Administrative Agency Civil Procedure Insurance

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If A Tree Falls In The City, Is It Serving A Public Purpose?

Today’s posting has nothing to do with corporate law and everything to do with trees. On November 30 and December 1, 2011, the City of Pasadena experienced an unusually violent windstorm. Wind speeds in excess of 100 miles...more

Florida Court of Appeal Holds Insured’s Death Alone Does Not Trigger Unclaimed Property Law Obligations

In an opinion filed August 5, Florida’s First District Court of Appeal held that Florida’s unclaimed property law does not make life insurance proceeds due and payable at the time of the insured’s death and does not impose an...more

A Tale of Two Circuits: D.C. Circuit, Fourth Circuit Split on ACA Subsidies

It was the best of times for ACA subsidies, it was the worst of times for ACA subsidies. On Tuesday, the Court of Appeals for the D.C. Circuit (“D.C. Circuit”) and the Court of Appeals for the Fourth Circuit (“Fourth...more

Harsh Justice

Concerned that its own decision might have "the potential to conflict" with that of the Pennsylvania Insurance Department, a Pennsylvania federal court relied on the primary jurisdiction doctrine to dismiss a putative class...more

High Court allows application for permission to bring judicial review proceedings relating to the jurisdiction of the Financial...

In this case report, Sarah Hitchins, an associate in Allen & Overy LLP’s Banking, Finance and Regulatory Litigation Group, considers the High Court’s decision to allow an application for permission to bring judicial review...more

Proposed Expansion of OIG’s Exclusion Authority

In May, the Office of Inspector General of the Department of Health and Human Services (OIG) proposed a new rule (Rule) that would implement changes included in the ACA. The Rule would expand OIG’s authority to exclude...more

I Can’t Get No SATISFACTION-- In the Eleventh Circuit, Is Discretionary Language Still "Satisfactory to Us"?

Ever since the United States Supreme Court addressed the question of whether a wholesale adoption of the "arbitrary and capricious" standard of review would be appropriate for judicial review of denial of benefit...more

Employee Benefit Plan is Governmental Plan, Even Though Employees are Not, says District Court in 11th Circuit.

It is a deceptively simple statement: Governmental employee benefit plans are exempt from ERISA. 29 U.S.C. § 1003(b)(1). But what about an employee benefit plan of an entity affiliated with a governmental entity, but whose...more

Unclaimed Property Round Up

The battle over unclaimed property continues to spawn increased litigation and regulatory activity. Litigation Highlights - In December 2013, a West Virginia court dismissed 63 lawsuits brought by the Treasurer...more

New York Trial Court Holds that Administrative Orders Do Not Constitute "Final Adjudications"

New York Trial Court Holds that Administrative Orders Do Not Constitute “Final Adjudications” For Purposes of Applying Fraud/Dishonesty Exclusion in Professional Liability Policy - A recent New York trial court...more

NC Medicaid Providers, Are You Required to Seek an Informal Appeal Prior to Filing a Contested Case at OAH?

Recently, numerous clients have come to me asking whether they have the right to appeal straight to the Office of Administrative Appeals or whether they have to attend informal appeals first, whether the informal appeal is...more

What Amount of Deference, If Any, Is Accorded to CMS' Interpretation of the State Operations Manual?

On May 17, 2013, the United States Court of Appeals for the Fifth Circuit (Court) ruled on a Petition for Review of a Decision of the United States Department of Health and Human Services (DHHS) in the case styled, Elgin...more

State Insurance Commissioner’s “Non-Binding” Opinion Banning Discretionary Language Has No Effect in Court

An Insurance Commissioner’s non-binding opinion banning discretionary language in an ERISA governed plan has no effect. Here’s the case of Frazier v. Life Insurance Company of North America, __ F.3d __ (6th Cir. August...more

Court Sides With CMS Stark Regulations on Physician-Owned Under Arrangement Service Providers

On May 24, the U.S. District Court for the District of Columbia in Council for Urological Interests v. Sebelius1 (‘‘CUI’’) sided with the Centers for Medicare & Medicaid Services in a lawsuit brought by a group of urologists...more

Court Grants Unexpected Victory to Providers on Medicare DSH Adjustment

The United States District Court for the Eastern District of Pennsylvania’s opinion in Nazareth Hosp. v. Sebelius, slip op. no. 10-3513 furnished a surprising victory to two providers that challenged the calculation of the...more

Recent Changes Impact Appeal of Medicare Denials and Reimbursement Strategies

Recovery Audit Contractors (“RACs”) and other Centers for Medicare and Medicaid Services (CMS) contractors are charged with identifying overpayments made by Medicare to healthcare providers. However, with the increase in RAC...more

Judge Invalidates California Regulation on Estimating Replacement Costs for Homeowners Insurance

On March 25, 2013, Los Angeles Superior Court Judge Gregory Alarcon issued a decision which found the California Department of Insurance’s regulation on estimating replacement costs for homeowners insurance to be invalid. The...more

Subrogation Claims are “Equitable Relief” Governed by ERISA

That subrogation claim you have might be governed by ERISA, at least in some circuits… Here’s the case of Thurber v. Aetna Life Insurance Company, __F.3d__ (2nd Cir. March 13, 2013) (Insurer’s counterclaim for return...more

Resubmission of Hospital Claims

On February 13, CGS Administrators, the Parts A and B Medicare Administrative Contractor for Kentucky and Ohio, relayed instructions to Medicare hospitals paid under the Inpatient Prospective Payment System from the Centers...more

No Judicial Review of Contractor’s Finding of a High Payment Error Rate, a Condition for Extrapolation

Before a Medicare contractor can use extrapolation to determine an overpayment amount, the Medicare statute requires that it must make a finding that there is a sustained or high level of payment error or that documented...more

U.S. Supreme Court Holds Equitable Tolling Doctrine Does Not Apply To Administrative Appeal Deadline

On January 22, 2013, the U.S. Supreme Court issued a unanimous decision in Sebelius v. Auburn Regional Medical Center, 568 U.S. _____ (2013), holding that hospitals cannot appeal Medicare inpatient reimbursement...more

California Federal District Court Holds Force-Placed Insurance Claims Not Preempted By National Bank Act

On December 11, the U.S. District Court for the Northern District of California refused to preempt under the National Bank Act claims that a mortgage lender breached its contract by force-placing a backdated flood insurance...more

The False Claims Act and Healthcare Providers: Key Results from 2012 and Likely Trends for 2013

From the perspective of False Claims Act (FCA) results, 2012 was a decidedly mixed year for healthcare providers. The bad news was quite bad—increased FCA scrutiny by the Department of Justice (DOJ) led to $3 billion of...more

Business Litigation Report -- December 2012

In This Issue: Firm News: ..Quinn Emanuel Deutschland Named “IP Law Firm of the Year” and “Patent Law Firm of the Year” by JUVE ..Intellectual Property Trial Lawyer Amar Thakur Joins Quinn Emanuel...more

Providers Again Win in Medicare Disproportionate Share Adjustment Challenge

In a 2011 decision, Northeast Hospital Corp. v. Sebelius, 657 F. 3d 1 (D.C. Cir. 2011), the United States Court of Appeals for the District of Columbia Circuit ruled for the providers in a challenge to the Secretary’s...more

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