Managed Care Litigation Update Volume 202: June 15, 2022

• Citation: Vol. 202
• Publication year: 2022

NEWSWORTHY

Supreme Court determines state may recover future medical expenses through its Medicaid subrogation rights, permitting recovery of settlement payments allocated for future medical care. Gallardo v. Martiller, USSC, No. 20- 1263, 596 U.S. ___, (Decided Jun. 6, 2022).

Ninth Circuit affirms summary judgment in favor of plan denying air ambulance claim for transport from Lima to Miami, where plan advised prior to transport that it would not be covered because it was not medically necessary. Continental Medical Transport, LLC v. Health Care Service Corp., USAC 9^th Cir., No. 21- 35481, 2022 WL 2045385 (Doc. 57, filed Jun. 7, 2022). Previously reported at MCLU Vol. 145.

District court dismisses behavioral health claims against third-party administrator of government plan where the SPD designated United Healthcare as the administrator and indicated the Plan was self-funded and solely responsible for paying benefits. Megan Daniels, et al. v. United Healthcare Services, Inc., et al., USDC WD WI, No. 19-cv-1038-WMC, 2022 WL 2116184, (Doc. 40, filed Jun. 13, 2022). Previously reported at MCLU Vol. 143.

District court dismisses chiropractor's suit alleging approximately $3 million underpayment where the Court was "flummoxed as to how Plaintiff can confidently contend that it has been underpaid when it has neither reviewed the Plan or Plans, nor delineated in the FAC any applicable terms of the Plan or Plans." Gotham City Orthopedics, LLC v. Cigna Health & Life Ins. Co., USDC D NJ, No. 21-cv-1703-SDW-LDW, 2022 WL 2116864, (Doc. 35, filed Jun. 13, 2022). Previously reported at MCLU Vol. 170.

RECENTLY FILED ACTIONS

Yvan Jayne v. Health Care Service Corporation, U.S.D.C. W.D. TX, Doc. No. 6:22-cv-564, (filed Jun. 1, 2022). Removed action in which member seeks benefits where hospital is balance billing following treatment for injuries incurred in a horse-riding accident. Billed charges were $85,458.54 and the balance billed amount is $48,526.16.

J.K., et al. v. Anthem Blue Cross and Blue Shield, et al., U.S.D.C. D. UT, Doc. No. 2:22-cv-370-JNP, (filed Jun. 2, 2022). Member seeks over $140,000 in ERISA benefits from self-funded plan for separate periods of residential treatment at Cascade Academy, LLC. The claims were denied as not medically necessary pursuant to the MCG guideline Residential Behavioral Health Level of Care, Adult.

RECENTLY FILED ACTIONS

A.H. v. Healthkeepers, Inc., U.S.D.C. D. UT, Doc. No. 2:22-cv-368-JCB, (filed Jun. 2, 2022). Member seeks over $250,000 in ERISA benefits associated with residential treatment at UINTA Academy. The claim was denied on the grounds the facility was not properly accredited.

Tzvi Small, M.D. v. Aetna Life Insurance Company, U.S.D.C. D. NJ, Doc. No. 2:22-cv-3401, (filed Jun. 2, 2022). Removed action in which OON plastic surgeon seeks benefits associated with allegedly pre-approved, post-mastectomy breast reconstruction where provider received in-network exception. Billed charges were $61,375. The claim was denied on the alleged mistaken grounds that no PA was provided. Other actions filed by this provider and reported in MCLU Vol. 96, 107, 108, 111, 159, 197.

Robert...