WASHINGTON, D.C. - The State of Vermont and an insurer squared off before the U.S. Supreme Court Dec. 2 in oral arguments over whether the Employee Retirement Income Security Act, as amended by the Patient Protection and Affordable Care Act (ACA), preempts state level collection of health insurance data (Alfred Gobeille, in his official capacity as chair of the Vermont Green Mountain Care Board v. Liberty Mutual Insurance Co., No. 14-181, U.S. Sup.).
NEW YORK - The Second Circuit U.S. Court of Appeals on Oct. 15 determined that a health benefits insurer did not wrongfully deny a claim for residential treatment because four physicians noted in the administrative record that residential treatment was not necessary (Neil Tansey, et al. v. Anthem Health Plans Inc., et al., No. 14-3931, 2nd Cir.; 2015 U.S. App. LEXIS 17889).
CHICAGO - Because a number of medical providers alleging that an insurer wrongfully reduced payments on health claims are not beneficiaries to an insurance contract, they are not entitled to allege claims under the Employee Retirement Income Security Act of 1974, the Seventh Circuit U.S. Court of Appeals said Oct. 1 in reversing a district court's ruling in favor of the medical providers (Pennsylvania Chiropractic Association et al. v. Independence Hospital Indemnity Plan Inc., Nos. 14-2322, 14-3174 & 15-1274, 7th Cir.; 2015 U.S. App. LEXIS 17269).
GREENVILLE, S.C. - A health insurer was not the primary payer for an employee's medical claims because the plan at issue clearly stated that Medicare was the primary payer if an insured received Medicare benefits, a South Carolina federal judge said Sept. 30 (Jennifer Perkins v. US Airways Inc., et al., No. 14-2577, D. S.C.; 2015 U.S. Dist. LEXIS 132502).
ST. LOUIS - A multiemployer health fund is not entitled to equitable relief in the amount it paid in medical benefits to students who were also covered by student accidental medical insurance under the fund's coordination-of-benefits provision pursuant to the Employee Retirement Income Security Act, the Eighth Circuit U.S. Court of Appeals affirmed Aug. 10 (Central States, Southeast and Southwest Areas Health and Welfare Fund v. Student Assurance Services, Inc., et al., No. 14-2376, 8th Cir.; 2015 U.S. App. LEXIS 13941).
PHILADELPHIA - A federal judge in Pennsylvania did not err when sentencing a woman to 96 months in prison for her role in an insurance fraud scheme that resulted in Medicare and other supplemental insurers paying approximately $1.8 million in false claims, a Third Circuit U.S. Court of Appeals panel ruled July 23, finding that the judge properly found that the defendant's scheme involved 10 or more victims (United States of America v. Anna Mudrova, No. 14-3580, 3rd Cir.; 2015 U.S. App. LEXIS 12733).
NEW YORK - Health care providers are not beneficiaries of their patients' health insurance plans and, therefore, do not have standing to assert anti-retaliation protections under the Employee Retirement Income Security Act, the Second Circuit U.S. Court of Appeals affirmed July 15 (Henry L. Rojas, M.D., et al. v. Cigna Health and Life Insurance Company, et al., No. 14-3455, 2nd Cir.; 2015 U.S. App. LEXIS 12210).
ATLANTA - An 11th Circuit U.S. Court of Appeals panel on July 15 found no error in a federal judge in Florida's decision to sentence a pharmacy owner to 144 months in prison, ruling that the judge did not err when finding that the defendant's fraudulent billing of prescription medication to Medicare resulted in an intended loss of $2.5 million to the government and that the evidence supported the defendant's conviction for conspiracy to commit health care fraud (United States of America v. Guido Halayn De La Torre, No. 13-15179, 11th Cir.; 2015 U.S. App. LEXIS 12179).
PHILADELPHIA - A Pennsylvania Superior Court panel on July 7 affirmed the conviction of a pain clinic owner for conspiracy, theft and insurance fraud after finding that the evidence presented during his trial supported the verdict and that the trial court judge did not err when allowing the Commonwealth of Pennsylvania's insurance billing expert to offer lay testimony (Commonwealth of Pennsylvania v. Owen Rogal, No. 5 EDA 2014, Pa. Super.; 2015 Pa. Super. LEXIS 397).
BOSTON - A former district sales manager for drug maker Warner Chilcott Sales U.S. LLC on July 7 pleaded guilty to one count of conspiracy to commit health care fraud for directing a scheme to have other sales representatives submit falsified authorizations for the osteoporosis drugs Actonel and Atelvia (United States of America v. Jeffrey Podolsky, No. 15-cr-10132, D. Mass.).
MIAMI - The U.S. Department of Justice announced July 2 that American Access Care Holdings (AAC) agreed to pay $1.2 million to resolve allegations that it violated the False Claims Act by billing Medicare for medically unnecessary percutaneous transluminal angioplasties (PTAs) and thrombectomies and by billing for more PTAs per patient encounter than permitted (United States of America, ex rel. Dennis Souza v. American Access Care of Miami LLC, No. 11-cv-22686, S.D. Fla.).
CHICAGO - An attorney may not recover fees under the common-fund doctrine in addition to or in lieu of fees awarded under a fee-shifting statute like the Employee Retirement Income Security Act "in the absence of a contract," the Seventh Circuit U.S. Court of Appeals ruled July 1 (Darryl Pierce, et al. v. Visteon Corporation, et al., No. 14-2542, 7th Cir.; 2015 U.S. App. LEXIS 11333).
WASHINGTON, D.C. - The U.S. Supreme Court on June 29 granted review of a divided Second Circuit U.S. Court of Appeals ruling that the Employee Retirement Income Security Act preempts Vermont's health care data collection law, which requires health care payers to report claims and health care-services data to a state agency, as applied to a self-funded ERISA benefit plan or its third-party administrators (Alfred J. Gobeille v. Liberty Mutual Insurance Company, No. 14-181, U.S. Sup.).
PHILADELPHIA - An expert may opine regarding, among other things, how Patient Protection and Affordable Care Act (ACA) medical loss ratio (MLR) regulations affect class ascertainability, a federal judge held June 30 in decertifying a class of indirect purchasers of Wellbutrin XL (In re: Wellbutrin XL Antitrust Litigation, No. 08-2433, E.D. Pa.; 2015 U.S. Dist. LEXIS 84444).
TALLAHASSEE, Fla. - A trial court erred in ordering a hospital to produce confidential contracts between it and 37 health insurers, a Florida appeals panel ruled June 22, finding that the scope of the law under which the order was issued did not extend to such documents (Shands Jacksonville Medical Center Inc. v. State Farm Mutual Automobile Insurance Co., No. 1D14-2001, Fla. App., 1st Dist.).
WASHINGTON, D.C. - The Patient Protection and Affordable Care Act (ACA)'s structure suggests the availability of tax subsidies in the federal exchange, and Congress could not have intended the state insurance market "death spirals" likely to result from barring such subsidies, a divided U.S. Supreme Court held June 25 (David King, et al. v. Sylvia Mathew Burwell, et al., No. 14-114, U.S. Sup.).
WASHINGTON, D.C. - The U.S. Department of Justice announced June 16 that a Florida-based skilled nursing facility, its former president and executive director and its subsidiaries have agreed to pay $17 million to resolve allegations that it violated the False Claims Act (FCA) and Anti-Kickback Statute by improperly paying doctors for their referrals of Medicare patients to the defendants' facilities (United States of America, ex. rel. Stephen M. Beaujon v. Hebrew Homes Health Network Inc., et al., No. 12-cv-20951, S.D. Fla.).
WASHINGTON, D.C. - The U.S. Department of Justice on June 15 announced that Children's National Medical Center Inc., Children's Hospital and its affiliated entities (collectively CNMC) agreed to pay $12.9 million to resolve allegations in a False Claims Act (FCA) lawsuit that they submitted false cost reports to the U.S. Department of Health and Human Services (HHS) and Medicare programs in the District of Columbia and Virginia (United States of America, ex rel. James A. Roark Sr. v. Children's Hospital, et al., No. 14-cv-616, D. D.C.).
JACKSONVILLE, Fla. - The federal government filed an intervener complaint in Florida federal court on June 12 in a False Claims Act (FCA) and Anti-Kickback Statute lawsuit brought against an ambulance service company accused of engaging in a 10-year scheme in which it fraudulently billed Medicare for services that were medically unnecessary (United States of America v. Liberty Ambulance Services Inc., No. 15-cv-, M.D. Fla.).
BOSTON - A First Circuit U.S. Court of Appeals panel on June 10 affirmed the conviction and sentencing of man found guilty for his role in a scheme of fraudulently billing Medicare for durable medical equipment (DME), finding that the judge presiding over the case did not err in any of his evidentiary rulings and used the proper guidelines when determining his sentence (United States of America v. Blessing Sydney Iwuala, No. 13-2497, 1st Cir.; 2015 U.S. App. LEXIS 9685).
WASHINGTON, D.C. - The U.S. Supreme Court on June 8 denied the State of Maine's petition challenging mandatory continued Medicaid coverage for older children under the Patient Protection and Affordable Care Act's maintenance of effort requirements, according to the docket (Mary C. Mayhew, in her capacity as Secretary of the Maine Department of Health and Human Services v. Sylvia M. Burwell, et al., No. 14-992, U.S. Sup.).
WASHINGTON, D.C. - The U.S. Supreme Court on May 26 declined to review the Eighth Circuit U.S. Court of Appeals ruling that a shareholder-owner's state law claims related to improper cancellation of her health care coverage were preempted by the Employee Retirement Income Security Act (CeCelia Catherine Ibson v. United Healthcare Services, Inc., No. 14-1119, U.S. Sup.).
MEMPHIS, Tenn. - A Tennessee federal judge on May 18 declined to strike or exclude testimony of three experts for a couple alleging medical malpractice in the death of their 11-year-old son but ruled that testimony by a fourth expert for the plaintiffs should be excluded from trial based on state law geographic requirements and the relevancy of the testimony (Thomas G. Hensley, et al. v. Methodist Healthcare Memphis Hospitals, et al., No. 2:13-cv-02436, W.D. Tenn.; 2015 U.S. Dist. LEXIS 64518).
CHICAGO - Notre Dame is not entitled to a preliminary injunction while it challenges the opt-out provision of the Patient Protection and Affordable Care Act (ACA)'s contraceptive mandate, a divided Seventh Circuit U.S. Court of Appeals held May 19 (University of Notre Dame v. Kathleen Sebelius, et al., No. 13-3853, 7th Cir.).
NEW ORLEANS - A plan management agreement between Humana Health Plan and a health plan's administrator, which provided that Humana would supply subrogation and recovery services, did not vest Humana with discretionary authority sufficient to make Humana a fiduciary with standing to bring claims under the Employee Retirement Income Security Act, the Fifth Circuit U.S. Court of Appeals ruled 2-1 on May 11 (Humana Health Plan, Inc. v. Patrick Nguyen, No. 14-20358, 5th Cir.; 2015 U.S. App. LEXIS 7741).