LexisNexis® Legal Newsroom
    5th Circuit Affirms Order Denying Judicial Review Of Part D Coverage Dispute

    NEW ORLEANS - The Fifth Circuit U.S. Court of Appeals on May 1 affirmed a federal trial court order denying judicial review of a challenge to the U.S. Department of Health and Human Services (HHS) Medicare Part D rule allowing prescription drug plans (PDPs) to establish preferred pharmacy networks. The appeals court found that the limited exception to the requirement of exhausting the administrative appeals process does not apply in the instant case (Southwest Pharmacy Solutions Inc. v. Centers for Medicare and Medicaid Services, et al., No. 12-40097, 5th Cir.; 2013 U.S. App. LEXIS 8923).

    Government Seeks Stay Of Plan B Contraceptive Order Pending 2nd Circuit Appeal

    BROOKLYN, N.Y. - The federal government on May 1 asked a judge to stay, pending appeal, his order that the Food and Drug Administration make all Plan B emergency contraceptive products available without age or point-of-sale restrictions, saying the court exceeded its authority in ordering the agency to approve a drug (Annie Tummino, et al. v. Dr. Margaret Hamburg, et al., No. 1:12-763, E.D. N.Y.).

    Florida Federal Judge Affirms Order Revoking Facility Billing Privileges

    MIAMI - A federal judge in the U.S. District Court for the Southern District of Florida on April 30 affirmed a U.S. Department of Health and Human Services (HHS) ruling that an outpatient rehabilitation facility's Medicare billing privileges were properly revoked because the facility was not properly staffed with qualified medical professionals (CompRehab Wellness Group Inc. v. Kathleen Sebelius, Secretary of Health and Human Services, No. 1:11cv23377, S.D. Fla.; 2013 U.S. Dist. LEXIS 61567).

    Judge Dismisses 1 Claim From Reimbursement Suit, Remands Remaining Claims

    LOS ANGELES - A California federal judge on April 29 dismissed a federal false advertising claim from a reimbursement dispute between medical providers and health insurers and declined to exercise supplemental jurisdiction over the remaining state claims (Los Angeles County Medical Association, et al. V. Aetna Health of California Inc., et al., No. 12-11020, C.D. Calif.).

    California Federal Judge Allows Medicaid Claims To Continue

    OAKLAND, Calif. - A California federal judge on April 26 declined to dismiss a federal and state False Claims Act case brought against a nonprofit health center for alleged Medicaid violations (United States of America, et al. v. Northeast Medical Services Inc., No. 10-1904, N.D. Calif.; 2013 U.S. Dist. LEXIS 60126).

    6th Circuit Denies Medicaid Appeal As Moot, Affirms Denial Of Bond Motion

    CINCINNATI - A Sixth Circuit U.S. Court of Appeals panel on April 24 dismissed as moot an appeal challenging an order granting a temporary injunction in a Medicaid provider dispute and affirmed the lower court decision denying the defendant's bond motion (Appalachian Regional Healthcare Inc., et al. v. Coventry Health and Life Insurance Co., et al., No. 12-5779, 6th Cir.; 2013 U.S. App. LEXIS 8286).

    Federal Judge Upholds Benefit Denial Despite Faulty Administrative Claims Process

    MEMPHIS, Tenn. - A health insurance plan administrator's denial of benefits was not arbitrary and capricious, even though the administrator gave three different reasons for the denial at different times in the administrative process, because substantial evidence supported one of the three proffered reasons, a federal judge in Tennessee ruled April 23 (Joseph M. Morrison, et al. v. Regions Financial Corporation, et al., No. 10-2843, W.D. Tenn.; 2013 U.S. Dist. LEXIS 57921).

    County Mental Health Board Is Immune From Antitrust Suit, Federal Judge Rules

    ROCKFORD, Ill. - An action alleging that a community mental health board established by McHenry County, Ill., violated federal antitrust law by demanding recoupment of fees paid from an organization that the board found engaged in improper billing practices is barred by the state-action immunity doctrine because the board's actions were foreseeable under the statutory grant of authority, a federal judge in Illinois ruled April 23 (The Advantage Group Foundation v. McHenry County Mental Health Board, et al., No. 12 C 50374, N.D. Ill.; 2013 U.S. Dist. LEXIS 57595).

    Judge Finds 'Expense Incurred' Applies To Insured's Medicare-Adjusted Amount

    BEAUFORT, S.C. - A health insurance provider properly reimbursed its insured for the actual amount paid to a medical provider after adjustments were made by Medicare, a South Carolina federal judge ruled April 24, granting summary judgment to the insurer on bad faith and breach of contract claims against it (Dennis Barker v. Washington National Insurance Co., No. 9:12-cv-01901, D. S.C.; 2013 U.S. Dist. LEXIS 58437).

    11th Circuit: Participant's Benefits-Denial And Disclosure Claims Fail

    ATLANTA - A plan insurer's calculation of benefits due to a participant for his out-of-network surgery was not wrong under the plan terms, and the insurer did not violate the Employee Retirement Income Security Act by failing to provide documents on which the insurer relied to calculate and verify the benefits due, the 11th Circuit affirmed April 22 (Brian Fox v. Blue Cross and Blue Shield of Florida Inc., No. 12-14569, 11th Cir.; 2013 U.S. App. LEXIS 7906).

    Supreme Court Denies Review Of 7th Circuit Indiana Medicaid Dental Care Dispute

    WASHINGTON, D.C. - The U.S. Supreme Court on April 22 denied a writ of certiorari to the Indiana Family and Social Services Administration's appeal of a federal appeals court decision requiring the state Medicaid agency to cover all "medically necessary" dental care. The Seventh Circuit U.S. Court of Appeals on Sept. 26 affirmed a federal court order granting a class of Medicaid plaintiffs from Indiana preliminary injunctive relief in their challenge of the state's cap on "medically necessary" dental care under the state's Medicaid program (Sandra M. Bontrager, et al., v. Indiana Family and Social Services Administration, et al., No. 12-1037, U.S. Sup.).

    4th Circuit Affirms Health Care Fraud Conviction Against Doctor

    RICHMOND, Va. - The Fourth Circuit U.S. Court of Appeals on April 23 affirmed a federal jury conviction of a Maryland cardiologist for health care fraud, saying there was sufficient evidence that he willfully made false statements and submitted fraudulent bills to Medicare, Medicaid and private insurers for medically unnecessary cardiac stent procedures (United States of America v. John R. McLean, No. 11-5130, 4th Cir.; 2013 U.S. App. LEXIS 8160).

    6th Circuit Affirms Decision In Medicaid Payment Dispute

    CINCINNATI - A Sixth Circuit U.S. Court of Appeals panel on April 22 affirmed that the U.S. Department of Health and Human Services secretary's decision to omit waiver-expansion population patients from the Medicaid fraction provision in the disproportionate share hospital (DSH) adjustment calculation was based on a permissible construction of the DSH statute (Adventist Health System/Sunbelt Inc. v. Kathleen Sebelius, No. 11-5990, 6th Cir.; 2013 U.S. App. LEXIS 7907).

    FTC Seeks Expedited Remand In Hospital Merger Case

    ATLANTA - The Federal Trade Commission on April 18 asked the 11th Circuit U.S. Court of Appeals to issue an expedited order remanding its challenge to the merger between Georgia hospitals following the U.S. Supreme Court's recent ruling that the state-action doctrine does not immunize the merger from antitrust scrutiny (Federal Trade Commission v. Phoebe Putney Health System, Inc., et al., No. 11-12906, 11th Cir.).

    Ark. Federal Judge Declines To Dismiss Wrongful Rescission Of Health Policy Suit

    JONESBORO, Ark. - An Arkansas federal judge on April 18 denied a health insurer's motion to dismiss a wrongful rescission of a health insurance policy, saying the plaintiff pleaded a plausible claim for breach of contract (William Masterson v. Starr Indemnity & Liability Co., No. 13-79, E.D. Ark.; 2013 U.S. Dist. LEXIS 55641).

    9th Circuit: Medicare Does Not Allow Insurer To Recover Survivor's Benefits

    SAN FRANCISCO - A Ninth Circuit U.S. Court of Appeals panel on April 19 affirmed that a private Medicare Advantage Organization (MAO) plan cannot sue a plan participant's survivors for reimbursement of expenses paid out of the proceeds of an automobile insurance policy (Guillermina Parra, et al. v. PacifiCare of Arizona Inc., No.11-16069, 9th Cir.; 2013 U.S. App. LEXIS 7861).

    New York Federal Judge Dismisses Copay Dispute For Lack Of Standing

    NEW YORK - A New York federal judge on April 19 dismissed a health care copayment dispute, finding that the plaintiff lacked standing to bring her claims (Marianne Gates v. United Healthcare Insurance Co., et al., No. 11-3487, S.D. N.Y.; 2013 U.S. Dist. LEXIS 56619).

    Texas Supreme Court: Providers Cannot Assert Pay Violation Against HMO

    AUSTIN, Texas - The Texas Supreme Court on April 19 held that health care providers could not assert a prompt-pay violation against a health maintenance organization because it had contracts only with the HMO's network and not the HMO (Christus Health Gulf Coast, et al. v. Aetna Inc., et al., No. 11-483, Texas Sup.; 2013 Tex. LEXIS 296).

    Mich. Appeals Court Affirms, Reverses Class Order In Reimbursement Suit

    DETROIT - A Michigan appeals panel on April 18 partially affirmed and partially reversed class certification in a suit alleging that a health insurer failed to properly reimburse chiropractors (Michigan Association of Chiropractors, et al. v. Blue Cross Blue Shield, No. 304763, Mich. App.; 2013 Mich. App. LEXIS 721).

    Michigan Appeals Court Modifies Class Definitions In Reimbursement Dispute

    DETROIT - A Michigan appeals panel on April 18 partially affirmed and partially reversed class certification of five classes in a suit alleging that a health insurer failed to properly reimburse chiropractors (Michigan Association of Chiropractors, et al. v. Blue Care Network of Michigan Inc., No. 304783, Mich. App.; 2013 Mich. App. LEXIS 724).

    Oklahoma Federal Judge Declines To Dismiss Prescription Drug Payment Suit

    OKLAHOMA CITY - An Oklahoma federal judge on April 18 denied a motion to dismiss a breach of contract claim related to the payment for prescription drugs, saying that the court had personal jurisdiction over the out-of-state defendants and that the plaintiff sufficiently supported its claims (Pharmacy Providers of Oklahoma Inc. v. Q Pharmacy Inc., et al., No. 12-1405, W.D. Okla.; 2013 U.S. Dist. LEXIS 55567).

    Pa. Federal Judge Grants Preliminary Injunction In Birth Control Mandate Case

    PITTSBURGH - A Pennsylvania federal judge on April 19 granted a motion for a preliminary injunction in a case brought by a private, nonprofit college, two for-profit entities and the owners of those entities who are challenging the "birth control" mandate contained in the Patient Protection and Affordable Care Act (PPACA) (Geneva College, et al. v. Kathleen Sebelius, et al., No. 12-207, W.D. Pa.; 2013 U.S. Dist. LEXIS 56087).

    Federal Judge Dismisses 4 Defendants In Payment Dispute; 7 Defendants Remain

    NEWARK, N.J. - A New Jersey federal judge on April 17 dismissed claims against four health care payers in a reimbursement dispute, saying that either the defendants were not subject to the Employee Retirement Income Security Act or were not proper parties; he left claims against seven other defendants, saying that the plaintiff exhausted administrative remedies before filing suit (Sportscare of America v. Multiplan Inc., et al., No. 10-4414, D. N.J.; 2013 U.S. Dist. LEXIS 54947).

    Va. Provider Must Repay Medicaid For Services By Unqualified Workers

    RICHMOND, Va. - The Virginia Court of Appeals on April 16 affirmed a trial court order granting summary judgment to the Virginia Department of Medical Assistance Services (DMAS) ordering the Family Redirection Institute Inc. (FRI) to reimburse the state Medicaid program for payments made to FRI for services by unqualified mental health care professionals (Family at Redirection Institute Inc. v. Commonwealth of Virginia Department of Medical Assistance Services, No. 1274-12-2, Va. App.; 2013 Va. App. LEXIS 116).

    Louisiana Federal Judge Affirms Denial Of Benefits, Says Plan Excluded Coverage

    LAFAYETTE, La. - A Louisiana federal judge on April 11 granted summary judgment in favor of a health insurance company in a wrongful denial of benefits case, agreeing with the insurer that the plan excluded coverage for bariatric surgery and complications arising from the surgery (Amy Macip v. Louisiana Service & Indemnity Co., No. 10-1678, W.D. La.; 2013 U.S. Dist. LEXIS 53342).