- The insurance company Highmark, Inc. recently filed a suit against the federal government seeking $223 million in unpaid obligations it says it is owed for participating in exchanges created by the ACA. For more information on the case, see, First Priority Life Insurance Co. Inc. et al. v. U.S., case number 1:16-cv-00587, in the U.S. Court of Federal Claims.
- Two lawsuits were recently filed by physicians against Coventry Health Care of Florida, Inc., claiming that the health insurer underpaid out-of-network health providers by millions of dollars for their services to the HMO’s members. For more information on these cases, see, Hialeah Anesthesia Specialists et al. v. Coventry Health Care of Florida Inc., case number 2016-12264-CA-01, and Emergency Services of Zephyrhills PA et al. v. Coventry Health Care of Florida Inc., case number 2016-12265-CA-01, in the Circuit Court for the Eleventh Judicial Circuit of Florida.
- UnitedHealthcare recently filed a lawsuit in Florida claiming that a dialysis clinic operator has cost the insurer millions of dollars by pushing consumers into private kidney treatments instead of recommending what Medicaid would cover. Specifically, UnitedHealthcare claims that the provider pushed consumers to use private health insurance because it provided them with the greatest reimbursement rate (i.e. the facility could bill Medicare and Medicaid $300 for services it billed UnitedHealthcare $4,000 for). For more information on the suit and the alleged scheme, see, UnitedHealthcare of Florida Inc. et al. v. American Renal Associates Holdings Inc. et al., case number 9:16-cv-81180, in the U.S. District Court for the Southern District of Florida.
- Blue Shield of California recently has accused a public managed care organization of engaging in patient shifting to avoid paying for its most expensive patients. Specifically, Blue Shield has alleged that the managed care organization has cost the insurer nearly $12 million dollars by moving their most expensive patients to private insurance and paying those patients’ premiums so that they can afford to stay on the private plans. For more information on the suit, see, California Physicians’ Service v. Santa Barbara San Luis Obispo Regional Health Authority et al., case number CGC-16-552950, in the Superior Court of the State of California, County of San Francisco.
- A Colorado federal judge recently ruled to partly dismiss conspiracy allegations lodged against certain surgical centers by Aetna and UnitedHealthcare, stating that the Court did not agree that the centers committed fraud by waiving patient fees or violated antitrust laws by sending their bills to the insurers. Specifically, as the reduction in patient fees was to approximate in-network rates, the Court found that the insurers were not deceived. For more information on the suit, see, Kissing Camels Surgery Center LLC et al. v. Centura Health Corp. et al., case number 1:12-cv-03012, in the U.S. District Court for the District of Colorado.
- Over 400 hospitals have recently entered confidential settlements over disputed calculations of Medicare reimbursement for uncompensated care closing out lawsuits that had been ongoing since 2010. For more information on these claims, the lead case had been Alegent Health – Bergan Mercy Health System et al. v. Burwell, case number 1:10-cv-01354, in the U.S. District Court for the District of Columbia.
- A New Jersey church-affiliated hospital has urged the Supreme Court to rule that employee retirement plans maintained by church-affiliated hospitals are exempt from ERISA. This appeal comes in the wake of the Third Circuit’s December 2015 ruling that the exemption only applies to plans established by churches. For more information on the case, see, Laurence Kaplan v. Saint Peter's Healthcare System, et al, case number 15-1172, in the U.S. Court of Appeals for the Third Circuit.
- The DOJ recently announced that in conjunction with attorneys general from several states that they have filed lawsuits designed to block the Anthem-Cigna and Aetna-Humana mergers. For more information on the cases, see, United States of America et al. Anthem Inc. et al., case number 1:16-cv-01493, and United States of America et al v. Aetna, Inc. et al., case number 1:16-cv-01494 both in the federal district court for the District of Columbia.
- Recently, Anthem, Inc. had the remainder of claims it faced in a multidistrict litigation over their alleged use of distorted reimbursement rates for out-of-network services dismissed. Specifically, the California federal judge decided that the remaining policyholders had failed to prove injuries and filed untimely suits. For more information on the cases, see, In re WellPoint, Inc. Out-of-Network “UCR” Rates Litigation, case number 2:09-ml-02074, in the United States District Court for the Central District of California.
- A Florida appeals court recently reversed a lower court’s order compelling arbitration of a medical malpractice claim against a Kindred Healthcare entity signed by a patient which was void because it was against public policy. Specifically, the Court found that the arbitration agreement was void because the agreement incorporated some, but not all, of the provisions of Florida’s Medical Malpractice Act. For more information on the suit, see, Klemish et al. v. Villacastin et al., case number 5D15-2574, in the Fifth District Court of Appeal of Florida.