Managed Care Litigation Update Volume 206: August 15, 2022

• Publication year: 2022

NEWSWORTHY

District court dismisses underpayment claim by OON provider where provider failed to exhaust the administrative appeals applicable to the state plan. Modern Orthopedics of New Jersey v. Horizon Healthcare Services, Inc., USDC D NJ, No. 21-cv-20174, 2022 WL 3211417, (Doc. 13, filed Aug. 8, 2022). Previously reported at MCLU Vol. 189.

District court grants summary judgment in favor of UHC, affirming denial of extended residential care after covering two weeks of care, applying the arbitrary and capricious standard. Ian C., et al. v. United Healthcare Insurance Company, USDC D UT, No. 2:19-cv-474-HCN, 2022 WL 3279860 (Doc. 64, filed Aug. 11, 2022). Previously reported at MCLU Vol. 132.

Summary judgment granted in favor of beneficiary who alleged wrongful denial of claim for residential care, where the Court applied the abuse of discretion standard, and determined that the "barebones" denial letter failed to discuss any parts of the record or evidence that beneficiary submitted or relied upon. Doe v. Blue Shield of California, USDC ND CA, No. 21 -cv-2138-RS, 2022 WL 3155158 (Doc. 52, filed Aug. 8, 2022). Previously reported at MCLU Vol. 173.

Partial summary judgment granted, dismissing certain IONM claims from OON provider for lack of evidence demonstrating breach of PPO plans, holding that plaintiff failed to identify evidence showing that Defendant specifically promised the provider would be paid a reasonable amount for providing the services. MedARC, LLC, et al. v. Scott and White Health Plan, USDC ND TX, No. 3:20-cv-3241-BH, 2022 WL 3044569 (Doc. 58, filed Aug. 1, 2022). DISCLOSURE - I am counsel of record for SWHP.

RECENTLY FILED ACTIONS

East Coast Spine Joint and Sports Medicine v. Anthem Blue Cross Blue Shield, et al., U.S.D.C. D. NJ, Doc. No. 2:22-cv-4841-WJM-JBC, (filed Aug. 1, 2022). Removed action in which OON orthopedic surgeon seeks $139,444.92 in benefits and alleges underpayment on preapproved claim. Billed charges were $142,072 and the amount paid was $2,627.08. Other claims by this provider reported at MCLU Vols. 95, 130, 139, 147, 151, 162, 166, 180, 187, 195, 197, 199.

Fairview Health Services v. Cigna Behavioral Health, Inc., et al. U.S.D.C. D. MN, Doc. No. 0:22-cv-1910-MJD-JFD, (filed Aug. 1, 2022). Removed action in which in-network mental health services provider seeks $86,770.95 in ERISA benefits associated with residential treatment. A portion of the claim was denied as not medically necessary and the provider challenges this determination.

RECENTLY FILED ACTIONS

SC Shine PLLC v. Aetna Dental Inc., U.S.D.C. W.D. TX, Doc. No. 5:22-cv-834-JKP, (filed Aug. 7, 2022). Removed action in which dental provider seeks $1,026,157 in benefits associated with treatment of seven members, including those insured by ERISA plans. Provider asserts implied conduct based on course of dealing. Underlying complaint indicates Aetna had raised concerns regarding alleged overutilization of x-rays.

Jeffrey M. Glauber v. United Healthcare Insurance Company, U.S.D.C. S.D. FL, Doc. No. 9:22-cv-81215-RS, (filed Aug. 2, 2022). Member seeks ERISA benefits associated with pre-authorized "major orthognathic double jaw surgery" performed by 00N surgeon. Billed charges were $52,575 and the amount allowed was $3,488.67.

Rachel Davis, et al. v. Cigna Health and Life Insurance...