Managed Care Litigation Update Volume 197: March 31, 2022

• Jurisdiction: United States,Federal
• Publication year: 2022
• Citation: Vol. 197

NEWSWORTHY

Ninth Circuit reverses district court judgments requiring reprocessing of 67,000 behavioral health claims and rules that "UBH's interpretation—that the Plans do not require consistency with the [Generally Accepted Standards of Care]—was not unreasonable" and therefore UBH did not abuse its discretion in applying its behavioral health guidelines. David Wit, et al. v. United Behavioral Health, USAC 9^th Cir., No. 20-17363, (Doc. 92-1, filed Mar. 22, 2022), 2022 WL 850647.

District court grants summary judgment in favor of air ambulance provider requiring payment of $295,600 where plan sought to negotiate an allowance of $295,600 "subject to benefit determinations" when payment of only $16,646.82 was subsequently received. Aerocare Medical Transport System, Inc. v. Advanced Homecare Management, Inc., USDC ND IL, No. 1:20-cv-1735, (Doc. 46, filed Mar. 29, 2022), 2022 WL 910542.

District court grants plan's motion to dismiss underpayment claims where billed charges were $79,252.34 and the amount paid was $1,312.64. The breach of contract and promissory estoppel claims were dismissed for failure to state a claim and the prompt pay and unjust enrichment claims were dismissed as preempted by ERISA. Anjani Sinha Medical P.C. v. Empire Healthchoice Assurance, Inc., USDC ED NY, No. 1:21-cv-138-RPK-TAM, (filed Mar. 31, 2022), 2022 WL 970771. Previously reported in MCLU Vol. 168.

RECENTLY FILED ACTIONS

California Physicians' Service v. Homeland Insurance Company of New York, et al., U.S.D.C. N.D. CA, Doc. No. 3:22-cv-1695-SK, (filed Mar. 16, 2022). Plan seeks E&O coverage for similar lawsuits by Prime hospitals alleging underpayment of OON emergency care. At issue is whether the $3 million self-insured retention is owed for each of the separate, similar lawsuits.

Surgery Center of Viera, LLC v. Cigna Health and Life Insurance Company, et al., U.S.D.C. M.D. FL, Doc. No. 6:22-cv-542-PGB-GJK, (filed Mar. 16, 2022). Removed action in which OON emergency services provider seeks ERISA benefits and alleges underpayment. Billed charges were $167,168 and the amount paid was $8,029.47. Other actions filed by this provider are reported in multiple MCLU Vols.

Princeton Neurological Surgery, P.C. v. Aetna, Inc., et al., U.S.D.C. D. NJ, Doc. No. 3:22-cv-1414-FLW-DEA, (filed Mar. 16, 2022). Removed action in which OON neurosurgery specialist seeks ERISA benefits and alleges underpayment associated with surgery to treat C5-6, C6-7 disc herniation and spondylosis with foraminal stenosis. Billed charges were $304,715 and the amount paid was $3,319.36.

Same Day Procedures, LLC v. Cigna Corp., et al., U.S.D.C. D. NJ, Doc. No. 2:22-cv-1533-JMV-MAH, (filed Mar. 18, 2022). Removed action in which OON practice asserts eleven New Jersey causes of action and alleges $1.7 million underpayment of claims associated with ERISA plans where 16% of billed charges were paid.

RECENTLY FILED ACTIONS

Saloojas, Inc. v. Aetna Health of California, Inc., U.S.D.C. N.D. CA, Doc. No. 3:22-cv-1696-JSC, (filed Mar. 16, 2022). Removed action in which laboratory seeks benefits and asserts underpayment of...