General Business Health Civil Procedure

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Fifth Circuit Affirms Order Compelling Arbitration Against Non-Signatories Based On “Intertwined Claims” Estoppel

A physician sued several healthcare entities for wrongful termination of employment, negligence, breach of contract, and tortious interference with at-will employment. While two of the defendants were signatories to...more

Refusal to Pay Claims to Gain Negotiating Leverage Is Abuse of Discretion Under ERISA, Court Says

A federal district court found that Cigna Healthcare abused its discretion, and thus was liable under section 502(a)(1)(B) of ERISA, when its primary motivation for refusing to pay a hospital’s claims was to enhance its...more

A Superficial Analysis of Competitive Foreclosure Won’t Play in Peoria

A federal trial court rejected a hospital’s antitrust claims that it was substantially foreclosed from the market by its rival’s exclusive contracts with payors. The court concluded that foreclosure in healthcare services...more

Dealing with Long-Winded Out-of-Network Provider Nuisance Letters

Over the past couple years, more and more of my clients with self-funded plans have received letters from out-of-network providers appealing denied claims. The letters are usually 20 to 30 pages long, not very specific, and...more

Big Summary Judgment Win for Hospital Defending $300M Exclusive Dealing Antitrust Suit

After fending off a motion for judgment on the pleadings in March 2015, a small hospital in Peoria, Illinois lost on summary judgment in its $300 million antitrust suit alleging illegal exclusive dealing and attempted...more

One Year Later: The Yates Memo, False Claims Act and Director & Executive Liability

On September 19 and 27, 2016, the US Department of Justice announced two False Claims Act settlements that required corporate executives to make substantial monetary payments to resolve their liability. How will director and...more

Florida Federal District Court Dismisses Plaintiff’s Qui Tam Action Against Hospice Providers

On September 22, 2016, the United States District Court for the Middle District of Florida granted defendant hospice providers’ motions to dismiss plaintiff-relator’s claims under the False Claims Act, Florida’s False Claims...more

Eleventh Circuit Finds Mere Existence Of Insurance Contract Satisfies Condition Precedent To Action For Double Damages Under The...

The Eleventh Circuit Court of Appeals recently held that a private insurance company/PART C Medicare Advantage Organization (MAO) may sue a Personal Injury Protection (PIP) insurance carrier for reimbursement of medical...more

US Supreme Court False Claims Act Decision in Escobar Has Significant Implications for Contractors

On June 16, 2016, the U.S. Supreme Court ruled in the matter of Universal Health Services, Inc. v. United States ex rel. Escobar, 136 S. Ct. 1989 (2016), changing the legal landscape for False Claims Act qui tam claims...more

11th Circuit Awards Humana Double Damages Under Medicare Secondary Payer Act

Humana Medical Plan, Inc. v. Western Heritage Insurance Co., case number 15-11436. Liability insurers beware, as the 11th Circuit held that Medicare Advantage Organizations (MAO) are entitled to the same rights...more

No Resuscitation of Hospital’s Exclusive Dealing Antitrust Suit against Competing Hospitals and Physicians

The Third Circuit reminds, “[i]n antitrust suits, definitions matter.” Last week, in applying that maxim, the court affirmed a lower court’s dismissal of a suit filed by a hospital against a competing hospital and physician...more

The Dennis Decision: A Shot Across the Bow for Hospitals

A recent Virginia court decision questions the reasonable value of health care services and creates a challenge to debt collection efforts by hospitals. In March, the Circuit Court for Henry County, Patrick County, and the...more

No Health Insurers Need Apply: Health Plan Can’t Recover Medical Costs From NY No-Fault Insurer

Under no-fault laws, automobile policies typically must cover the cost of certain medical services provided to policyholders who have been injured in covered accidents. New York’s insurance laws also permit those costs to be...more

Is There Coverage for The Pill Mill Lawsuits?

In an effort to deal with the terrible epidemic of drug abuse and the human and economic costs of this dilemma, the state of West Virginia has brought lawsuits in several jurisdictions against pharmaceutical companies and...more

Illinois Supreme Court Upholds "Willful and Wanton" Immunity Protection in Peer Review Cases

Background - Dr. Steven Valfer is a licensed OB-GYN who was a member of the medical staff at Evanston Northwestern Hospital ("Hospital") until March 16, 2005 when the Hospital's board of directors approved the...more

Corridors - June 2016 - News for North Carolina Hospitals

Final CMS Rule on the Reporting and Returning of Medicare Overpayments Is a Wake-Up Call for Physicians - Effective March 14, 2016, a final rule published in February 2016 by the Centers for Medicare and Medicaid...more

New Restrictions on Physician Non-Competes in Connecticut

A new Connecticut law significantly restricts the use of physician non-compete agreements. Public Act No. 16-95 (the “Act”), signed into law by Governor Dannel Malloy on June 2, 2016, limits the allowable duration and...more

Employees and Employers

Following are two interesting and recent federal court rulings related to arbitration. Future Disputes are beyond Arbitral Authority Minnesota Nurses Association v. North Memorial Health Care After completing 30...more

Federal District Court Confirms Arbitration Award In Hospital Services Dispute

Weirton Medical Center, Inc. (“WMC”), a hospital in West Virginia, entered into an agreement with QHR Intensive Resources, LLC, under which QHR provided hospital administrative services. WMC ultimately terminated the...more

False Claims Act “Implied Certification” Update: Supreme Court Oral Argument Forecasts Continued Vitality of Controversial...

The U.S. Supreme Court heard oral argument on April 19, 2016, in United Health Services v. United States ex rel. Escobar, No. 15-7, a case expected to resolve the current split among federal appellate courts on the so-called...more

Supreme Court Hears Oral Arguments in Significant False Claims Act Case

Our colleagues Jackie Baratian and Jason Popp summarize...the oral argument for Universal Health Services v. United Sates ex rel. Escobar heard by the U.S. Supreme Court on Tuesday, April 19th, laying out the various...more

Rhode Island Trial Court Decision Could Spell Trouble for Employers Seeking to Enforce Restrictive Covenants Against Healthcare...

One of an employer’s first steps in a suit against a former employee to enforce a restrictive covenant is to seek a preliminary injunction to prevent the employee from continuing to violate his or her contractual obligations....more

What You Say in Your SPD About Claims Processing Makes a Difference

Employers who self fund their medical plans often have contracts with their third party administrators about claims processing. Some of those contracts provide that the claims processor has discretion to decide claims; others...more

Insurer Must Defend Data Breach Claim Under Traditional Commercial General Liability Policies

On April 11, 2016, the U.S. Court of Appeals for the Fourth Circuit affirmed a ruling by Judge Gerald Bruce Lee of the U.S. District Court for the Eastern District of Virginia that Travelers Indemnity Company of America...more

Did the FCA’s “Implied Certification” Theory Dodge a Bullet?

Yesterday’s argument before the Supreme Court in Universal Health Services, Inc. v. U.S. ex rel. Escobar had the potential to put false claims based on an “implied certification” in the crosshairs. Instead, based on the...more

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