Managed Care Litigation Update Volume 222: April 15, 2023

• Publication year: 2023

NEWSWORTHY

District court grants in part and denies in part plan's MTD, finding provider failed to state an ERISA claim by failing to identify the plans or provisions the plan breached, but finding provider did state a claim for breach of provider contract without needing to specify a fee schedule. Texienne Physicians Medical Association, PLLC v. Health Care Service Corporation, USDC ND TX, No. 3:22-cv-0591-G, 2023 WL 2799726 (Doc. 52, filed Apr. 4, 2023). Previously reported at MCLU Vol. 195.

District court grants health plan's MTD, finding the provider failed to allege an assignment of benefits or basis for its alleged third-party beneficiary status. My Premier Nursing Care v. [ ], United Healthcare Insurance Co., USDC ED MI, No. 21-cv-12657, 2023 WL 2839073 (Doc. 24, filed Apr. 7, 2023).

District court grants in-network provider's MTD, finding the claims for reimbursement were barred by the contract limitation period. Blue Cross and Blue Shield of North Carolina v. MH Master Holdings, LLP, et al., NC Super., No. 22-cv-3957, 2023 WL 2928309 (filed Apr. 4, 2023).

District court grants plan's MTD, finding doctor's claims were subject to complete preemption under ERISA. Taylor B. Theunissen, MD, LLC, et al., v. United Healthcare of Louisiana, Inc., et al., USDC ED LA, No. 22-cv-2812, 2023 WL 2913523 (Doc. 47, filed Apr. 12, 2023). Previously reported at MCLU Vol. 207.

RECENTLY FILED ACTIONS

Gerard A. Begley DMD PA v. Horizon Blue Cross Blue Shield of New Jersey, et al., U.S.D.C. D. NJ, Doc. No. 2:23-cv-1871-MCA-JSA, (filed Apr. 3, 2023). Removed action in which OON physician and alleged assignee seeks ERISA benefits following treatment for injuries sustained in a bike accident, particularly "an open reduction with internal fixation via multiple surgical approaches of a right zygomaticomaxillary complex fracture." Billed charges were $49,000 and the amount paid was $1,920.24.

Cypress Emergency Room, LLC v. Bluecross and Blueshield of Texas, Inc., U.S.D.C. S.D. TX, Doc. No. 4:23-cv-1242, (filed Apr. 3, 2023). Removed action in which OON emergency care facility seeks ERISA benefits and alleges underpayment. Plaintiff alleges participation in the Texas mandatory mediation and now seeks benefits after the mediation was unsuccessful.

Modern Orthopaedics of New Jersey v. Anthem Blue Cross Blue Shield, et al., U.S.D.C. D. NJ, Doc. No. 2:23-cv-1864-CCC-JBC, (filed Apr. 3, 2023). Removed action in which OON emergency specialist performed certain treatment for a "left hand palmar complex laceration with tendon, nerve, and vessel injuries." Billed charges were $297,387 and the amount paid was $4,236.80.

RECENTLY FILED ACTIONS

Amy Nicki Stuckert v. Highmark Bluecross Blueshield of Western New York, U.S.D.C. W.D. NY, Doc. No. 1:23-cv-295-LJV, (filed Apr. 3, 2023). Removed action in which pro se member seeks $277,398.89 in ERISA...