Tag Archives: Lawsuit

Cigna prevails in Texas hospital’s suit over $50M in unpaid claims

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , • Leave a comment

https://www.bna.com/cigna-prevails-texas-n73014481565/

Image result for hospital out of network fee forgiving

Cigna Healthcare defeated a lawsuit by a Houston hospital accusing it of underpaying hundreds of medical benefit claims.

Cigna didn’t abuse its discretion when it reduced benefit payments to North Cypress Medical Center Operating Co. Ltd after it learned that the hospital engaged in fee-forgiving—a practice where out-of-network providers charge patients less than what they owe under their health insurance plans, a federal judge in Texas held Aug. 7.

Multiple lawsuits challenging the billing and payment practices between out-of-network providers and health insurers have been filed in the past decade, when insurers started reducing or withholding payments to providers that engaged in fee-forgiving. Insurers such as Cigna, Aetna, and UnitedHealthcare allege this practice is fraudulent.

The ruling, which came after an eight-day bench trial, is a significant victory for Cigna in a long-running lawsuit by North Cypress, which sought to hold the insurer liable for at least $50 million in unpaid claims.

In 2016, Judge Keith P. Ellison held that Cigna violated federal benefits law by denying full payment of benefit claims.

Since then, the U.S. Court of Appeals for the Fifth Circuit issued a number of opinions in favor of insurers, including one where it reversed a $16.4 million judgment against Cigna in a case in which another small Texas-based hospital accused it of underpaying medical claims. Last week, the Fifth Circuit affirmed a ruling against the hospital in its lawsuit accusing Aetna Life Insurance Co. of underpaying medical claims in violation of the Employee Retirement Income Security Act and Texas law.

After the parties Cigna and North Cypress engaged in full discovery, the claims at issue were limited to the 575 benefit claims for which the hospital exhausted its administrative remedies. Cigna argued at trial that in these 575 claims, it didn’t apply its fee-forgiving protocol to reduce payments to 395 of them because they were for nonemergency services.

Cigna’s interpretation of its plans to require an out-of-network provider to collect the full portion of coinsurance from a patient was reasonable, Ellison said.

Ellison, who sits in the U.S. District Court for the Southern District of Texas, pointed out that Cigna had substantial evidence to support its determination that North Cypress engaged in fee-forgiving. Cigna had sent surveys to patients who had received treatment at North Cypress and it discovered that the hospital was discounting or forgiving out-of-network coinsurance, Ellison said.

 

 

Humana files suit against 37 drug makers accusing them of price fixing

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , , , , , , , , , , , , , , , , • Leave a comment

https://www.healthcarefinancenews.com/news/humana-files-suit-against-37-drug-makers-accusing-them-price-fixing?mkt_tok=eyJpIjoiWlROaE56WXlNV1JrTlRRNSIsInQiOiJtQUlRODhrK2xUNW00em4rcUIyWEg0enJuVFBPXC9DUEl0VGhLTWNNUHFwcmdCMG5FTm9cLzNPbzQ4Sm5pR1hcL1wvSzBvNmU2Z0RFVGloQlBpU0Z4bnFhZmFEWnJUWXVmdHZcL3V1UEd0dzB5MFF5XC96OTNHWUpPVkpyaVRDRTRPaTYraSJ9

Image result for humana headquarters

The conspiracy involving secret meetings resulted in higher prices for insurers, the government and consumers, the lawsuit claims.

Humana has brought a lawsuit against 37 pharmaceutical companies including Novartis, Mylan and Teva, alleging price fixing for numerous generic drugs.

The conspiracy increased the profits of the drug makers and others working with them at the expense of consumers, the government and private payers such as Humana, the lawsuit said.

Humana wants to recover damages it said it incurred from overcharges for certain widely-used generics, according to the lawsuit filed Friday in federal court for the Eastern Division of Pennsylvania.

Humana said the conspiracy is far-reaching among the drug makers to manipulate markets and obstruct generic competition. They agreed to fix, increase, stabilize and/or maintain the price of the drugs specified, along with other drugs, the court document said.

Humana accuses the pharmaceutical companies of secret meetings and communications at public and private events such as trade association meetings held by the Generic Pharmaceutical Association and others.

Humana’s allegations are based on personal knowledge and information made public during ongoing government investigations, the insurer said.

The pricing fixing is also under investigation by federal and state authorities, the lawsuit said.

The Attorneys General of 47 states, Washington, D.C. and Puerto Rico have filed a civil enforcement action against most of the named defendants, alleging agreements to fix 15 drug prices, the lawsuit said.

The Department of Justice has convened a grand jury to investigate a number of the defendants for price increases ranging from 100 percent to 400, 2,600 and 8,000 percent, Humana said.

The price increases are consistent with Medicare Part D price increases found by the Government Accountability Office for many of the subject drugs.

Among the drugs for which GAO identified “extraordinary price increases” — defined as a price increase of 100 percent or more — between the first quarter of 2011 and the first quarter of 2015, are, according to Humana, Amitriptyline, an antidepressant; Baclofen, a muscle relaxant and anti-spastic agent; Benazepril, an ACE inhibitor to treat hypertension; Clobetasol, a steroid and anti-inflammatory agent;  Clomipramine, an antidepressant for obsessive compulsive disorder; Digoxin, used to treat heart failure and atrial fibrillation; Divalproex for seizure disorders; Doxycycline (in Hyclate form) an antibiotic; Leflunomide for rheumatoid arthritis; Levothyroxine, a thyroid drug to treat hypothyroidism; Lidocaine, an anesthetic;  Nystatin, an antifungal for skin infections; Pravastatin to lower cholesterol; Propranolol, a beta blocker to treat hypertension; Ursodiol, to decrease the amount of cholesterol produced by the liver; and Verapamil, to treat hypertension, angina and certain heart rhythm disorders.

 

Trump’s undermining of Obamacare violates the Constitution, new lawsuit charges

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , • Leave a comment

https://www.nbcnews.com/politics/donald-trump/trump-s-undermining-obamacare-violates-constitution-new-lawsuit-charges-n896626

Image: People Sign Up For Health Care Coverage Under The Affordable Care Act During First Day Of Open Enrollment

ASHINGTON — After congressional Republicans repeatedly failed last year to repeal the Affordable Care Act, President Donald Trump promised to “let Obamacare implode” on its own.

A new lawsuit being filed Thursday argues that Trump’s efforts to make good on that promise violate the U.S. Constitution.

Trump has “waged a relentless effort to use executive action alone to undermine and, ultimately, eliminate the law,” the complaint charges, according to a draft obtained by NBC News. The lawsuit is being filed in Maryland federal court by the cities of Baltimore, Chicago, Cincinnati and Columbus, Ohio.

Since Trump’s first executive order directing federal agencies to claw back as much of the Affordable Care Act as possible, his directives have increased health coverage costs and depressed enrollment, the complainants say.

Specifically, the suit argues that Trump is violating Article II of the Constitution, requiring the president to “take care that the laws be faithfully executed.”

“There’s a clear case of premeditated destruction of the Affordable Care Act,” said Zach Klein, Columbus city attorney.

This includes making it easier for individuals and trade groups to purchase coverage outside the law’s insurance markets; threatening to eliminate cost-sharing reduction payments; cutting funding for “navigators,” or those who help individuals enroll in the program; and using federal funds Congress dedicated to implementing the law toward making videos criticizing it.

On Wednesday, Health and Human Services Secretary Alex Azar announced a plan for cheaper, short-term insurance plans, the latest example of actions that critics say will drive up costs on Obamacare exchanges.

During a call-in appearance on Rush Limbaugh’s radio show Wednesday, Trump took credit for all but ending the Affordable Care Act.

“I have just about ended Obamacare. We have great health care,” he said. “We have a lot of great things happening right now. New programs are coming out.”

The suit also relies on a list of Trump’s tweets indicating his intent to unravel the law, according to a lawyer involved in the case.

Constitutional scholars have long debated the extent to which the chief executive must “faithfully” execute U.S. laws under Article II — from Franklin Roosevelt’s objections to legislative veto provisions and Harry Truman’s seizure of steel mills.

Citing the same “take care” clause, Republicans took issue with President Barack Obama’s executive orders on immigration as well as his delayed implementation of the health law.

This case stands apart from all others, says Abbe Gluck, a Yale University law professor and expert on Article II, because it’s not about the extent to which Trump is “faithfully” implementing a law. Rather Trump has been frank that he is sabotaging the law, she said.

“That’s what makes this case novel, first of its kind and really important,” Gluck said. “No scholar or court has ever said the president can use his discretion to implement a statute to purposely destroy it.”

“If there’s ever going to be a violation of the ‘take care’ clause, this is it,” she said.

If successful, the suit would strike down aspects of a Trump rule designed to undercut insurance markets; render a judgment he’s violating his constitutional obligation to enforce the statute; and issue an injunction that he implement the law faithfully.

LOCAL IMPACT

The suit also cites Trump scaling back oversight of insurance issuers, cutting open enrollment in half, urging a federal court to throw out Obamacare’s protections for pre-existing conditions and undermining the individual mandate.

All of these actions, they say, undercut confidence in the program and enrollment, the keys to its success. The whole concept of insurance, whether it’s for cars, homes or people, is to minimize risk by creating a diverse pool — in this case of healthy and unhealthy, young and old participants.

John Yoo, a law professor at the University of California, Berkeley, and former Bush Justice Department official, said a president can’t refuse to enforce a law just because he disagrees with it.

Still, Obamacare was written in a way that gives great leeway to the executive, said Yoo.

“Is there something specific in the statute that he is refusing?” he said, adding that funding reductions don’t qualify. “That’s the constitutional standard,” said Yoo.

In 2017, there was a 37 percent average increase in premiums nationwide, and 3 million more people lacked health insurance than did in 2016. In Columbus, city-subsidized health centers saw almost 3,000 more uninsured patients in 2017. As the uninsured rate increases, Columbus must also pay more for ambulance transports, draining millions of dollars from localities.

“The accumulation of these (acts) has cost Americans thousands of dollars more, and it was done in a way that can be clearly traced” to Trump’s orders, said Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid under Obama.

The budget strain is also hampering efforts to address the opioid crisis. Ohio has the second-highest drug overdose death rate, according to the Centers for Disease Control and Prevention, with the city of Columbus averaging nine or 10 Naloxone administrations a day to prevent deaths.

“The time for criticism is over,” Klein said. “We have no ability to recoup that money. We just have to eat it due to the Trump administration’s efforts to sabotage the law.”

HEALTH CARE POLITICS

The plaintiffs deny politics play a role in the timing of the suit, which they say they have been building for the past year.

But it will likely serve as a reminder to voters of Trump’s hand in rising premiums just as they are set to skyrocket. Trump’s 2016 campaign platform was built in part on greater economic security for working-class Americans.

Insurance companies are hiking rates in the individual market, citing decisions being made in Washington. And premiums are set to surge in 2019, with a majority of states proposing increases over and above the previous year.

After several elections in which Republicans used Obamacare to attack Democrats, the party says it’s regained the advantage on the health care issue. In the past few years, the Republican-led Congress has voted dozens of times to try and repeal the law, failing each time. “People got to see they (the GOP) have no better alternative,” said Slavitt.

“Most Democrats are saying ‘look we never said the ACA is perfect, but the other person is trying to take away your coverage,” said Slavitt.

Trump’s former Health and Human Services Secretary Tom Price has also faulted Congress’s repeal of the individual mandate for coming premium increases. Further, Trump’s Justice Department is taking aim at Obamacare’s most popular provisions: a ban on insurance companies’ discriminating against individuals with pre-existing conditions.

CONSTITUTIONAL OBLIGATION

The suit seeks to force Trump to adopt policies intended to expand rather than shrink enrollment; reduce rather than increase premiums; and promote instead of attack the ACA.

Among the specific rules plaintiffs seek to reverse are allowing exchanges to strip individuals of tax credits without notification and reducing oversight of insurance agents and brokers, as well as oversight of the law in general.

“What’s insidious here is the administration is doing it knowing that confidence in the act is key to its success,” said Adam Grogg, senior counsel at Democracy Forward and the lead litigator on the case. The fewer Americans who enroll in the program, the more volatile the market, he said.

“The overall picture here is one of sabotage that drives up the rates of uninsured and underinsured and leaves cites and counties holding the bag,” Grogg said.

Four cities are charging that the president is failing to execute the law by actively undercutting the Affordable Care Act.

 

States sue Trump administration over AHP expansion

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , • Leave a comment

https://www.healthcaredive.com/news/states-sue-trump-administration-over-ahp-expansion/528875/

Dive Brief:

  • Attorneys general from 11 states and Washington, D.C. are suing the Trump administration in hopes of putting the brakes on association health plan expansion.
  • Expanding AHPs is a key plank in President Donald Trump’s healthcare platform, but critics call the plans “junk insurance” that will sidestep Affordable Care Act regulations.
  • Meanwhile, the House of Representatives passed two bills last week that look to lower restrictions on health savings accounts (HSAs).

Dive Insight:

Trump, who repeatedly calls the ACA a “disaster,” said AHPs and allowing anyone to get catastrophic health insurance will offer flexibility and reduce health insurance costs.

In announcing the final rule last month, the Department of Labor said the regulation included anti-discrimination protections similar to those for large employers. It also allows states to regulate AHPs.

Though supportive of those protections, AHP critics are still concerned about the plans. They charge that AHPs will offer fewer consumer protections, lead to higher premiums in individual and small-group markets and result in fraudulent companies in the AHP market.

Tempting people with lower-cost offerings, AHPs and catastrophic plans could cause millions to flee the ACA exchanges. A recent report from the Society of Actuaries predicted between 3% and 10% of those in ACA marketplace plans will leave for AHPs. Those people are more likely to be young and healthy. Leaving the marketplace plans will result in an unstable risk pool with higher premiums in the exchanges.

A recent report from Avalere predicted individual rates would increase by between 2.7% and 4% and small group by between 0.1% and 1.9% with AHP expansion. Avalere said 130,000 to 140,000 more people will become uninsured because of the premium increases in the individual market by 2022.

Millions of people and small employers once got coverage through AHPs. However, the ACA instituted consumer protections for AHPs and said they should be regulated the same as individual and small-group market plans, such as requiring them to cover people with pre-existing conditions. The consumer protections increased the costs of AHPs, and many of them folded. The Kaiser Family Foundation said only 6% of employers with fewer than 250 employees offered health insurance through AHPs in 2017.

The Trump administration wants to make AHPs a low-cost solution with fewer regulations and consumer protections. However, the lawsuit involving 11 states and Washington, D.C. alleges the Department of Labor’s rule to expand AHPs violates the Administrative Procedures Act. The suit said that allowing for more AHPs “increases the risk of fraud and harm to consumers, requires states to redirect significant enforcement resources to curb those risks and jeopardizes state efforts to protect their residents through stronger regulation. The rule is unlawful and should be vacated.”

Meanwhile, the Republican-led House of Representatives is promoting more use of health savings accounts, which are a crucial part of high-deductible health plans and the drive toward consumerism.

One bill the House passed would allow members more flexibility to use their HSA until meeting their deductible. It also lets spouses contribute to an HSA and loosens restrictions on how members can use the account. The second piece of legislation would let people set aside more money for their HSA. That bill would also reduce the health insurance tax for two years, a change supported by the insurance lobby. The ACA created the tax as a way to pay for coverage improvements, but payers say it increases premiums.

 

 

Anthem Sued by Doctors in Dispute Over Emergency-Room Coverage

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , • Leave a comment

https://www.bloomberg.com/news/articles/2018-07-17/anthem-sued-by-doctors-in-dispute-over-emergency-room-coverage

Image result for Anthem Sued by Doctors in Dispute Over Emergency-Room Coverage

The health insurer Anthem Inc. was sued by doctors in Georgia for declining to pay for some emergency-room care, escalating a long-running battle over how far insurance plans can go to push patients to seek lower-cost treatment.

The American College of Emergency Physicians and the Medical Association of Georgia filed suit on Tuesday in U.S. District Court in Atlanta against Anthem’s Blue Cross and Blue Shield of Georgia unit over the denied payments. The doctors asked the court to require Anthem to halt its policy and cover the claims.

“Providers and patients alike are operating in fear of denial of payment by defendants when patients seek emergency department care,” the groups said in the filing.

It’s the latest legal challenge over a change in policy that Anthem says was designed to cut down on patients going to an emergency room in situations that don’t require it. Emergency-room care usually costs significantly more than treatment at a doctor’s office or an urgent-care clinic. Georgia’s Piedmont Hospital and five related facilities also have sued Anthem over the policy, the Atlanta Journal-Constitution reported in February.

Before putting the policy in place, Anthem sent letters to customers explaining the policy and urging them to use other sites for care. The insurer also held meetings with physicians, according to the suit.

Anthem didn’t immediately respond to a request for comment on the suit.

Medical Records

Anthem’s strategy went beyond what’s legally allowed, the doctors say in their lawsuit. The insurer reviewed the cases of patients who went to an emergency room, and decided whether to pay for their care based on billing information or medical records related to the incident. The suit says Anthem violated legal requirements that insurers cover care in a situation where a “prudent layperson” would believe he or she was experiencing an emergency.

According to the suit, Anthem began reviewing emergency-room visits in Georgia, Kentucky and Missouri, and has also brought the policy to Ohio, New Hampshire and Indiana. Based in Indianapolis, Anthem operates under the Blue Cross and Blue Shield brand in 14 states. The company has almost 40 million health-insurance members.

Lawmakers including U.S. Senator Claire McCaskill of Missouri have criticized Anthem’s policy. McCaskill and a fellow Democrat, Senator Ben Cardin of Maryland, sent a letter in March to the Health and Human Services Department and Labor Department, asking them to investigate the payment denials.

“By denying patient claims based on the patient’s final diagnosis and ignoring the patient’s symptoms present at the time of the emergency, we believe that Anthem likely violated federal law,” the senators wrote.

 

 

 

Atrium Health releases 92 physicians looking to break away

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , • Leave a comment

https://www.beckershospitalreview.com/hospital-physician-relationships/atrium-health-releases-92-physicians-looking-to-break-away.html

Hospital-Physician Relationships

Charlotte, N.C.-based Atrium Health said April 25 it will grant the request of a group of physicians looking to separate and end their employment agreements with the health system Sept. 1, according to The Charlotte Observer.

In an emailed statement to Becker’s Hospital Review April 25, Atrium confirmed it will release a group of roughly 92 Mecklenburg Medical Group physicians from their noncompete agreements, effective Sept. 1. The physicians will continue practicing as part of the health system until Aug. 31.

“While we were hopeful that our many months of discussions would lead to an acceptable solution for everyone involved, we will not seek to prevent these physicians from forming a standalone practice,” the health system told Becker’s.

Atrium said it will also offer the physicians new employment agreements “in the hopes they remain at Atrium Health and their MMG practice … and join the other 1,900 physicians who provide care for our patients,” the health system told Becker’s.

The group of roughly 92 Mecklenburg Medical Group physicians filed a lawsuit against Atrium April 2, arguing the health system engaged in monopolistic and anticompetitive behavior. Atrium said the same day it would allow the physicians to leave the organization. On April 16, the physicians filed a complaint against the health system with the North Carolina Medical Board, alleging the health system violated board regulations by intentionally misleading patients.

Atrium acquired Mecklenburg Medical Group in 1993, according to The Charlotte Observer. In a statement to the publication, the physicians said their attorneys will meet with Atrium’s lawyers to further assess the situation.

Atrium Health CEO Eugene Woods told The Charlotte Observer the health system is in the process of hiring roughly 20 physicians to help fill the vacant positions left by physicians planning to leave Mecklenburg Medical Group. The health system also previously offered to give employees who choose to say a bonus of up to 10 percent of their salary if they remain through the end of the year.

“We feel for our staff, and our first concern was making sure that they feel that we’re with them,” Mr. Woods told the publication. “We offered them retention bonuses because some of them were scared about what the future is going to be.”

 

 

St. Joseph Health hit with anti-trust lawsuit for allegedly stifling competition: 5 things to know

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , • Leave a comment

https://www.beckershospitalreview.com/legal-regulatory-issues/st-joseph-health-hit-with-anti-trust-lawsuit-for-allegedly-stifling-competition-5-things-to-know.html

Image result for unfair competition

Wahidullah Medical Corp., which owns Eureka, Calif.-based Redwood Urgent Care and its outpatient medical testing laboratory, filed an anti-trust lawsuit against Eureka-based St. Joseph Hospital claiming the hospital used unfair business tactics and stifled competition to protect 10-fold price markups, according to The North Coast Journal.

Here are five things to know.

1. Wahidullah Medical Corp. filed the lawsuit in early April seeking a preliminary injection to bar St. Joseph from attempting to monopolize the outpatient laboratory testing industry. In addition, the medical company is seeking a jury trial, legal fees and damages.

2. The lawsuit claims St. Joseph Hospital, which is owned by Irvine, Calif.-based St. Joseph Health, illegally conspired to stifle competition for medical lab testing in the Eureka market by actively tarnishing its competition’s reputation, misleading consumers and implementing an EMR that was incompatible with Redwood Urgent Care.

3. The suit claims lab tests at St. Joseph’s medical lab were nearly 10 times more expensive than the Redwood outpatient testing lab, citing an instance where St. Joseph charged a patient without insurance $327 for a vitamin D test — a test that would cost $36 at Redwood for an uninsured patient. Specifically, the suit alleges St. Joseph’s failed to inform patients that there was another medical testing facility that could save them money.

4. “St. Joseph Health … decided to protect its lab-testing business from fair competition by resorting to tortuous and anticompetitive behavior designed to put Redwood Lab out of business and thereby leave consumers of out-patient medical laboratory testing services in Eureka with no option but St. Joseph Health,” the lawsuit reads, according to The North Coast Journal.

5. In total, the suit accuses St. Joseph’s of seven specific violations of state and federal anti-trust laws.

 

Pharma karma catches up: Shkreli sentenced to 7 years

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , • Leave a comment

Pharma karma catches up: Shkreli sentenced to 7 years

The man who embodied the phrase “pharma bro” and once urged his fans to pull a hair from Hillary Clinton’s head at a book signing has had a visit from pharma karma. The judge in Martin Shkreli’s fraud case, Kiyo Matsumoto, has sentenced the poster man for pharmaceutical company greed to seven years. Estimates are that Shkreli, 34, might get out in a couple of years if his behavior is good.

At his sentencing hearing, Shkreli apparently, and rather uncharacteristically, expressed contrition and shed enough tears that the judge called for the court officer to bring the defendant a box of tissues. Shkreli, in making his plea for leniency, tearfully told the judge that “the one person to blame for me being here today is me.” The judge apparently was unmoved, although the sentence is less than the 15 years the prosecution requested.

Shkreli drew the time after a jury found him guilty of one count of conspiracy to commit securities fraud and 2 counts of securities fraud. The same jury found him not guilty on an additional five counts, raising some hope from his legal team that his sentence would be light. The crimes, related to stock manipulation of shares in Retrophin, one of Shkreli’s companies, and ripping off hedge fund backers, could have carried a sentence of up to 20 years.

In February 2018, Matsumoto found that losses resulting from Shkreli’s crimes tallied up to $10.4 million.

Although he’s probably best known for overseeing a 5,000 percent price hike of a toxoplasmosis drug for HIV-positive patients, Shkreli’s post-pharmaceutical shenanigans caught a much attention as his venality while helming Turing Pharmaceuticals. He dropped $2 million on the sole copy of the Wu-Tang Clan album ‘Once Upon a Time in Shaolin,” which the judge has included in his assets. He harassed a journalist on Twitter, getting himself suspended, and seemed to want to fashion himself into the Snark King of Social Media.

His posturing ended up being his downfall.

While awaiting sentencing, Shkreli boasted that he would end up serving hardly any time and what time he did serve would be in the relatively posh environs of a “Club Fed” prison for white collar criminals. But after he exhorted Facebook followers to pluck a hair from Clinton’s head and offered $5000 per sample, the judge who sentenced him revoked Shkreli’s bail and ordered him to be placed in Brooklyn’s Metropolitan Detention Center, a far different experience for the pharma bro.

Although Shkreli is at the center of his own story, some believe that the industry overall is not blame-free. STAT journalist Adam Feuerstein has pointed out that the pharmaceutical industry can’t entirely disown Pharma Bro and his behavior, noting that Shkreli “was doing what lots of other biotech and pharma CEOs did, and still do to various degrees. Legally.”

 

20 states sue over Obamacare mandate — again

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

https://www.politico.com/story/2018/02/26/20-state-sue-over-obamacare-again-425825

A man is pictured entering health insurance exchange center. | Getty

Twenty states are suing the Trump administration over Obamacare’s individual mandate — again.

Wisconsin, Texas and several other red states said in a lawsuit filed today that since Congress repealed the individual mandate’s tax penalty for not having coverage, that means the mandate itself — and the whole health care law — is invalid.

The GOP tax law “eliminated the tax penalty of the ACA, without eliminating the mandate itself,” the states argue in a complaint filed today in U.S. District Court in the Northern District of Texas. “What remains, then, is the individual mandate, without any accompanying exercise of Congress’s taxing power, which the Supreme Court already held that Congress has no authority to enact.”

The Supreme Court in 2012 upheld Obamacare’s individual mandate in one of the highest-profile court cases in years. The justices did not agree then with the Obama administration’s main argument that the mandate penalty was valid under the Commerce Clause. But the justices did say that the mandate was a constitutional tax. The ruling riled conservatives who felt that Chief Justice John Roberts bent legal reasoning to preserve Obamacare.

Now, the states want to use that same Supreme Court ruling to take down the Affordable Care Act — which has withstood numerous legal challenges but which over the past year has been undermined by executive and regulatory actions the Trump administration has taken.

The states also argue that since the mandate is unconstitutional, the whole law should go. They note that Obamacare did not have a “severability clause” — a provision that says if one part of the law is struck by the courts, the rest would stand — so that once part of it is struck down, the rest in invalid.

 

 

Lawsuit filed against ObamaCare insurer over coverage

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

Lawsuit filed against ObamaCare insurer over coverage

Lawsuit filed against ObamaCare insurer over coverage

The insurance carrier Centene misled enrollees about the benefits of its ObamaCare exchange plans and offered far skimpier coverage than promised, according to a class-action lawsuit filed Thursday.

The lawsuit, filed in federal court in Washington state, claims customers who bought Centene’s ObamaCare plans had trouble finding in-network doctors or hospitals and often found that doctors who were advertised as in-network actually were not.

ObamaCare requires plans to meet certain minimum requirements.

Centene covers about 10 percent of the ObamaCare individual market and is one of the largest insurance carriers that participates on the exchanges.

As many other insurers have pared back their ObamaCare exchange plans, or completely left the market, Centene has expanded. In some areas of the country, Centene is the only insurer offering plans for ObamaCare customers.

Centene markets its signature product — its three-tiered Ambetter plans — in at least 15 states, and covers more than 1.4 million customers.

According to the lawsuit, Centene targets low-income customers who qualify for substantial government subsidies “while simultaneously providing coverage well below what is required by law and by its policies.”

A spokeswoman for the company told The Hill they have not been served papers and only learned of the lawsuit Thursday morning.

“We believe our networks are adequate. We work in partnership with our states to ensure our networks are adequate and our members have access to high quality health care,” Marcela Manjarrez Hawn said in an email.

Narrow networks — insurance plans that limit which doctors and hospitals customers can use — are not uncommon, as they are cheaper than more expansive plans. But the lawsuit says Centene went far beyond the norm.

“Centene misrepresents the number, location and existence of purported providers by listing physicians, medical groups and other providers — some of whom have specifically asked to be removed — as participants in their networks and by listing nurses and other non-physicians as primary care providers,” the lawsuit claims.

According to the lawsuit, customers found the provider network Centene said was available was “largely fictitious. Members have difficulty finding — and in many cases cannot find — medical providers who will accept Ambetter insurance.”

The suit was filed on behalf of two Centene customers, but seeks class-action status to represent all customers who purchased Centene plans on the ObamaCare exchange.