/ en Wed, 30 Apr 2025 22:38:18 -0500 Wed, 16 Apr 25 16:04:05 -0500 /news/headline/2025-04-16-minnesota-court-dismisses-phrma-lawsuit-challenging-state-340b-law <p>A Minnesota state court April 15 <a href="https://sponsors.aha.org/rs/710-ZLL-651/images/04162025-62-CV-24-5744%20Order%20Granting%20Motion%20to%20Dismiss.pdf?version=0">dismissed</a> a lawsuit filed by PhRMA challenging the state’s law protecting 340B pricing for contract pharmacy arrangements. The court ruled that the state law is not preempted by federal law, does not engage in unconstitutional extraterritorial regulation and does not violate Minnesota’s Single Subject and Title Clause.</p><p>The AHA filed an <a href="https://sponsors.aha.org/rs/710-ZLL-651/images/04162025_2024-12-26%20AHA%20et%20al.%20Amicus%20Brief.pdf?version=0">amicus brief</a> in the case last year and filed others in similar cases for multiple states, in defense of those states’ 340B contract pharmacy laws.</p> Wed, 16 Apr 2025 16:04:05 -0500 Claims & Litigation /news/headline/2024-07-08-healthcare-equality-network-sends-letter-cms-claims-denials-commercial-insurers <p>The Healthcare Equality Network July 3 sent a <a href="https://www.healthcareequalitynetwork.com/hen-writes-letter-to-hhs-cms">letter</a> to the Centers for Medicare & Medicaid Services, expressing concerns about claims denials by commercial insurance companies. "According to a KFF analysis, insurance companies, on average, deny 1 in 5 claims, with one insurer rejecting 49 percent and another rejecting a shocking 80 percent," the group wrote. "This problem extends to Medicare Advantage plans, which were created to offer more choice and comprehensive benefits and now cover more than half of all Medicare beneficiaries but are now inundated with prior authorization requirements and coverage denials."</p> Mon, 08 Jul 2024 16:04:07 -0500 Claims & Litigation /news/headline/2023-08-01-dol-sues-unitedhealth-third-party-administrator-improperly-denying-ed-claims <p>The Department of Labor July 31 <a href="https://www.documentcloud.org/documents/23893268-department-of-labor-v-umr" target="_blank">sued</a> a third-party administrator owned by UnitedHealth Group in the U.S. District Court for the Western District of Wisconsin, alleging it improperly denied claims for emergency services and urinary drug screening since 2015. The department asks the court to require the third-party administrator (UMR Inc.) to reform its claims processing procedures for such claims, readjudicate the affected claims in compliance with the Employee Retirement Income Security Act, and enjoin it from committing future violations. </p> <p>The AHA in June 2021 sent a letter to UnitedHealthcare’s CEO responding to the insurer’s decision to allow retroactive denial of coverage for emergency-level care in facilities. “Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency,” the <a href="/lettercomment/2021-06-08-letter-unitedhealthcare-retroactive-denial-coverage-emergency-level-care" target="_blank">letter</a> stated. “Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care.” </p> <p>In addition, the AHA letter said, “this is exactly why federal law requires insurers to adhere to the prudent layperson standard, which prohibits insurers from putting up coverage roadblocks to emergency services, such as by determining retroactively whether a service will be covered based on the patient’s final diagnosis.”</p> Tue, 01 Aug 2023 16:49:56 -0500 Claims & Litigation /news/headline/2023-04-19-report-anthem-has-yet-process-nearly-300-million-nh-hospital-claims <p>The New Hampshire Hospital Association recently <a href="https://www.nhha.org/resources-reports/new-hampshire-hospitals-report-on-anthem-performance/" target="_blank">released a report</a> highlighting the challenges New Hampshire hospitals and health systems face in dealing with Anthem, the state’s largest insurance provider, including nearly $300 million in unprocessed claims for services provided by New Hampshire hospitals. </p> <p>“This is absolutely unacceptable, and while we had hoped to see demonstrative progress, Anthem has yet to implement real change, has failed to improve known system failures, and continues to rely on hospitals to identify and track their own broken processes,” said NHHA President Steve Ahnen.</p> Wed, 19 Apr 2023 16:00:01 -0500 Claims & Litigation <p class="text-align-center"><strong><a class="btn btn-primary btn-wide" href="/system/files/media/file/2022/05/anthem-indianas-ed-downgrade-policy-found-to-clearly-violate-federal-law-advisory-5-11-22.pdf">Download the Legal Advisory</a></strong></p> <p>An arbitrator has ordered that Anthem Insurance Company, Inc. (“Anthem”) pay a group of 11 acute care hospitals in Indiana (“hospitals”) $4.5 million as compensation for adopting a policy of processing claims for emergency services that the arbitrator found is a “clear” violation of federal and state law.</p> <p>According to recent court filings, under the policy in question, Anthem refused to pay the hospitals at the parties’ contracted reimbursement rates for the emergency services they rendered to Anthem’s Indiana Medicaid patients whenever the patient’s diagnosis, as reflected on the claim form, failed to match any of the codes on a list of diagnosis codes that Anthem deemed to be “emergent.” That is, for any claim for emergency services which lacked a corresponding emergent diagnosis code, Anthem unilaterally downgraded the claim and paid the Hospital only a nominal triage fee of between $50 and $70 for the entire course of treatment. The fee amounted to a fraction of the full reimbursement rate the hospitals had agreed to accept from Anthem for the emergency services they rendered to Anthem’s members. Anthem also required the hospitals to submit medical records as part of an appeals process if they wanted to receive additional reimbursement at the contracted rate for any downgraded claims.</p> <p>Under federal law, whether a patient who presents to an emergency department (ED) has an emergency medical condition (and therefore receives “emergency services” at the hospital) depends on whether the patient’s symptoms are such that a “prudent layperson” would reasonably expect serious harm to result in the absence of immediate medical attention, see 42 C.F.R. § 438.114(a). Because the focus of this inquiry is on the reasonableness of the patient’s decision to go to the ED — and not on whether the patient was experiencing an actual medical emergency — federal regulations explicitly prohibit a health plan, including a Medicaid managed care organization, from “limit[ing] what constitutes an emergency medical condition” based on “lists of diagnoses or symptoms” 42 C.F.R. § 438.114(d)(1)(i). In promulgating rules to implement the federal No Surprises Act, the Centers for Medicare & Medicaid Services (CMS) reiterated that health plans are prohibited from using lists of diagnosis codes to deny emergency room claims and require resubmission or appeals of the claims for providers to obtain full reimbursement, see 86 Fed. Reg. 36872, 36879-80.</p> <p>The arbitrator therefore ruled that Anthem’s policy of denying and down coding claims based on the diagnoses listed on the claim form was a “crystal clear” violation of federal and related state law. The arbitrator also found that Anthem’s policy of requiring the hospitals to submit medical records to obtain additional reimbursement was impermissible. The hospitals, represented by the Florida-based law firm Lash & Goldberg LLP, have filed a petition in Indiana state court to confirm the arbitrator’s award.</p> <p>The arbitrator’s award is the latest in a string of successful legal challenges to Anthem’s payment policies using diagnosis codes to deny or downgrade ED claims. In Georgia, the American College of Emergency Physicians and Georgia Medical Association filed a federal lawsuit challenging BlueCross/BlueShield’s (BCBS) downgrade-list policy, which ultimately resulted in a settlement after BCBS withdrew its policy in that state earlier this year.</p> <h2>AHA TAKE</h2> <p>Insurance companies throughout the country have been increasingly aggressive in denying and underpaying claims for emergency services based on the diagnoses or symptoms listed on a claim form. These practices inherently conflict with the governing “prudent layperson” standard in federal law and the laws of many states, which prohibit insurers like Anthem from using a list of codes to downgrade ED claims and then requiring the re-submission of the claim with medical records as part of an appeal. Before insurers like Anthem deny or downgrade an ED claim, they should conduct a reasonable investigation and review all pertinent information in their possession.</p> <p>While payers like Anthem may argue they are trying to control health care costs through these ED policies, Congress and CMS (and now the arbitrator in the Anthem Indiana case) have made clear that payers cannot seek to do so off the backs of providers who are performing a service they are required by law to perform — i.e., their legal obligation under the Emergency Medical Treatment and Labor Act (EMTALA) to provide ED services to all patients regardless of insurance status or ability to pay. Payers have other means to try to control what they deem as inappropriate ED utilization, for example, through member education, primary care provider availability, and a robust network of alternative, lower acuity care settings. It is an encouraging sign to see hospitals succeeding in pushing back against these abusive payer policies.</p> <h2>WHAT YOU CAN DO</h2> <ul> <li>Share this Advisory with your legal team and managed care department and watch for updates from the AHA on developments in similar cases.</li> <li>Consult with your revenue cycle management department to evaluate whether you are experiencing similar, systematic denials and/or downcoded ED claims.</li> </ul> <h2>FURTHER QUESTIONS</h2> <p>This Legal Advisory was prepared with the assistance of Alan Lash, Jason Coe and Nicholas Ortiz at Lash & Goldberg. If you have further questions, please contact Mindy Hatton, AHA’s general counsel, at 202-626-2336 or <a href="mailto:mailto:mhatton@aha.org">mhatton@aha.org</a>, or Molly Smith, AHA’s group vice president for public policy, at 202-626-4639 or <a href="http://mailto:msmith@aha.org" target="_blank">msmith@aha.org</a>.</p> Wed, 11 May 2022 12:07:27 -0500 Claims & Litigation /news/headline/2019-05-09-doj-releases-formal-guidance-litigators-false-claims-act-cases <p>The Department of Justice this week issued <a href="https://www.justice.gov/jm/jm-4-4000-commercial-litigation#4-4.112">formal guidance</a> on how it awards credit to defendants who cooperate during a False Claims Act investigation. Under the policy, defendants may earn credit by voluntarily disclosing misconduct unknown to the government, cooperating in an ongoing investigation or undertaking remedial measures in response to a violation. The credit will usually take the form of a reduction in the damages multiplier and civil penalties, the agency said. AHA outside counsel Jonathan Diesenhaus, a partner at Hogan Lovells, said, “The release of guidance makes it clear that self-disclosure and cooperation should produce real benefit to hospitals settling False Claims Act investigations, including lower settlement amounts and public acknowledgement of good compliance practices; unfortunately, unlike similar guidance issued by other federal agencies, these guidelines don’t provide a clear recipe or formula for how or when DOJ will confer those benefits.”  </p> Thu, 09 May 2019 15:32:35 -0500 Claims & Litigation /press-releases/2016-02-09-statement-appeals-court-decision-aha-alj-delay-lawsuit-upholding <div class="outlineContent clearfix"><p class="text-align-center"><strong>Melinda Hatton</strong></p><p class="text-align-center"><strong>Senior Vice President and General Counsel</strong></p><p class="text-align-center"><strong>���������� Association</strong></p><p class="text-align-center"> </p><p class="text-align-center"><strong>February 9, 2016</strong></p><p>Today’s Appeals Court decision moves the hospital field closer to getting relief for timely reviews of Medicare claims denials, which they asked for more than a year ago. Through its ruling, the court recognized the problem continues to worsen and urges the lower court to issue relief unless the Department of Health and Human Services and Congress act in a timely way to resolve the problem.</p><p>Specifically, it urges the lower court to provide the relief hospitals are requesting unless Congress and the agency make meaningful progress to address the backlog of appeals by the close of the next appropriations cycle.</p><p>The appeals court today affirms that hospitals simply cannot afford to have billions of dollars that are needed for patient care tied up indefinitely in the appeals process. Today’s decision confirms that the agency has a clear duty to comply with the congressionally mandated deadlines and that the statute gives hospitals a corresponding right to demand compliance. And, it refutes attempts by the agency to excuse compliance because of the Recovery Audit Contractor program, noting that congressional mandates trump discretionary decisions.</p><p>We fully expect that the lower court to rule in favor of hospitals when it reconsiders the case unless HHS and Congress makes meaningful progress to resolve the backlog.</p><p class="text-align-center">###</p><h2>About the AHA</h2><p>The AHA is a not-for-profit association of health care provider organizations and individuals that are committed to the health improvement of their communities. The AHA is the national advocate for its members, which include nearly 5,000 hospitals, health care systems, networks, other providers of care and 43,000 individual members. Founded in 1898, the AHA provides education for health care leaders and is a source of information on health care issues and trends. For more information, visit the AHA website at <a href="/">www.aha.org</a>.</p></div> Tue, 09 Feb 2016 00:00:00 -0600 Claims & Litigation