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Mealey's Health Law - Top Court Declines Review In Case Involving ACA-ERISA Appeal Interplay

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 ...

Mealey's Health Law - New Jersey Magistrate Denies Insurance Department Motion To Quash Subpoena

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...

Mealey's Health Law - High Court Denies Review Of Ruling On Standing To Sue Insurer Under ERISA

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...

Mealey's Health Law - Reconsideration Of Class Certification Denied In Suits Over Denial Of Care

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...

Mealey's Health Law - Skilled Nursing Facility, Director To Pay $2.5M Over Inflated Medicare Claims

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.

Mealey's Health Law - DOJ: Skilled Nursing Company, Owner, To Pay $145M To Settle Billing Suit

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...

Mealey's Health Law - 7th Circuit Panel Finds Suit Against Insurers Not Allowed By Section 502(a)(3)

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...

Mealey's Health Law - Texas Federal Judge Lets ERISA Claim Stand In Action Against Employer

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...

Mealey's Health Law - 5th Circuit Panel Upholds 97-Month Sentence For Health Care Fraud

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...

Mealey's Health Law - Federal Judge: Tribe's ERISA Claim Over 'Hidden' Plan Fees Can Proceed

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...

Mealey's Health Law - High Court Won't Review Reversal Of Benefits Ruling For Moen Inc. Retirees

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...

Mealey's Health Law - Class Claims Insurer Misrepresents Quality Of Replacement Plans

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...

Mealey's Health Law - DOJ: Co-Owner Of Home Health Care Agency Sentenced To 96 Months In Prison

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...

Mealey's Health Law - Home Health Agency Owner Convicted For Role In $13M Medicare Fraud Scheme

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).

Mealey's Health Law - Former Pharmacy Owner Convicted For Role In $700,000 Medicare Fraud Scheme

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...

Mealey's Health Law - Pennsylvania Federal Judge: ERISA Controls Breach Of Contract, Fiduciary Duty Claims

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...

Mealey's Health Law - Rehabilitator Asks Court To Order ACA Insurer Into Liquidation

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...

Mealey's Health Law - 6th Circuit Panel: Insureds Lack Sufficient Injury To Claim Insurer Shirked ERISA Duties

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...

Mealey's Health Law - 11th Circuit Panel Affirms COBRA Ruling In Favor Of Fired Staffing Employee

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...

Mealey's Health Law - 4th Circuit Upholds Requirement Of Proof Of Marriage For Health Insurance Coverage

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...

Mealey's Health Law - Judge Orders Health Care Fraud Defendant To Turn Over Retirement Funds

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...

Mealey's Health Law - DOJ: Neurosurgeon Sentenced To 235 Months In Prison For Fraud Scheme

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 ...

Mealey's Health Law - Supreme Court Won't Review 6th Circuit ERISA Preemption Ruling

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...

Mealey's Health Law - Michigan Tribe, Blue Cross Settle ERISA Plan Administration Claims

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...

Mealey's Health Law - Holistic Doctor's Expert Unqualified To Testify, Judge Finds

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...