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FCA Issues to Watch: Pharmaceutical and Device Developments | INSIDE THE FCA

by Bass, Berry & Sims PLC on

The government’s FCA enforcement efforts have continued to focus on key areas concerning the pharmaceutical and medical device industries. In fact, drug and device manufacturers accounted for nearly half of the enforcement...more

Second Circuit Affirms Dismissal of FCA Cases

by Jones Day on

The Second Circuit affirmed the dismissal of two False Claims Act ("FCA") cases brought by private relators against insurance and other companies based on the alleged failure to reimburse the Centers for Medicare & Medicaid...more

Justice Department Joins Whistleblower Suit Accusing UnitedHealth Group of Overcharging Medicare by “Hundreds of Millions”

The U.S. Department of Justice (DOJ) has joined a whistleblower lawsuit, United States of America ex rel Benjamin Poehling v. Unitedhealth Group Inc., No. 16-08697 (Cent. Dist. Cal. Sep. 17, 2010), ECF No. 79, against...more

A Liar and A Cheat? 3 Ways to Pay...

by Seyfarth Shaw LLP on

Seyfarth Synopsis: Insurer gets to pick its remedy when hospital engages in dishonest billing and illegal kickbacks…to the tune of $41 million. Judge Lynn Hughes of the U.S. District Court for the Southern District of...more

UnitedHealth Plan Holders Win Class Certification in ERISA Lawsuit

by Williams Venker & Sanders on

The District Court for the Northern District of California recently granted certain members of UnitedHealth health plans class certification in their suit alleging improper denial of benefits. Plaintiffs in the putative...more

Do Your Assignment of Benefits Clauses Need a Check-up? Recent Southern District of Florida Decision Highlights the Importance of...

by K&L Gates LLP on

A frequently litigated issue in reimbursement cases brought by in- and out-of-network healthcare providers against insurers under the Employee Retirement Income Security Act of 1974 (“ERISA”) is provider standing. Because...more

CMS Fines Insurer for Misleading Medicare Part D Beneficiaries

by BakerHostetler on

The federal agency that oversees Medicare’s prescription drug program has alleged that a major U.S. insurance company misled beneficiaries about the pharmacies included in the company’s drug plan, and imposed a $1 million...more

California Court Rejects Insurer’s Right to Rescind Policy

In DuBeck v. California Physicians’ Service, 2015 Cal. App. LEXIS 203 (March 5, 2015, opinion filed), the California Court of Appeal examined whether a health insurer’s conduct constituted a waiver of the right to rescind its...more

No Private Right to Recoup Funds Based on Corporate Practice of Medicine Violation

The United States District Court for the Western District of Washington ruled recently that the state’s corporate practice of medicine doctrine does not provide a private right of action, either express or implied, and...more

Catch Me If You Can: Fake Doctor’s Application Voids Coverage for Himself But Not for Innocent Co-Insureds

by Reed Smith on

Written like a blockbuster Hollywood film, the U.S. District Court in South Carolina, in Evanston Insurance Company v. Agape Senior Primary Care, et al., 2014 WL 5365679, issued a ruling October 21, 2014, in which it held...more

Ninth Circuit Holds That Provider Cannot Sue Nonsignatory Insurer for Breach of Contract

On October 10, 2014, the Ninth Circuit affirmed a grant of summary judgment in favor of Manatt client The MEGA Life and Health Insurance Company. In an unpublished memorandum opinion, the Ninth Circuit held that a health care...more

Lawsuit Against Medtronic Alleges Racketeering Over Infuse Bone Graft

When one big industry sues another we learn a lot about how business as usual is conducted. In this case Humana, a giant health insurer, has sued the medical device company Medtronic, maker of the Infuse bone graft. ...more

Two Federal Circuits Find Health Insurance Claims Outside Scope Of Arbitration Clauses

Because courts apply a presumption of arbitrability when they analyze whether particular claims fall within the scope of an arbitration clause, and arbitration clauses are generally drafted very broadly, I don’t usually get...more

Important Court Decision For No-Fault Insurers; Second Circuit Court Of Appeals Rejects Limitation On State Farm v. Mallela

We are pleased to inform you that our firm, together with our co-counsel Bob Stern of Stern & Montana, obtained a very favorable and significant decision for no-fault insurers on an issue of first impression at the appellate...more

Private Health Insurance Fraud — Billions And Billions

by Michael Volkov on

When it comes to health insurance fraud, Carl Sagan’s obsession with the words – billions and billions — are particularly accurate. As the government’s role in health care increases, it is inevitable that fraud against...more

Eighth Circuit Adopts Novel False Claims Act Fraud-in-the-Inducement Theory Long Espoused by Government

by Epstein Becker & Green on

On October 15, 2013, a divided three-judge panel of the United States Court of Appeals for the Eighth Circuit rendered a federal False Claims Act ("FCA") judgment against Bayer Healthcare Pharmaceuticals ("Bayer"), based on a...more

Drug Manufacturer’s Liability Under Insurance Frauds Prevention Act May Not Be Inferred From Alleged Kickbacks to Physicians

Three former employees of Bristol Myers Squibb, Inc. (BMS) brought a qui tam action alleging that BMS violated California’s Insurance Frauds Prevention Act, California Insurance Code section 1871.7 et seq. (IFPA), by giving...more

In Pipefitters, Sixth Circuit Holds Service Provider Is Fiduciary in Assessing Fee

by Goodwin on

Speed Read - The Sixth Circuit, in a unanimous decision, affirmed a lower court ruling in Pipefitters Local 636 Insurance Fund v. Blue Cross and Blue Shield of Michigan, holding that an entity providing services to a...more

OIG and MA Plan Sponsor Settle Allegations of Altering Records Submitted During Audit

Bravo Health Pennsylvania, Inc. (Bravo), a Medicare Advantage Plan Sponsor and subsidiary of Cigna Corporation, agreed to pay $225,000 to the Government for allegedly misrepresenting or falsifying information furnished to the...more

PA Court Holds Coverage is Barred Under Professional Liability Policy for False Claim Act Lawsuit Costs

by Cozen O'Connor on

On July 16, 2013, the Pennsylvania Court of Common Pleas (Philadelphia County) granted summary judgment in favor of ACE American Insurance Company, holding that costs arising from False Claims Act Litigation were excluded...more

Health Insurance Carriers Must Also Be Careful In What They Tell Plan Participants

I blogged recently warning employers to be careful when enrolling employees in plan benefits because the employer could be responsible to pay life insurance or disability benefits if an employee who is improperly enrolled...more

PRIME Act: New Legislation to Curb Health Care Fraud

The United States Senate and House of Representatives recently introduced bipartisan legislation designed to reduce fraud, waste, and abuse in the Medicare and Medicaid programs. The legislation, entitled “Preventing and...more

Varnum Wins $5.1 Million Judgment Against Blue Cross Blue Shield Of Michigan For Hidden Fees

by Varnum LLP on

BCBSM Charges Self-funded Customers Hidden Fees starting in 1994 - Prior to 1994, BCBSM charged its self-funded customers various surcharges and subsidies to prop up its insured lines of business, but those surcharges...more

CMS Aims to Grease the Reporting Wheels for Medicare Fraud and Abuse

by Morgan Lewis on

Proposed rule would substantially increase rewards for fraud tips and enhance billing revocation authority. On April 29, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule (Proposed Rule) that...more

20 Million Reasons Why Class Action Defendants Need to Read Their Insurance Policies Closely

by BakerHostetler on

As previously noted in a recent blog post, defendants should immediately evaluate their insurance coverage upon receipt of a class action complaint. But as one defendant recently discovered the hard way, that evaluation must...more

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