Managed Care Litigation Update Volume 67: October 31, 2016

• Citation: Vol. 67
• Publication year: 2016

Newsworthy

BCBS Idaho sues USA for violations of the mandatory risk corridors payment obligations under the ACA. Blue Cross of Idaho Health Service Inc. v. USA, U.S. Court of Federal Claims, No. 16-01384, October 24, 2016.

Aetna sees rise in 3^rd quarter earnings with government business and cost cutting countering higher costs from ACA coverage. http://hosted.ap.org/dynamic/stories/U/US_EARNS_AETNA?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT

Presidential task force offers recommendations to improve mental health parity implementation. http://www.hhs.gov/about/aqencies/advisory-committees/parity/index.html

NY Attorney General and CIGNA reach settlement where prior authorization for medication to treat opioid addition is not required. http://www.americanbar.org/groups/health law/news/2016/10/nyattorney_general.html

Recently filed actions

Kayal Orthopaedic Center, P.C. v. Horizon Blue Cross Blue Shield of New Jersey, U.S.D.C. D. NJ, Doc. No. 2:16-cv-07378-JMV-JBC, (filed Oct. 17, 2016). Removed action in which provider and alleged assignee seek recovery of benefits for services rendered, contending that $10,214.00 is an underpayment against billed charges of $84,500.00. Basis for payment made is not set forth in underlying Complaint.

OSF Healthcare System d/b/a St. Francis Medical Center v. Peoria Riverfront Museum Group Employee Welfare Benefit Plan, et al., U.S.D.C. C.D. IL, Doc. No. 1:16-cv-01402-JBM-JEH, (filed Oct. 18, 2016). As against United Healthcare Insurance Company of the River Valley, plaintiff contends it is an assignee under the two member's health benefit plans at issue, that it received a payment of $39,830.80 against billed charges of $90,461.15 for one member, and a payment of $147,239.47 against $306,748.90 in billed charges for the other. Provider alleges Explanation of Benefits states (both patients), "charges exceeds [sic] a fee schedule/maximum allowable or contracted/legislated fee arrangement." Plaintiff additionally alleges (for one of the patients) the services were due to an emergent, life-threatening medical condition and that bill should be paid at emergent, in-network level. Other actions filed by this provider and reported in MCLU Vol. 6, 20, 22, 24, 31, 57, 58, 61, 62, 63, 65, 66.

Merge International, Inc., et al. v. Oxford Health Plans (NY), Inc., U.S.D.C. S.D. NY, Doc. No. 1:16-cv-08173-WHP (filed Oct. 19, 2016). Removed action where Notice of Removal states "the Plaintiffs' causes of action in this lawsuit relate to Oxford's...