SANTA FE, N.M. - In a divided opinion, the New Mexico Supreme Court on Aug. 25 held that state law regulating the payment of pharmacists who dispense prescription drugs to Medicaid recipients applies only in the fee-for-services context and not in the managed care system (Starko Inc., et al. v. New Mexico Human Services Department, et al., Nos. 33,382, 33,383, 33,384, N.M. Sup.; 2014 N.M. LEXIS 302).
ST. LOUIS - An Eighth Circuit U.S. Court of Appeals panel on Aug. 25 affirmed the dismissal of a Medicare dispute, agreeing that the Medicare Prescription Drug Improvement Act's bar on judicial review precluded jurisdiction (Key Medical Supply Inc. v. Sylvia Matthews Burwell, et al., No. 13-2084, 8th Cir.; 2014 U.S. App. LEXIS 16284).
BATON ROUGE, La. - A federal judge in Louisiana sentenced a psychiatrist to 86 months in prison and ordered him to pay $43.5 million in restitution for his role in a $258.5 million health care fraud scheme, the U.S. Department of Justice announced Aug. 25 (United States of America v. Zahid Imran, M.D., No. 12-cr-00073-BAJ-SCR-8, M.D. La.).
BOSTON - In issuing findings of fact and conclusions of law following a four-day bench trial, a Massachusetts federal judge on Aug. 21 dismissed the remaining claim in a health care reimbursement suit brought by two companies that provide radiological services against two insurance companies (Spinal Imaging Inc. v. Aetna Health Management, et al.; Radiology Diagnostics v. Aetna Health Management, et al., Nos. 09-11873, 12-11521, D. Mass.; 2014 U.S. Dist. LEXIS 118090).
SALEM, Ore. - Saying it "sold the State of Oregon a lie" about its ability to deliver a Patient Protection and Affordable Care Act (ACA) insurance exchange, Oregon sued Oracle America Inc. on Aug. 22 for allegedly fraudulently inducing hundreds of millions of dollars in contracts but delivering only "abysmal" work described as "seemingly configured 'by a kindergartner'" (Ellen Rosenblum, et al. v. Oracle America Inc., et al., No. 14C20043, Ore Cir., Marion Co.).
PITTSBURGH - The filed-rate doctrine precludes the antitrust claims of individual and some small-group purchasers of health insurance against insurer Highmark Inc. and health care provider University of Pittsburgh Medical Center (UPMC), but the filed-rate doctrine may not be applicable to claims of small-group purchasers that asserted a measure of damages based on unregulated rates, a federal judge in Pennsylvania ruled Aug. 21 in granting in part the purchasers' motion for leave to file a third amended complaint (Royal Mile Company, Inc., et al. v. UPMC, et al. No. 2:10-cv-01609, W.D. Pa.; 2014 U.S. Dist. LEXIS 116224).
CHICAGO - An Illinois federal judge on Aug. 22 denied a health plan sponsor and insurer summary judgment on a breach of fiduciary claim in a health care denial of benefits dispute, saying a summary judgment motion was not the proper forum for deciding the issue (James E. Killian v. Concert Health Plan, et al., No. 07-4755, N.D. Ill.; 2014 U.S. Dist. LEXIS 116835).
OLYMPIA, Wash. - An en banc Washington Supreme Court on Aug. 21 affirmed a trial court's decision on how to determine the value of damages suffered by a group of state employees who were denied health benefits, saying that contrary to the defendants' argument, class members suffered more damages than the nonpayment of immediate medical expenses (Douglas L. Moore, et al. v. The Health Care Authority, et al., No. 89774-3, Wash. Sup.; 2014 Wash LEXIS 641).
WASHINGTON, D.C. - Eligible employers opposed to Patient Protection and Affordable Care Act (ACA) provisions mandating insurance coverage for contraceptives may notify the U.S. Department of Health and Human Services (HHS), which will in turn notify the employer's insurer under a new rule issued by the government Aug. 22.
PHILADELPHIA - A federal judge in Pennsylvania on Aug. 19 dismissed with prejudice an insurance company's unjust enrichment claim against a physician-owned surgical facility and its management companies after finding that it failed to state a claim upon which relief could be granted, but also allowed the company to pursue claims of insurance fraud against the defendants based on their billing and referral practices (Aetna Life Insurance Co. v. Huntington Valley Surgery Center, et al., No. 13-cv-3101-WY, E.D. Pa.; 2014 U.S. Dist. LEXIS 115688).
LOS ANGELES - Blue Cross of California misrepresented which providers its plans covered while transferring subscribers into limited-access Patient Protection and Affordable Care Act (ACA) "skinny networks" consisting of the cheapest medical services providers in an effort to save money, an Aug. 19 class action alleges (Jonathan Brown, et al. v. Blue Cross of California, dba Anthem Blue Cross and DOES 1 through 100 inclusive, No. BC554949, Calif. Super., Los Angeles Co.).
PITTSBURGH - The Patient Protection and Affordable Care Act (ACA) contraceptive mandate places a substantial burden on nonprofit plaintiffs' religious practices, and they are likely to succeed in their challenge to it, a Pennsylvania federal judge held Aug. 20 (Most Reverend Lawrence E. Brandt, et al. v. Sylvia Burwell, et al., No. 14-681, W.D. Pa.).
DENVER - The government's promise that amended rules are forthcoming does not alleviate the ongoing harm imposed by the Patient Protection and Affordable Care Act (ACA)'s contraceptive mandate, the law's challengers argue in telling the 10th Circuit U.S. Court of Appeals on Aug. 19 that they would continue with their appeal (Little Sisters of the Poor Home for the Aged, Denver Colorado, et al. v. Sylvia Burwell, et al., No. 13-1540, 10th Cir.).
CHICAGO - An Illinois federal judge on Aug. 19 granted an injunction against a health insurance company, requiring the company to change the way it issues notice and appeal procedures before recouping money from previously paid claims (Pennsylvania Chiropractic Association, et al. v. Blue Cross Blue Shield Association, et al., No. 09-5619, N.D. Ill.; 2014 U.S. Dist. LEXIS 114664).
WASHINGTON, D.C. - En banc review of a decision that tax credits apply only for individuals who receive insurance through state Patient Protection and Affordable Care Act (ACA) exchanges would only delay ultimate resolution before the U.S. Supreme Court, plaintiffs told the a federal appeals court Aug. 18 (Jacqueline Halbig, et al. v. Sylvia M. Burwell, et al., No. 14-5018, D.C. Cir.).
NEWARK, N.J. - In an unpublished opinion, a New Jersey federal judge on Aug. 15 remanded a health insurance breach of contract case to state court, holding that the Employee Retirement Income Security Act did not preempt the claims (Thomas R. Peterson, M.D., et al. v. Cigna Insurance Co., et al., No. 14-03818, D. N.J.; 2014 U.S. Dist. LEXIS 11349).
NEW YORK - A New York federal judge on Aug. 15 dismissed claims against one health insurer in a reimbursement dispute and partially dismissed claims against another group of insurers, leaving two claims brought pursuant to the Employee Retirement Act and one state law claim for prompt-payment violations (MBody Minimally Invasive Surgery, et al. v. Empire Healthchoice HMO Inc., et al., No. 13-6551, S.D. N.Y.; 2014 U.S. Dist. LEXIS 114012).
DETROIT - Burwell v. Hobby Lobby Stores, Inc. (134 S. Ct. 2751 ) dispensed with the idea that for-profit companies cannot follow religious tenets and requires reversal of a ruling denying injunction relief in a Patient Protection and Affordable Care Act (ACA) contraceptive mandate challenge, a company told the Sixth Circuit U.S. Court of Appeals on Aug. 14 (Mersino Management Co., et al. v. Sylvia Burwell, et al., No. 13-1944, 6th Cir.).
CHICAGO - In reversing a lower court decision, a panel of the Seventh Circuit U.S. Court of Appeals on Aug. 18 held that the secretary of Health and Human Services' determination that residents' pure research activities should not be compensable as part of the "indirect medical education" (IME) costs in calculating reimbursement rates for Medicare was entitled to deference (Rush University Medical Center v. Sylvia Mathews Burwell, secretary of Health and Human Service, No. 13-3285, 7th Cir.).
TAMPA, Fla. - A Florida federal judge on Aug. 14 declined to remand a health care reimbursement suit to state court, finding that federal question jurisdiction existed pursuant to the Employee Retirement Income Security Act, but also declined to dismiss the claims, saying it was unclear to what extent the claims involved ERISA plans (United Surgical Assistants LLC v. Aetna Life Insurance Co., No. 14-211, M. D. Fla.; 2014 U.S. Dist. LEXIS 112816).
NEW ORLEANS - Even with the availability of an opt out, the Patient Protection and Affordable Care Act (ACA)'s contraceptive mandate's requirement that a nonprofit religious employer provide insurance coverage for four contraceptives it finds objectionable violates religious beliefs and imposes a substantial burden, a Louisiana federal judge held Aug. 13 (Louisiana College v. Kathleen Sebelius, et al., No. 12-0463, W.D. La.; 2014 U.S. Dist. LEXIS 113083).
SHREVEPORT, La. - A Louisiana appeals court on Aug. 13 decertified a class action lawsuit challenging a hospital's practice of billing insured patients involved in motor vehicle accidents when a third party is liable for the accident, saying that more courts must have experience with the Health Care Consumer Billing and Disclosure Protection and Act before a class could be certified (Prentiss Baker, et al. v. PHC-Minden L.P. d/b/a Minden Medical Center, No. 49,122-CA, La. App., 2nd Cir.; 2014 La. App. LEXIS 1955).
INDIANAPOLIS - A state and 39 school districts challenging the legality of payments imposed on large employers under the Internal Revenue Services' implementation and interpretation of Patient Protection and Affordable Care Act (ACA) regulations allege an addressable injury in fact, an Indiana federal judge held Aug. 12 (State of Indiana v. Internal Revenue Service, et al., 13-1612, S.D. Ind.).
WASHINGTON, D.C. - More than half of large employers will offer employees a consumer directed health plan (CDHP) in 2015, and those plans will be the sole option at almost a third of large employers, according to an Aug. 13 National Business Group on Health (NBGH) survey.
NEW ORLEANS - A panel of the Fifth Circuit U.S. Court of Appeals on Aug. 11 affirmed a decision denying a motion to dismiss a False Claims Act (FCA) case, saying the defendants did not have qualified immunity (United States of America, ex rel. M.D. Dakshesh Kumar Parikh, et al. v. David Brown, et al., No. 13-41088, 5th Cir.; 2014 U.S. App. LEXIS 15465).