Managed Care Litigation Update Volume 217: January 31, 2023

• Publication year: 2023

NEWSWORTHY

District court grants motion for summary judgment in favor of ERISA plan, which is defending denial of residential care claims for lack of medical necessity. The Court held that the plan did not abuse its discretion. Howard W, et al. v. Providence Health Plan, et al., USDC WD WA, No. 2:21-cv-1346-JHC, (Doc. 68, filed Jan. 23, 2023).

District court grants, in part, plan's motion to dismiss counterclaims of OON Covid testing laboratory, finding that there is no private right of action under the CARES Act and that correspondence concerning the claims did not create contract to pay advertised charges. BCBSM, Inc. v. GS Labs, LLC, USDC D. MN, No. 0:22-cv-513-ECT-DJF, 2023 WL 1110453, (Doc. 68, filed Jan. 30, 2023). Previously reported at MCLU Vol. 196.

District court grants motion to dismiss breach of fiduciary duty claims against ERISA plan where plaintiffs assert a putative class action challenging underpayment of post-mastectomy claims of co-surgeons. Joseph F. Tamburrino, M.D., et al. v. United Healthcare Insurance Company, USDC D. NJ, No. 2:21-cv-12766-SDW-ESK, (Doc. 51, filed Jan. 26, 2023). Previously reported at MCLU Vol. 179.

RECENTLY FILED ACTIONS

Rowe Plastic Surgery of New Jersey, LLC, et al. v. Aetna Health and Life Insurance Company, U.S.D.C. E.D. NY, Doc. No. 2:23-cv-271-JMA-AYS, (filed Jan. 16, 2023). Removed action in which OON plastic surgeon seeks benefits and asserts underpayment associated with bilateral breast reduction. Billed charges were $150,000 for each co-surgeon, and the amounts paid were $35,127.92 and $1,773.81, respectively. Other actions by this provider reported at MCLU Vol. 187, 188, 192, 194, 203, 204, 206 - 215.

RECENTLY FILED ACTIONS

Jeffrey Farkas, M.D., LLC v. Cigna Health and Life Insurance Company, U.S.D.C. E.D. NY, Doc. No. 2:23-cv-284-JS-JMW, (filed Jan. 17, 2023). OON neurologist seeks benefits and alleges underpayment of emergency brain surgery following stroke. Billed charges were $128,000 and the amount paid was $1,395.67. Other actions by this provider reported in MCLU Vol. 77, 79, 80, 84, 113, 154, 157, 158, 160, 171, 177, 209.

Lori K. Harwood v. Aetna Health of Michigan, Inc., U.S.D.C. E.D. MI, Doc. No. 2:23-cv-10118-GAD-CI, (filed Jan. 17, 2023). Member seeks Medicare Advantage benefits for inpatient rehabilitation following cardiac arrest event. Plaintiff asserts her MA plan inappropriately applied an "Improvement Standard" in denying the authorization request as not medically necessary.

Norman...