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The Check’s in the Mail - Who Is Responsible for Payment in a Delegated-Network System?

In today’s healthcare system, reimbursement issues involve not only prompt pay statutory provisions but also various risk-shifting arrangements included in a delegated-network system of managed care. When the insolvency of...more

Missouri Supreme Court Holds Federal Act Does Not Preempt Missouri Law Barring Subrogation Of Personal Injury Claims

In essence overruling a previous opinion from the courts of appeal, the Missouri Supreme Court has held that the Federal Employee Health Benefits Act (“FEHBA”) does not preempt Missouri law prohibiting the subrogation of...more

Courts Split On Whether Mandatory Contraceptive Coverage Violates Religious Freedoms Of For-Profit Corporations

Under the Patient Protection and Affordable Care Act’s preventive services mandate, non-grandfathered group health plans must provide 100% coverage of contraceptives for women, subject to exemptions and safe harbors for...more

Hospital’s State Law Claims against Health Plan Held Preempted by ERISA, Rules NJ Appellate Division

Last month a NJ Appellate Division panel held in three consolidated appeals that a NJ hospital’s state law claims that a health care plan must pay full price for medical services the hospital provided to plan participants are...more

Physician Medicare Data: Has the Drought Ended?

After 34 years, a federal district court in Florida has overturned a 1979 injunction which prevented the Centers for Medicare and Medicaid Services (CMS) from releasing to the public Medicare data related to physician billing...more

US District Court Prohibits Enforcement of California 340B Medicaid Mandatory Carve-In Law

The 340B program permits eligible hospitals and other “safety-net” providers (340B Covered Entities) to purchase outpatient drugs from pharmaceutical manufacturers at significant discounts. To address its fiscal woes,...more

Employees Who Smoke (Part II) – The Exception for Health Insurance Plans

So yesterday, I made a convincing case that employees who smoke outside the workplace can’t be treated differently than your non-smokers. ...more

Seventh Circuit Rules that Medical Necessity Trumps State-Imposed Cap on “Optional” Medicaid Coverage

In a class action lawsuit, the U.S. Court of Appeals for the 7th Circuit recently affirmed a lower court decision granting a preliminary injunction that prevented the state of Indiana from enforcing a $1,000 annual cap on...more

Letters of Protection- A Hobson’s Choice for Patient, Doctor and Attorney A Personal Injury Lawyer/ Medical Practice...

A “Hobson’s Choice” is a choice that appears to give you more than one option, but in fact only offers one option. So it is with the Letter of Protection (LOP). You, the patient, doctor or attorney, think...more

Hall v. Sebelius

Brief of the CATO Institute as Amicus Curiae in Support of Petitioners

When Brian Hall, former House Majority Leader Dick Armey, and other over-65 retirees requested to opt out of Medicare's hospital insurance coverage (because they preferred their existing private coverage), the Social Security...more

The ERISA Litigation Newsletter - September 2012

In This Issue: - Editor's Overview - ERISA Preemption in Provider Misrepresentation Claims: An Overview of the Jurisprudence Leading Up to the Fifth Circuit's En Banc Review of Access Mediquip and What Lies...more

Affordable Care Act Runs Into Religious Freedom Issues in Court

Although the Supreme Court, in a landmark decision earlier this summer, affirmed the constitutionality of the Patient Protection and Affordable Care Act (ACA), the challenges to and controversies surrounding that Act are far...more

The Supreme Court’s Immigration Decision May Give Clues On The Upcoming Decision On The Affordable Care Act’s Individual Mandate

Casey Stengel once advised that it is best not to make predictions, particularly about the future. So we will step into ill-advised territory with caution. Nevertheless, the Supreme Court’s decision in Arizona v. United...more

Insurance Business & Regulatory News - Spring 2012

In This Issue: - NAIC Changes Target Insurance Holding Company System - Delaware Series LLC Captive Insurance Programs - State Spotlights - Insurance Business and Regulatory Law Excerpt from State...more

Effect of New Michigan Health Insurance Claims Assessment Act on Group Health Plans

The new Michigan Health Insurance Claims Assessment Act imposes a 1-percent tax on “paid claims” for health-related services of employer-sponsored health and welfare plans. Employer plan sponsors with...more

Supreme Court to Hear Appeal on Constitutionality of Health Reform Law

On Monday, November 14, the U.S. Supreme Court granted certiorari to hear an appeal from a decision by the U.S. Court of Appeals for the Eleventh Circuit that the individual mandate in the Patient Protection and Affordable...more

Supreme Court to Hear Challenges to Health Care Reform

The Supreme Court announced on Monday, November 14, 2011 that it will hear challenges to the Patient Protection and Affordable Care Act (PPACA). President Obama signed PPACA on March 23, 2010, and legal challenges to the...more

U.S. Supreme Court to Decide Constitutionality of Affordable Care Act

Yesterday, the United States Supreme Court granted certiorari (meaning it has agreed to hear an appeal) on three petitions concerning the constitutionality of the Affordable Care Act (“ACA”). Given the Supreme Court’s...more

Supreme Court Will Hear Challenge to Health Reform Law

Minutes after President Obama signed landmark Health Reform legislation on March 23, 2010, the first suit challenging the law was filed in U.S. district court in Florida. That case, after working its way through the district...more

Sedgwick Jury Trial Bad Faith Victory Results in Appellate Court Decision Barring Vicarious Liability

A couple of years ago, Sedgwick authored an amicus brief, which the California Court of Appeal in Watanabe v. California Physicians' Service (2008) 169 Cal.App.4th 56 relied upon to hold that California Health & Safety Code...more

In-Network Provider Has Standing to Pursue ERISA Remedies, But State Law Reimbursement Claim Completely Preempted by ERISA

In Montefiore Medical Center v. Teamsters Local 272, 642 F.3d 321 (2d Cir. 2011), the U.S. Court of Appeals for the Second Circuit held that an in-network provider's state law based reimbursement claim is completely preempted...more

Exhaustion of Administrative Remedies Under ERISA Not Required If Exhaustion Would Have Been Futile

Terrance Burnett was eligible for short-term disability (“STD”) benefits and long-term disability (“LTD”) benefits through employee welfare benefit plans funded by his employer, The Raytheon Company, and administered by...more

Health Alert: Key Portion of Health Reform Bill Struck Down by Virginia Federal Judge

The "Commerce Clause," Article I, Section 8, Clause 3 of the United States Constitution, provides that: "[Congress shall have Power] To regulate Commerce with foreign Nations, and among the several States, and with the Indian...more

Ninth Circuit Holds Medicare Act’s Exhaustion Requirements And Preemption Provision Bar Plaintiffs’ Common Law Claims

At long last, the Ninth Circuit Court of Appeals issued its second opinion in the Uhm v. Humana, Inc., -- F.3d -- (9th Cir. 2010), matter, which found the Medicare Act's exhaustion requirements and preemption provision barred...more

From Out of the Blue Comes a Proposed Exemption for Air Ambulance Companies to Avoid California Workers' Compensation Official...

This week, the Administrative Director of the Division of Workers? Compensation of the California Department of Industrial Relations (“DWC”) proposed a regulation, California Code of Regulations, title 8, Section 9789.70(c),...more

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