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.).
NEWARK, N.J. - A New Jersey federal magistrate judge on Sept. 30 denied the New Jersey Department of Banking and Insurance's motion to quash a subpoena related to the denial of a woman's mental health treatments, saying a confidentiality provision in the state Health Care Quality Act is preempted by the Employee Retirement Income Security Act (Rachel B. v. Horizon Blue Cross Blue Shield of New Jersey, No. 14-cv-01153, D. N.J.; 2016 U.S. Dist. LEXIS 135547).
WASHINGTON, D.C. - The U.S. Supreme Court on Oct. 3 declined to review a woman's case involving, among other issues, the proper way to handle external benefit denial appeal after the Patient Protection and Affordable Care Act (ACA)'s amendments to the Employee Retirement Income Security Act (S.M. v. Oxford Health Plans [NY] Inc., et al., No. 15-1540, U.S. Sup.).
HOUSTON - The U.S. Department of Justice (DOJ) announced Sept. 28 that Vibra Healthcare LLC (Vibra), a Mechanicsburg, Pa.-based national hospital chain, has agreed to pay $32.7 million to resolve claims that it violated the False Claims Act (FCA) when billing Medicare for medically unnecessary services (United States of America, ex rel. Daniel v. Vibra Healthcare LLC, No. 10-5099, S.D. Texas).
CHATTANOOGA, Tenn. - A Tennessee federal judge on Sept. 27 ruled that a health care provider's attempt to file an amended complaint against BlueCross BlueShield of Tennessee Inc. (BCBST) for alleged violations of the Employee Retirement Income Security Act was "futile" and accepted a magistrate judge's report and recommendation that the action should be dismissed because the plaintiff lacked standing to bring its ERISA claims (Apple Corporate Wellness Inc. v. BlueCross BlueShield of Tennessee Inc., No. 1:15-cv-324, E.D. Tenn.; 2016 U.S. Dist. LEXIS 131929).
HARRISBURG, Pa. - A federal jury in Pennsylvania on Aug. 19 found no negligence in a doctor's failure to properly diagnose and treat a woman's herpes zoster virus after a judge ruled that the jury would not hear testimony regarding the potential availability of Patient Protection and Affordable Care Act (ACA) benefits (Tami Bernheisel v. Martin Mikaya, M.D., Memorial Hospital Inc., et al., No. 13-1496, M.D. Pa.).
ANCHORAGE, Alaska - An Alaska federal judge on Aug. 16 ruled that Alaska's Prompt Pay Statute, requiring insurers to pay benefit claims within 30 days, is preempted by the Employee Retirement Income Security Act for claims related to employee benefit plans and the Federal Employees Health Benefits Act (FEHBA) for claims related to federal worker benefit plans (John D. Zipperer Jr. v. Premera Blue Cross Blue Shield of Alaska, No. 3:15-CV-00208, D. Alaska; 2016 U.S. Dist. LEXIS 109531).
BAY CITY, Mich. - An Indian tribe's claim that its health care plan administrator violated the Employee Retirement Income Security Act fails because the tribe cannot establish that the administrator had a fiduciary duty under ERISA to ensure payment of Medicare-like rates (MLRs) for certain health services, a Michigan federal judge ruled Aug. 3 in dismissing the claim (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 101610).
CHICAGO - An Illinois judge on July 14 placed a Patient Protection and Affordable Care Act (ACA) health care marketplace co-op into rehabilitation because, according to the state's acting director of insurance, the insurer will suffer a $68 million loss due to the actions of Congress and the Centers for Medicare & Medicaid Services, which would place the insurer in a hazardous position (People of the State of Illinois, ex rel. Anne Melissa Dowling, Acting Director of Insurance of the State of Illinois v. Land of Lincoln Mutual Health Insurance Company, No. 2016CH09210, Ill. Cir., Cook Co., Chanc. Div.).
TAMPA, Fla - The owner of a company that provided durable medical equipment was sentenced by a federal judge in Florida on June 13 to 37 months in prison and ordered to pay $$918,402 in restitution for his role in a $2.5 million Medicare fraud scheme (United States of America v. Ubert G. Rodriguez, No. 13cr372, M.D. Fla.).
PHILADELPHIA- A spouse lacks standing to assert a claim under the Employee Retirement Income Security Act against his spouse's former employer regarding an alleged failure to timely send notice for health insurance coverage because the spouse was not a beneficiary or participant in the plan, the Third Circuit U.S. Court of Appeals affirmed June 13 in an unpublished opinion (John Sacchi v. Katheryn J. Luciani, et al., No. 15-1453, 3rd Cir.; 2016 U.S. App. LEXIS 10651).
DETROIT - Claims by a Native American tribe that Blue Cross Blue Shield of Michigan violated the Employee Retirement Income Security Act (ERISA) by overbilling the tribe for services rendered as third-party administrator for tribal members' health care claims survived a motion to dismiss April 27 when a federal judge in Michigan found that the tribe alleged sufficient facts to establish a right to relief on its ERISA claims (Little River Band of Ottawa Indians, et al. v. Blue Cross Blue Shield of Michigan, No. 15-13708, E.D. Mich.; 2016 U.S. Dist. LEXIS 55866).
WASHINGTON, D.C. - The U.S. Supreme Court on March 7 directed the Sixth Circuit U.S. Court of Appeals to reconsider its ruling that the Employee Retirement Income Security Act does not preempt a Michigan state law established to generate revenue necessary to fund the state's obligations under Medicaid in light of the Supreme Court's recent ruling in Gobeille v. Liberty Mutual Insurance Co. (Self-Insurance Institute of America v. Rick Snyder, et al., No. 14-741, U.S. Sup.).
NEWARK, N.J. - Olympus Corp. of the Americas and a Latin America subsidiary will pay $646 million in criminal and civil penalties for paying kickbacks to health care providers to buy its endoscopes and causing false claims to be paid by federal health care programs, according to documents filed March 1 in the U.S. District Court for the District of New Jersey (United States of America v. Olympus Corporation of the Americas, No. 16-3524, and United States ex rel. Slowik, et al. v. Olympus America. Inc., et al., No. 10-5994, D. N.J.).
WASHINGTON, D.C. - A Maryland woman pleaded guilty on Feb. 25 to charges of forging prescriptions and being involved with a health care fraud scheme and agreed to pay $16,175 (United States of America v. Claire Elizabeth Rice, No. 14-cr-56, D. D.C.).
CINCINNATI - A divided Sixth Circuit U.S. Court of Appeals panel on Feb. 8, based on the U.S. Supreme Court's decision in M&G Polymers USA, LLC v. Tackett (135 S. Ct. 926 ), 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, Nos. 14-3633 and 14-3918, 6th Cir.; 2016 U.S. App. LEXIS 2118).
MADISON, Wis. - A challenge by the University of Wisconsin Hospitals and Clinics Authority (UWHCA) of an insurer's denial of payment was rejected on summary judgment Jan. 25 by a Wisconsin federal judge in light of an anti-assignment provision in the parties' contract; the same day, UWHCA's state law claims against defendants Aetna Life Insurance Co., Aetna Health and Life Insurance Co. and Aetna Health Insurance Co. (Aetna, collectively) were dismissed in a related case as preempted by the Employee Retirement Income Security Act (University of Wisconsin Hospitals and Clinics Authority v. Aetna Life Insurance Company, et al., No. 14-779, W.D. Wis.; 2016 U.S. Dist. LEXIS 8093; University of Wisconsin Hospitals and Clinics Authority v. Aetna Life Insurance Company, et al., No. 15-286, W.D. Wis.; 2016 U.S. Dist. LEXIS 8091).
SAN JOSE, Calif. - In respective reply briefs filed Jan. 19, Anthem Inc. and related insurers argued in support of their motions to dismiss a putative class action over a January 2015 breach of Anthem's network, asserting that the plaintiffs did not adequately specify the allegedly breached contractual provisions (In Re: Anthem Inc., Customer Data Security Breach Litigation, No. 5:15-cv-02617, N.D. Calif.).