Articles Posted in Health Care Law

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Kaiser Permanente covered three patients who received care at an emergency room operated by Dameron Hospital Association. The patients were injured due to the negligence of third party tortfeasors who had automobile liability insurance with California Automobile Association Inter-insurance Bureau (AAA) and Allstate Insurance Company. Unlike Kaiser, neither AAA nor Allstate had contracts with Dameron. In the absence of an agreement for negotiated billing rates, Dameron sought to collect from AAA and Allstate its customary billing rates by asserting liens filed under the Hospital Lien Act (HLA). AAA and Allstate ignored Dameron’s HLA liens when paying settlements to the three Kaiser patients. Upon learning of the settlements, Dameron sued AAA and Allstate to recover on its liens. The trial court granted the automobile liability insurers’ motions for summary judgment on grounds the patients’ debts had already been fully satisfied by their health care service plans. Reasoning the HLA liens were extinguished for lack of any underlying debt, the trial court dismissed the case. The trial court further found dismissal was warranted because Dameron failed to timely file some of its HLA liens against AAA. The issue this case presented for the Court of Appeal was whether a heath care service plan’s payment of a previously negotiated rate for emergency room services insulate the tortfeasor’s automobile liability insurer from having to pay the customary rate for medical care rendered? AAA and Allstate contended they were not responsible for any amount after Kaiser paid in full the bill for the emergency room services provided by Dameron. Dameron contended that it contracted with Kaiser to preserve its rights to recover the customary billing rates from tortfeasors and their automobile liability insurers. Dameron argued the tortfeasors and their liability insurers were responsible for the entire bill for medical services at the customary rate, not just the difference between the reimbursement received from Kaiser and the customary billing rate. Although Dameron claimed it should benefit from the California Supreme Court’s holding that it may avoid extinguishment of its HLA liens upon receiving payments from health insurers, the contract in this case preceded that case by 10 years. The Court of Appeal concluded that the Dameron/Kaiser contract did not preserve the right to recover the customary billing rate for emergency room services from third party tortfeasors: "[I]f Dameron wishes to preserve its right to recover its customary billing rates through an HLA lien, it is free to contract for this right. But Dameron must actually contract for this right. A history of voluntary cooperation with Kaiser does not suffice to avail Dameron of the [Supreme Court's] guidance on reservation of contractual rights under the HLA." Consequently, the trial court properly granted summary judgment in favor of AAA and Allstate. As to Dameron’s argument that it filed a timely claim relating to patient Rita H.’s HLA lien, the Court of Appeal affirmed the trial court’s dismissal based on the statute of limitations. Dameron has not made a sufficient showing of diligence to toll the claim under the discovery rule. View "Dameron Hospital Assn. v. AAA etc. Ins. Exchange" on Justia Law

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In this class action lawsuit, the trial court found that the State wrongfully denied health benefits to a number of its part-time employees. The issue this case presented for the Supreme Court's review was how to value the damages suffered by that group of employees when they were denied health benefits. The State argued that the only damages to the employees were immediate medical expenses paid by employees during the time they were denied health benefits. But evidence showed that people denied health care benefits suffer additional damage. They often avoid going to the doctor for preventive care, and they defer care for medical problems. This results in increased long-term medical costs and a lower quality of life. Based on this evidence, the trial court correctly rejected the State's limited definition of damages because it would significantly understate the damages suffered by the employees. The Supreme Court affirmed.View "Moore v. Health Care Auth." on Justia Law

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The health care service plan in this case, Kaiser Permanente, covered three patients who received care at an emergency room operated by Dameron Hospital Association. The patients were injured due to the negligence of third party tortfeasors who had automobile liability insurance with California Automobile Association Inter-insurance Bureau (AAA) and Allstate Insurance Company. Unlike Kaiser, neither AAA nor Allstate had contracts with Dameron. In the absence of an agreement for negotiated billing rates, Dameron sought to collect from AAA and Allstate its customary billing rates by asserting liens filed under the Hospital Lien Act (HLA). AAA and Allstate, however, ignored Dameron’s HLA liens when paying settlements to the three Kaiser patients. Upon learning of the settlements, Dameron sued AAA and Allstate to recover on its HLA liens. The trial court granted insurers’ motions for summary judgment on grounds the patients’ debts had already been fully satisfied by their health care service plans. Reasoning the HLA liens were extinguished for lack of any underlying debt, the trial court dismissed the case. The trial court further found dismissal was warranted because Dameron failed to timely file some of its HLA liens against AAA. The question this case presented to the Court of Appeal was whether the health care service plan’s payment of a previously negotiated rate for emergency room services insulated the tortfeasor’s automobile liability insurer from having to pay the customary rate for medical care rendered. AAA and Allstate argued they were not responsible for any amount after Kaiser paid in full the bill for the emergency room services provided by Dameron. Dameron argued that it contracted with Kaiser to preserve its rights to recover the customary billing rates from tortfeasors and their automobile liability insurers, and that the tortfeasors and their liability insurers were responsible for the entire bill for medical services at the customary rate - not just the difference between the reimbursement received from Kaiser and the customary billing rate. The Court of Appeal concluded that the Dameron/Kaiser contract did not contain the term described by case law as sufficient to preserve the right to recover the customary billing rate for emergency room services from third party tortfeasors. Consequently, the trial court properly granted summary judgment in favor of AAA and Allstate. View "Dameron Hosp. Assn. v. AAA Nor. Cal., Nev. & Utah Ins. Exc." on Justia Law

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The Louisiana Supreme Court granted this writ application to determine whether a plaintiff had a private right of action for damages against a health care provider under the Health Care and Consumer Billing and Disclosure Protection Act. Plaintiff Yana Anderson alleged that she was injured in an automobile accident caused by a third party. She received medical treatment at an Ochsner facility. Anderson was insured by UnitedHealthcare. Pursuant to her insurance contract, Anderson paid premiums to UnitedHealthcare in exchange for discounted health care rates. These reduced rates were available pursuant to a member provider agreement, wherein UnitedHealthcare contracted with Ochsner to secure discounted charges for its insureds. Anderson presented proof of insurance to Ochsner in order for her claims to be submitted to UnitedHealthcare for payment on the agreed upon reduced rate. However, Ochsner refused to file a claim with her insurer. Instead, Ochsner sent a letter to Anderson’s attorney, asserting a medical lien for the full amount of undiscounted charges on any tort recovery Anderson received for the underlying automobile accident. Anderson filed a putative class action against Ochsner, seeking, among other things, damages arising from Ochsner’s billing practices. Upon review of the matter, the Supreme Court found the legislature intended to allow a private right of action under the statute. Additionally, the Court found an express right of action was available under La. R.S. 22:1874(B) based on the assertion of a medical lien. View "Anderson v. Ochsner Health System" on Justia Law

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The South Carolina Supreme Court answered certified two questions from the U.S. District Court for the District of South Carolina. The case concerned supplemental health insurance policies, which differ from ordinary health insurance policies in both purpose and operation. The questions were: (1) whether the definition of "actual charges" contained within S.C. Code Ann. 38-71-242 be applied to insurance contracts executed prior to the statute's effective date; and (2) whether the South Carolina Department of Insurance could mandate the application of "actual charges" to policies already inexistence on the statute's effective dates by prohibiting an insurance company from paying claims absent the application of that definition. The South Carolina Supreme Court answered both questions "no." View "Kirven v. Central States" on Justia Law

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This case involved a petition for injunctive and declaratory relief brought by plaintiffs Harbor Homes, Inc. and Gary Dube, Thomas Taylor, Cynthia Washington, and Arthur Furber against defendants the New Hampshire Department of Health and Human Services (DHHS), the Commissioner of DHHS, the Associate Commissioner of DHHS, and the Administrator of the Bureau of Behavioral Health seeking, in part, to enjoin DHHS from denying the individual plaintiffs the right to obtain Medicaid-funded services from their chosen provider, Harbor Homes. The individual plaintiffs received Medicaid-funded rehabilitative services from Harbor Homes. Since 1991, Harbor Homes participated in New Hampshire's Medicaid program pursuant to a Medicaid Provider Enrollment Agreement. On June 23, 2008, Harbor Homes entered into an interagency agreement (IAA) with a community mental health program, Community Council of Nashua, NH, now known as Greater Nashua Mental Health Center (GNMHC), which authorized Harbor Homes to provide certain Medicaid-funded rehabilitative services to GNMHC patients. In February 2011, Harbor Homes learned that GNMHC did not intend to renew its IAA and that the Medicaid reimbursable services provided by Harbor Homes would be transitioned to GNMHC. This was done pursuant to Administrative Rule He-M 426.04(a)(2), which meant that Harbor Homes would no longer have an IAA with a community mental health provider, and it would no longer be permitted to provide Medicaid funded mental health services to approximately one hundred and forty of its clients, including the individual plaintiffs in this case. Plaintiffs filed a petition for injunctive and declaratory relief, seeking a court order enjoining DHHS from "terminating or limiting Harbor Homes' status as a qualified Medicaid provider" and to direct the State to allow the individual plaintiffs to obtain community mental health services from Harbor Homes, the provider of their choice. Following two hearings, the court denied the plaintiffs' request for a preliminary injunction. Thereafter, all parties moved for partial summary judgment on the plaintiffs' claim that DHHS's reliance upon the IAA requirement as a reason to terminate Harbor Homes' status as a qualified Medicaid provider was improper because the requirement was invalid both on its face and as applied in this case. Plaintiffs appealed rulings of the Superior Court that denied their summary judgment motions and granting the defendants' cross-motions for summary judgment on two counts in the plaintiffs' petition. Upon review of the matter, the Supreme Court reversed the Superior Court's ruling that New Hampshire Administrative Rules, He-M 426.04(a)(2) did not violate the federal Medicaid Act. The case was remanded for further proceedings. View "Dube v. New Hampshire Dept. of Health & Human Svcs." on Justia Law