CHICAGO - An Illinois federal judge on Jan. 12 denied a plaintiff's motion to remand after determining that her state law claims arising out of the disclosure of medical records without consent are preempted by the Employment Retirement Income Security Act (Jane Doe v. Aetna Inc., et al., No. 16-8390, N.D. Ill.; 2017 U.S. Dist. LEXIS 4866).
SANTA ANA, Calif. - Single calls placed to each health insurance customer about policy renewals were not telemarketing or advertising, a California federal judge ruled Jan. 13, granting summary judgment to the insurance provider in a Telephone Consumer Protection Act (TCPA) class complaint (Shannon Smith, et al. Blue Shield of California Life & Health Insurance Company, No. 16-108, C.D. Calif.; 2017 U.S. Dist. LEXIS 5620).
ALBUQUERQUE, N.M. - A federal judge in New Mexico on Jan. 11 granted the federal government's motion to exclude the testimony of an expert designated to discuss the medical necessity of tests administered by a holistic doctor who is accused of fraudulently billing Medicare and other insurers, after finding that the proposed testimony is not relevant and does not meet the standards of Daubert v. Merrell Dow Pharmaceuticals, Inc. (509 U.S. 579, 597 ) (United States of America v. Roy Heilbron, No. 15-CR-2030, D. N.M.; 2017 U.S. Dist. LEXIS).
DETROIT - Michigan's Little River Band of Ottawa Indians and Blue Cross Blue Shield have settled the tribe's claims that Blue Cross breached its fiduciary duty and violated the Employee Retirement Income Security Act (ERISA) in administering the tribe's health care plan for employees, according to a dismissal order filed Jan. 11 in federal court (Little River Band of Ottawa Indians, et al. v. Blue Cross Blue Shield of Michigan, No. 2:15-cv-13708, E.D. Mich.).
WASHINGTON, D.C. - The U.S. Supreme Court on Jan. 9 let stand a Sixth Circuit U.S. Court of Appeals' ruling that affirmed the dismissal of claims that the Michigan Health Insurance Claims Assessment Act is preempted by the Employee Retirement Income Security Act (Self-Insurance Institute of America Inc. v. Rick Snyder, et al., No. 16-593, U.S. Sup.).
DETROIT - The U.S. Department of Justice announced that a federal judge in Michigan on Jan. 9 sentenced a neurosurgeon to 235 months in prison for his role in a $2.8 million Medicare fraud scheme that involved the doctor billing public and private insurers for spinal fusions that he never performed (United States of America v. Aria O. Sabit, No. 15cr20311, E.D. Mich.).
CHICAGO - A cardiologist who pleaded guilty to one count of health care fraud for fraudulently billing Medicare and other insurance companies was ordered by a federal judge in Illinois to turn over three retirement funds valued at $300,738.60 after finding that forfeiture of the funds would not result in an overpayment of the $12 million he owes in restitution (United States of America v. Sushil Sheth, No. 09 CR 69-1, N.D. Ill.; 2017 U.S. Dist. LEXIS 2281).
RICHMOND, Va. - A Baltimore employee failed to show that the city's requirement that employees submit proof of marriage for their spouses to be eligible for health insurance coverage violates state or federal law, a Fourth Circuit U.S. Court of Appeals panel ruled Jan. 4, upholding a trial court's dismissal of an employee's complaint (Adris Abdus-Shahid, et al. v. Mayor and City Council of Baltimore, No. 15-2181, 4th Cir.; 2017 U.S. App. LEXIS 118).
ATLANTA - A 11th Circuit U.S. Court of Appeals panel on Dec. 30 affirmed an Alabama federal judge's ruling that a staffing business employer failed to notify a plaintiff of his rights under the Comprehensive Omnibus Budget Reconciliation Act (COBRA), saying that the evidence was sufficient that the former employee's health insurance was retroactively canceled in retaliation for filing an Equal Employment Opportunity Commission complaint and that the employer was not exempt from the COBRA requirement to provide notice to the employee of the right to continuation of health insurance coverage (Sam A. Virciglio v. Work Train Staffing LLC, et al., No. 15-10421, 11th Cir.; 2016 U.S. App. LEXIS 23422).
CINCINNATI - A Sixth Circuit U.S. Court of Appeals panel on Dec. 21 affirmed an Ohio federal judge's ruling that hypothetical situations lack the necessary concrete injury required to pursue claims that an insurer shirked its obligations under the Employee Retirement Income Security Act and the Patient Protection and Affordable Care Act (ACA) (Daniel Soehnlen, et al. v. Fleet Owners Insurance Fund, et al., No. 16-3124, 6th Cir.; 2016 U.S. App. LEXIS 22914).
TRENTON, N.J. - New Jersey's banking and insurance commissioner on Dec. 15 asked a state court to order an insolvent Patient Protection and Affordable Care Act (ACA) consumer-operated and oriented plan insurer's liquidation (Richard J. Badolato, Commissioner of the Department of Banking and Insurance of New Jersey v. Freelancers Consumer Operated and Oriented Program of New Jersey d/b/a Health Republic Insurance of New Jersey, No. MCR-C-000063-16, N.J. Super., Mercer Co., Chancery Div.).
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).
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.).
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).
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.).
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.).
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.).
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).
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.).
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).
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).
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.).
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.
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).
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.).