The U.S. Supreme Court on March 7 directed the Sixth Circuit U.S. Court of Appeals to reconsider its ruling that the Employee Retirement Income Security Act does not preempt a Michigan state law established to generate revenue necessary to fund the state's obligations under Medicaid in light of the Supreme Court's recent ruling in Gobeille v. Liberty Mutual Insurance Co. (Self-Insurance Institute of America v. Rick Snyder, et al., No. 14-741, U.S. Sup.).
NEWARK, N.J. - Olympus Corp. of the Americas and a Latin America subsidiary will pay $646 million in criminal and civil penalties for paying kickbacks to health care providers to buy its endoscopes and causing false claims to be paid by federal health care programs, according to documents filed March 1 in the U.S. District Court for the District of New Jersey (United States of America v. Olympus Corporation of the Americas, No. 16-3524, and United States ex rel. Slowik, et al. v. Olympus America. Inc., et al., No. 10-5994, D. N.J.).
WASHINGTON, D.C. - A Maryland woman pleaded guilty on Feb. 25 to charges of forging prescriptions and being involved with a health care fraud scheme and agreed to pay $16,175 (United States of America v. Claire Elizabeth Rice, No. 14-cr-56, D. D.C.).
CINCINNATI - A divided Sixth Circuit U.S. Court of Appeals panel on Feb. 8, based on the U.S. Supreme Court's decision in M&G Polymers USA, LLC v. Tackett (135 S. Ct. 926 ), 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, Nos. 14-3633 and 14-3918, 6th Cir.; 2016 U.S. App. LEXIS 2118).
MADISON, Wis. - A challenge by the University of Wisconsin Hospitals and Clinics Authority (UWHCA) of an insurer's denial of payment was rejected on summary judgment Jan. 25 by a Wisconsin federal judge in light of an anti-assignment provision in the parties' contract; the same day, UWHCA's state law claims against defendants Aetna Life Insurance Co., Aetna Health and Life Insurance Co. and Aetna Health Insurance Co. (Aetna, collectively) were dismissed in a related case as preempted by the Employee Retirement Income Security Act (University of Wisconsin Hospitals and Clinics Authority v. Aetna Life Insurance Company, et al., No. 14-779, W.D. Wis.; 2016 U.S. Dist. LEXIS 8093; University of Wisconsin Hospitals and Clinics Authority v. Aetna Life Insurance Company, et al., No. 15-286, W.D. Wis.; 2016 U.S. Dist. LEXIS 8091).
SAN JOSE, Calif. - In respective reply briefs filed Jan. 19, Anthem Inc. and related insurers argued in support of their motions to dismiss a putative class action over a January 2015 breach of Anthem's network, asserting that the plaintiffs did not adequately specify the allegedly breached contractual provisions (In Re: Anthem Inc., Customer Data Security Breach Litigation, No. 5:15-cv-02617, N.D. Calif.).
WASHINGTON, D.C. - The U.S Department of Justice (DOJ) announced Jan. 15 that a California hospital has agreed to pay $3.2 million to resolve allegations that it violated the Stark Law and False Claims Act by maintaining financial arrangements with referring physicians.
WASHINGTON, D.C. - The U.S. Supreme Court ruled 8-1 on Jan. 20 that an employee welfare plan fiduciary may not bring a suit under Employee Retirement Income Security Act Section 502(a)(3) to attach a participant's separate assets when the participant wholly dissipated a third-party settlement on nontraceable funds, concluding that such a suit was not permissible "equitable relief" (Robert Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan, No. 14-723, U.S. Sup.).
ST. LOUIS - Compounding pharmacies are not entitled to injunctive relief against a pharmacy benefits manager for denial of claims in violation of the Employee Retirement Income Security Act's claims regulation, the Eighth Circuit U.S. Court of Appeals affirmed Jan. 11 (Grasso Enterprises, LLC, et al. v. Express Scripts, Inc., No. 15-1578, 8th Cir.).
PORTLAND, Ore - A federal judge in Oregon on Jan. 7 denied a health insurers' motion to dismiss claims alleging that it breached its fiduciary duties under the Employee Retirement Income Security Act by denying coverage for applied behavioral analysis (ABA) therapy for the treatment of autism-related spectrum disorder to children who have been diagnosed as autistic (A.F., by and through his parents and guardians, Brenna Legaard and Scott Fournier, et al. v. Providence Health Plan, No. 13-776, D. Ore.; 2016 U.S. Dist. LEXIS 1503).
HACKENSACK, N.J. - A New Jersey judge on Dec. 17 granted a motion for expedited discovery brought by a group of hospitals, finding that their requests for documents related to certain hospital-ranking methodology and resulting scores of hospitals that are not parties to the suit are relevant to their breach of contract claims about the insurer's newly announced tiered health plan (Capital Health Systems Inc., et al. v. Horizon Healthcare Services Inc., No. BER-C-369-15, N.J. Super., Chanc. Div.; 2015 N.J. Super. Unpub. LEXIS 2957).
WHEELING, W.Va. - A breach of contract counterclaim brought in response to an action seeking a declaration that the Employee Retirement Income Security Act preempts a request for indemnification was dismissed Dec. 10 by a West Virginia federal judge (Ohio Valley Health Services & Education Corporation, et al. v. Health Plan of the Upper Ohio Valley Inc., et al., No. 15-65, N.D. W.Va.; 2015 U.S. Dist. LEXIS 165705).
WASHINGTON, D.C. - The State of Vermont and an insurer squared off before the U.S. Supreme Court Dec. 2 in oral arguments over whether the Employee Retirement Income Security Act, as amended by the Patient Protection and Affordable Care Act (ACA), preempts state level collection of health insurance data (Alfred Gobeille, in his official capacity as chair of the Vermont Green Mountain Care Board v. Liberty Mutual Insurance Co., No. 14-181, U.S. Sup.).
NEW YORK - The Second Circuit U.S. Court of Appeals on Oct. 15 determined that a health benefits insurer did not wrongfully deny a claim for residential treatment because four physicians noted in the administrative record that residential treatment was not necessary (Neil Tansey, et al. v. Anthem Health Plans Inc., et al., No. 14-3931, 2nd Cir.; 2015 U.S. App. LEXIS 17889).
CHICAGO - Because a number of medical providers alleging that an insurer wrongfully reduced payments on health claims are not beneficiaries to an insurance contract, they are not entitled to allege claims under the Employee Retirement Income Security Act of 1974, the Seventh Circuit U.S. Court of Appeals said Oct. 1 in reversing a district court's ruling in favor of the medical providers (Pennsylvania Chiropractic Association et al. v. Independence Hospital Indemnity Plan Inc., Nos. 14-2322, 14-3174 & 15-1274, 7th Cir.; 2015 U.S. App. LEXIS 17269).
GREENVILLE, S.C. - A health insurer was not the primary payer for an employee's medical claims because the plan at issue clearly stated that Medicare was the primary payer if an insured received Medicare benefits, a South Carolina federal judge said Sept. 30 (Jennifer Perkins v. US Airways Inc., et al., No. 14-2577, D. S.C.; 2015 U.S. Dist. LEXIS 132502).
ST. LOUIS - A multiemployer health fund is not entitled to equitable relief in the amount it paid in medical benefits to students who were also covered by student accidental medical insurance under the fund's coordination-of-benefits provision pursuant to the Employee Retirement Income Security Act, the Eighth Circuit U.S. Court of Appeals affirmed Aug. 10 (Central States, Southeast and Southwest Areas Health and Welfare Fund v. Student Assurance Services, Inc., et al., No. 14-2376, 8th Cir.; 2015 U.S. App. LEXIS 13941).
PHILADELPHIA - A federal judge in Pennsylvania did not err when sentencing a woman to 96 months in prison for her role in an insurance fraud scheme that resulted in Medicare and other supplemental insurers paying approximately $1.8 million in false claims, a Third Circuit U.S. Court of Appeals panel ruled July 23, finding that the judge properly found that the defendant's scheme involved 10 or more victims (United States of America v. Anna Mudrova, No. 14-3580, 3rd Cir.; 2015 U.S. App. LEXIS 12733).
NEW YORK - Health care providers are not beneficiaries of their patients' health insurance plans and, therefore, do not have standing to assert anti-retaliation protections under the Employee Retirement Income Security Act, the Second Circuit U.S. Court of Appeals affirmed July 15 (Henry L. Rojas, M.D., et al. v. Cigna Health and Life Insurance Company, et al., No. 14-3455, 2nd Cir.; 2015 U.S. App. LEXIS 12210).
ATLANTA - An 11th Circuit U.S. Court of Appeals panel on July 15 found no error in a federal judge in Florida's decision to sentence a pharmacy owner to 144 months in prison, ruling that the judge did not err when finding that the defendant's fraudulent billing of prescription medication to Medicare resulted in an intended loss of $2.5 million to the government and that the evidence supported the defendant's conviction for conspiracy to commit health care fraud (United States of America v. Guido Halayn De La Torre, No. 13-15179, 11th Cir.; 2015 U.S. App. LEXIS 12179).
PHILADELPHIA - A Pennsylvania Superior Court panel on July 7 affirmed the conviction of a pain clinic owner for conspiracy, theft and insurance fraud after finding that the evidence presented during his trial supported the verdict and that the trial court judge did not err when allowing the Commonwealth of Pennsylvania's insurance billing expert to offer lay testimony (Commonwealth of Pennsylvania v. Owen Rogal, No. 5 EDA 2014, Pa. Super.; 2015 Pa. Super. LEXIS 397).