LexisNexis® Legal Newsroom
    Mealey's Health Law - Judge Dismisses Tribe's ERISA Claims Against Blue Cross Blue Shield

    ANN ARBOR, Mich. - A Native American tribe cannot pursue claims that its health care plan administrator violated the Employee Retirement Income Security Act (ERISA) by failing to charge the tribe Medicare-like rates for contracted services at a hospital because the tribe waited too long to sue, a Michigan federal judge held July 21 (Grand Traverse Band of Ottawa and Chippewa Indians, et al. v. Blue Cross Blue Shield of Michigan v. Munson Medical Center, No. 5:14-cv-11349, E.D. Mich., 2017 U.S. Dist. LEXIS 113759).

    Mealey's Health Law - Administrators Cannot Violate Anti-Kickback Law, 3rd Circuit Finds

    PHILADELPHIA - A Third Circuit U.S. Court of Appeals panel ruled July 19 that administrators of an outpatient surgical facility cannot be found liable for violating Pennsylvania's insurance fraud statute because the anti-kickback provision of the statute applies only to health care providers (Aetna Life Insurance Company v. Huntingdon Valley Surgery Center, et al., No. 16-1468, 3rd Cir., 2017 U.S. App. LEXIS 12971).

    Mealey's Health Law - Government Says Failed ACA Insurer Should File Case In Federal Claims Court

    COLUMBIA, S.C. - A failed Patient Protection and Affordable Care Act (ACA) co-operative insurer's liquidator should file his lawsuit challenging a federal loan repayment demand in the U.S. Court of Federal Claims, the government says in a July 19 motion filed in South Carolina federal court (Raymond G. Farmer v. United States of America, et al., No. 17-cv-00956, D. S.C.).

    Mealey's Health Law - DOJ: 3 Companies, Executives To Pay $19.5M For False Billing

    CINCINNATI - Three companies and their executives have agreed to pay $19.5 million for allegedly violating the False Claims Act (FCA) by billing Medicare for medically unnecessary rehabilitation therapy and hospice services, the U.S. Department of Justice announced July 18 (United States, ex rel. Trakhter v. Provider Services Inc., et al., No. 11-CV-217, United States, ex rel. Goodwin, et al. v. Brian Colleran, et al.., No. 11-CV-935, S.D. Ohio.).

    Mealey's Health Law - Tribe Wins $8.4 Million Judgment Against Blue Cross For Hidden Plan Fees

    BAY CITY, Mich. - A health care plan administrator owes a Michigan Indian tribe more than $8.4 million for violating the Employee Retirement Income Security Act by charging hidden administrative fees for the tribe's employee benefit program but is not liable for any alleged damages related to the tribe's separate health care plan for all of its members, even though some are also employees, a federal judge held July 14 (Saginaw Chippewa Indian Tribe of Michigan, et al. v. Blue Cross Blue Shield of Michigan, No. 1:16-cv-10317, E.D. Mich., 2017 U.S. Dist. LEXIS 109366).

    Mealey's Health Law - Judge Finds Standing In ACA Out-Of-Network Lactation Coverage Suit

    WASHINGTON, D.C. - A trio of women successfully allege standing in their class action claiming that an insurer improperly charged them for out-of-network lactation services in violation of the Patient Protection and Affordable Care Act (ACA), a federal judge in the District of Columbia held July 17 (Lindsay Ferrer, et al. v. CareFirst Inc., et al., No. 16-2162, D. D.C., 2017 U.S. Dist. LEXIS 110304.)

    Mealey's Health Law - DOJ: Owners Of Psychological Services Companies Sentenced For $25.2M Fraud Scheme

    NEW ORLEANS - The owners of two psychological services companies were sentenced by a federal judge in Louisiana for their roles in a $25.2 million Medicare fraud scheme, the U.S. Department of Justice announced July 14 (United States of America v. Rodney Hesson, et al., No. 15-cr-152, E.D. La.).

    Mealey's Health Law - Discovery Of Non-ACA Plan Information Denied In Insurer's Dialysis Fraud Suit

    WEST PALM BEACH, Fla. - Finding that a health insurer's fraud claims related to kidney dialysis were pleaded only for its Patient Protection and Affordable Care Act (ACA) plans, a Florida federal magistrate judge on July 10 denied in part a motion to compel non-ACA plan information from the dialysis provider defendants (UnitedHealthcare of Florida Inc., et al. v. American Renal Associates Holdings Inc., et al., No. 9:16-cv-81180, S.D. Fla.).

    Mealey's Health Law - Judge: Opioid Possession, Intent To Distribute Charges Preclude Pretrial Release

    PHILADELPHIA - A federal judge in Pennsylvania on July 7 denied a motion for pretrial release filed by a man accused of health care fraud, conspiracy to commit and 15 counts of possession of oxycodone with intent to distribute, finding that the nature of the drug trafficking claims showed that no condition would reasonably assure the safety of other people in the community (United States of America v. Michael Milchin, No. 17-cr-284, E.D. Pa., 2017 U.S. Dist. LEXIS 105570).

    Mealey's Health Law - Connecticut Judge Grants Injunction For Union Workers In Medical Coverage Dispute

    HARTFORD, Conn. - A Connecticut federal judge on June 27 granted union employees' motion for a preliminary injunction and ordered Honeywell International Inc. to reinstate previously existing medical coverage benefits, saying that the threat of termination and the actual termination of medical coverage benefits constitute irreparable harm (David Kelly, et al. v. Honeywell International Inc., No. 3:16-cv-00543, D. Conn., 2017 U.S. Dist. LEXIS 99419).

    Mealey's Health Law - Defense Expert Excluded In Case Alleging Illegal Kickbacks For Lab Work

    CHARLESTON, S.C. - An expert for health care defendants accused of running kickback schemes cannot testify because his opinion draws on legal conclusions that should be left to the court to decide, is based on unsound methodology and would mislead a jury, a South Carolina federal judge held June 26 in excluding the expert from the case (United States of America, et al. v. Berkeley Heartlab, Inc., et al., Nos. 9:14-cv-00230, 9:11-cv-1593 and 9:15-cv-2485, D. S.C., 2017 U.S. Dist. LEXIS 98147).

    Mealey's Health Law - 4th Circuit Panel Affirms Judgment For Michelin Plan On Injection Payment Rulings

    RICHMOND, Va. - A Fourth Circuit U.S. Court of Appeals panel on June 13 affirmed the grant of summary judgment to defendants in a case where a plaintiff sued under the Employee Retirement Income Security Act seeking additional reimbursement for a series of steroid knee injections that an orthopedic surgeon administered to his spouse, finding no abuse of discretion in the defendants' decision to not provide additional insurance coverage and no error in the trial court's refusal to consider information that the plaintiff failed to provide during the administrative appeals process (Monte Hooper, et al. v. UnitedHealthcare Insurance Co., et al., No. 15-2157, 4th Cir., 2017 U.S. App. LEXIS 10482).

    Mealey's Health Law - Class Action Over Cost Of EpiPens Filed In Minnesota Federal Court

    MINNEAPOLIS - A putative class action brought pursuant to the Employee Retirement Income Security Act alleging that pharmacy benefits managers' violation of their fiduciary duty caused the price of a drug used to treat severe, life-threatening allergic reaction to skyrocket was filed June 2 in Minnesota federal court (Elan and Adam Klein, et al. v. Prime Therapeutics LLC, et al., No. 0:17-cv-01884, D. Minn.).

    Mealey's Health Law - Judge Affirms Ruling Finding Conflict Between Fraud Defendant And Attorney

    BUFFALO, N.Y. - A federal judge in New York on May 12 upheld a magistrate judge's decision finding that an attorney representing a man accused of health care fraud should be removed as his counsel due to a conflict of interest because the government intends to call him as a witness (United States of America v. Eugene Gosy, No. 16-cr-46-FPG, W.D. N.Y., 2017 U.S. Dist. LEXIS 72989).

    Mealey's Health Law - Failed ACA Insurer Claims HHS Improperly Withholds Reinsurance Funds

    COLUMBIA, S.C. - The government is improperly withholding payments from, and setting off debts owed by, a failed South Carolina Patient Protection and Affordable Care Act (ACA) co-operative insurer, illegally placing its own interests before those of policyholders and others entitled to priority, the insurer's liquidator allege in an April 12 federal complaint filed in South Carolina (Raymond G. Farmer, et al. v. The United States of America, et al., No. 17-956, D. S.C.).

    Mealey's Health Law - Washington Settles Class Suit Over Denial Of Hepatitis C Medication

    SEATTLE - A Washington federal judge on April 10 issued an order granting final approval of a settlement under which the Washington State Health Care Authority (WHCA) has agreed to provide coverage for direct-acting antiviral medications for the treatment of hepatitis C (HCV) for Medicaid enrollees who claimed that they were previously denied the drugs due to the cost (B.E., et al. v. Dorothy F. Teeter, No. 16-227, W.D. Wash.).

    Mealey's Health Law - Judge Hands Insurer Mixed Results In Colorectal Cancer Test Coverage Case

    GREENSBORO, N.C. - An insurer received mixed results in its challenge to claims that it failed to properly compensate the developer of a colorectal cancer screening test, with a federal judge in North Carolina dismissing some of the claims on March 27 but largely allowing Employee Retirement Income Security Act claims to proceed (Exact Sciences Corp. and Exact Sciences Laboratories LLC v. Blue Cross and Blue Shield of North Carolina, No. 16-125, M.D. N.C., 2017 U.S. Dist. LEXIS 44679).

    Mealey's Health Law - Judge Trims Some Claims Over Billing For Vein Procedures Due To Pleadings

    CHICAGO - A federal judge in Illinois dismissed without prejudice claims from a man that his former employer falsely billed Medicare, Medicaid and other private insurers for endovascular laser therapy (EVLT) procedures that were not medically necessary or done with reused laser fibers, finding that the allegations were not made with the required level of specificity to support his False Claims Act (FCA) allegations (United States of America, ex rel. Constantine Zverev, et al. v. USA Vein Clinics of Chicago, LLC, et al., No. 12 CV 8004, N.D. Ill., 2017 U.S. Dist. LEXIS 43807).

    Mealey's Health Law - Judge Dismisses ERISA Action Involving Proton Beam Therapy Coverage Denial

    BIRMINGHAM, Ala. - A man's Employee Retirement Income Security Act (ERISA) suit impermissibly seeks equitable relief in the face of other available remedies, a federal magistrate judge in Alabama held March 23 (Jeffrey Woodruff v. Blue Cross and Blue Shield of Alabama, et al., 2017 U.S. Dist. LEXIS 41921).

    Mealey's Health Law - ERISA Not The Vehicle For Health Centers' Suits Against Insurers, 9th Circuit Says

    SAN FRANCISCO - Health care centers designated to receive direct payment from a health plan administrator for medical services cannot file suit in federal court under the Employee Retirement Income Security Act because they lack both direct statutory authority and derivative authority through assignment under ERISA's civil enforcement provisions, a Ninth Circuit U.S. Court of Appeals panel held March 22 (DB Healthcare, LLC, et al. v. Blue Cross Blue Shield of Arizona, Inc., No. 14-16518, Advanced Women's Health Center, Inc. v. Anthem Blue Cross Life and Health Insurance Company, No. 14-16612, 9th Cir., 2017 U.S. App. LEXIS 5082).

    Mealey's Health Law - Judge Nixes Class In Insureds' Suit Claiming Pharmacy Gouged On Generic Drugs

    SAN FRANCISCO - The variety of contracts at issue and evidence that at least some of the contracted pharmacy benefit managers (PBMs) understood that a pharmacy's usual and customary rate did not include the rate offered for generic drugs in its membership program defeat a motion for class certification of insured purchasers of generic drugs, a federal judge in California held March 21 (Christopher Corcoran, et al. v. CVS Health, et al., No. 15-3504, N.D. Calif., 2017 U.S. Dist. LEXIS 40783).

    Mealey's Health Law - Drug Makers, Benefit Managers Hit With Class Suit Alleging Insulin Pricing Scheme

    NEWARK, N.J. - Three drug makers and the three largest pharmacy benefit managers have engaged in a pricing scheme to drive up the cost of diabetes insulin - by more than 150 percent in the last five years - in violation of the Racketeer Influenced and Corrupt Organizations Act, the Employee Retirement Income Security Act of 1974, the Sherman Act and numerous state laws, four consumers and Type 1 Diabetes Defense Foundation allege in a March 17 class complaint filed in the U.S. District Court for the District of New Jersey (Julia Boss, et al. v. CVS Health Corporation, et al., No. 17-1823, D. N.J.).

    Mealey's Health Law - Judge Finds Jurisdiction Lacking In Insolvent Insurer's Suit Over ACA Payments

    ST. LOUIS - An insolvent insurer's suit against the government over its handling of the Patient Protection and Affordable Care Act (ACA) risk corridor and how it offset debts properly belongs before the U.S. Court of Federal Claims, a federal judge in Iowa said March 17 in finding that she lacked jurisdiction and entering judgment (Nick Gerhart, et al. v. United States Department of Health and Human Services, et al., No. 16-151, S.D. Iowa, 2017 U.S. Dist. LEXIS 37620).

    Mealey's Health Law - 4th Circuit Reinstates Retaliation Claim In Suit Over Overbilling Clinics

    RICHMOND, Va. - A federal judge in Virginia erred in finding that a physical therapist assistant's retaliation claim against his employer should be dismissed, finding that they were not subject to the False Claims Act's (FCA) first-to-file rule, a Fourth Circuit Court of Appeals ruled March 16, but affirmed the dismissal of his qui tam claims under the statute (United States of America, ex rel. Patrick Gerard Carson v. Manor Care, Inc., a./k/a Manor Care, Inc., et al., No. 16-1035, 4th Cir., 2017 U.S. App. LEXIS 4617).

    Mealey's Health Law - Judge Refuses To Dismiss State Farm's Suit Alleging No-Fault Insurance Scheme

    DETROIT - A federal judge in Michigan on March 6 denied a motion to dismiss filed by defendants accused by State Farm Mutual Automobile Insurance Co. of submitting false bills under Michigan's No-Fault Automobile Insurance Act for services that were either medically unnecessary or never provided, ruling that the defendants' arguments lacked merit (State Farm Mutual Automobile Insurance Company v. Elite Health Centers, Inc., et al., No. 16-13040, E.D. Mich., 2017 U.S. Dist. LEXIS 30826).