Insights on Managed Care, Payer Disputes & Reimbursement

The US District Court for the Eastern District of New York in Manalapan Surgery Ctr., et al. v. 1199 SEIU National Benefit Fund, No. 23-CV-03525 (EDNY March 12, 2025), recently granted a motion to dismiss a complaint filed by four out-of-network ambulatory surgery centers against 1199 SEIU National Benefit Fund.

A federal court recently rejected arguments by MultiPlan, Inc. and Cigna Health and Life Insurance Company that they had no obligation to ensure payments at the contractually negotiated, in-network rate to Anatomic and Clinical Laboratory Associates, P.C. (ACLA).

California is leading the way in ensuring that determinations of medically necessary health care services are made by licensed physicians and not artificial intelligence (AI) algorithms.

On September 9, the US Departments of Labor, Treasury, and Health and Human Services (the Departments) jointly released a final rule to ensure that group health plans comply with the Mental Health Parity and Addiction Equity Act (MHPAEA).

On August 2, health care providers scored yet another significant victory when the US Court of Appeals for the Fifth Circuit affirmed the vacatur of various federal regulations regarding the arbitration procedures used to resolve billing disputes between providers and insurers.

On July 19, the US District Court for the Northern District of Texas denied a motion to dismiss Blue Cross Blue Shield of Texas (BCBSTX), which claimed sovereign immunity in a suit brought by a group of providers.

In a recent opinion, Smith et al. v. UnitedHealth Group Inc. et al., the US Court of Appeals for the Eighth Circuit affirmed the dismissal of an Employee Retirement Income Security Act (ERISA) class action suit brought by health plan participants.

On April 23, the US Department of Labor (DOL) released a final rule significantly expanding the definition of who qualifies as a fiduciary under the Employee Retirement Income Security Act (ERISA) (the Retirement Security Rule or Final Rule).

Last week, the US Court of Appeals for the Fourth Circuit issued a decision holding that state health care plans in North Carolina and West Virginia must cover gender-affirming surgeries.

In a win for plaintiffs, the US Court of Appeals for the Ninth Circuit recently reversed a district court’s dismissal of key claims in the case of Ryan S. v. UnitedHealth Group, Inc.

In a recent opinion, E.W. v. Health Net Life Insurance Co., the US Court of Appeals for the Tenth Circuit clarified the elements that plaintiffs must plead to state claims under the Mental Health Parity and Addiction Equity Act (MHPAEA).

On December 18, 2023, the US Departments of Treasury, Labor, and Health and Human Services (the Departments) issued a rule finalizing the 2024 non-refundable administrative fee parties must pay to access the arbitration process established under the No Surprises Act (the Act).

On October 27, the US Departments of Treasury, Labor, and Health and Human Services (the Departments) issued new proposed rules intended to revamp the negotiation and arbitration proceedings established under the No Surprises Act (the Act).

On September 21, 2023, the US Departments of Treasury (DOT), Labor (DOL), and Health and Human Services (HHS) (the Departments) issued new rulemaking governing the administrative fee required to access the arbitration process established under the No Surprises Act (the Act). Under the proposed rule, the new fee would be set at $150.

On August 24, 2023, health care providers in Texas scored yet another victory when a federal court vacated additional portions of the Biden Administration’s rulemaking under the federal No Surprises Act (the Act).

Last week, the US Court of Appeals for the Ninth Circuit, in its third opinion in the case, reversed a lower court’s decision allowing patients challenging United Behavioral Health’s (UBH) internal mental health coverage guidelines to seek reprocessing of their benefits claims.

On August 3, 2023, health care providers in Texas scored yet another victory when a federal court vacated additional portions of the Biden Administration’s rules governing fee collection and claim batching under the federal No Surprises Act (the Act).

On July 25, 2023, the US Departments of Labor (DOL), Treasury (USDT), and Health and Human Services (HHS) (the Departments) released a much-anticipated interim final rule to ensure that group health plans comply with the Mental Health Parity and Addiction Equity Act (MHPAEA).

In a recent decision, the US District Court for the District of Utah granted United Healthcare’s (UHC) motion for summary judgment on the plaintiff’s facial and as-applied claims under the Mental Health Parity Act.

In parallel cases, health care providers are continuing to challenge rulemaking by the US Departments of Treasury, Labor, and Health and Human Services (the Departments) under the No Surprises Act (the Act).

On February 6, 2023, health care providers scored a second significant victory when a federal court in Texas again vacated portions of the Biden Administration’s rules governing the arbitration procedures to resolve surprise billing disputes under the federal No Surprises Act (NSA).

In late September 2022, health care providers in Texas sued the Departments of Treasury, Labor, and Health and Human Services (collectively, the Departments) over a recently issued final rule implementing the federal No Surprises Act (the NSA).

Earlier this month, the US District Court for the Western District of Washington certified a class of individuals who were denied gender-affirming care by a third-party administrator, Blue Cross Blue Shield of Illinois (BCBSIL).

Health Care Partner Stephanie Trunk will present twice at the Informa Medicaid Drug Rebate Program Summit on October 12-14.

In Advisory Opinion 22-17, the US Department of Health and Human Services (HHS) Office of Inspector General (OIG) concluded that a proposed restructuring of a loan and other contractual relationships between a health system and a federally qualified health center (FQHC) “look-alike” clinic.