SAN JOSE, Calif. - A federal judge in California on June 8 denied a general practitioner's motion for acquittal on charges of health care fraud, finding that the spreadsheets and explanation of benefit (EOB) documents presented by the government constituted sufficient evidence showing that the doctor submitted fraudulent claims to insurance companies (United States of America v. Vilasini Ganesh, et al., No. 16cr00211, N.D. Calif., 2018 U.S. Dist. LEXIS 97028).
SAN FRANCISCO - Health insurance plans covering room and board for medical and surgical procedures must do so for inpatient mental health stays as well under federal law, a Ninth Circuit U.S. Court of Appeals panel held June 6 in reinstating an Employee Retirement Income Security Act action (Danny P., et al. v. Catholic Health Initiatives, No. 16-35609, 9th Cir.).
WASHINGTON, D.C. - An Oklahoma Supreme Court ruling finding an insured's suit against a provider outside ERISA's preemption powers could topple the first domino in a chain leading to higher prices for health care generally, an amicus curiae group warns the nation's top court in a June 4 brief urging it to review the ruling (INTEGRIS Health Inc. v. Elizabeth Cates, et al., No. 17-1501, U.S. Sup.).
LOS ANGELES - Intentional tort claims escape ERISA preemption, but the failure to allege that insurance defendants denied payments specifically to assist a competing provider dooms a chiropractic care provider's unfair competition law (UCL) claim, a California appeals court held in an opinion published June 1 (Port Medical Wellness Inc. v. Connecticut General Life Insurance Co., et al., No. B275874, Calif. App., 2nd Dist.).
PHILADELPHIA - Anti-assignment provisions in health insurance contracts are enforceable and bar a provider's Employee Retirement Income Security Act suit, the Third Circuit U.S. Court of Appeals held May 16 (American Orthopedic & Sports Medicine v. Independence Blue Cross Blue Shield, et al., No. 17-1663, 3rd Cir.).
BOSTON - A man's suit against a provider who allegedly misled him regarding potential insurance coverage for his daughter's mental health treatments in an effort to trump up prices does not implicate ERISA at this stage, a federal judge in Massachusetts held May 14 in remanding the case (Samuel S. Halberg, et al. v. McLean Hospital, No. 17-11341, D. Mass., 2018 U.S. Dist. LEXIS 80469).
MADISON, Wis. - Direct employers are not subject to liability in a case alleging discrimination against transgender individuals in the provision of health insurance, but claims against the providers of that insurance may proceed, and the plaintiffs can amend their Patient Protection and Affordable Care Act (ACA) claims, a federal judge in Wisconsin held May 11 (Alina Boyden and Shannon Andrews v. State of Wisconsin Department of Employee Trust Funds, et al., No. 17-264, W.D. Wis., 2017 U.S. Dist. LEXIS 191306).
LOS ANGELES - While not preempted by ERISA, substance abuse providers' California unfair competition law (UCL) claim alleging that insurers misrepresented the assignability of health insurance benefits falls short of pleading an injury for standing purposes, a California federal judge held May 1 in dismissing the claim with prejudice (Dual Diagnosis Treatment Center Inc., et al. v. Blue Cross of California, et al., No. 15-736, C.D. Calif.).
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).