From accusations that Clover Health misled investors to UnitedHealthcare dodging an attempt to reveal negotiated rates with contracted providers, here are five recent legal actions involving payers:
1. A judge denied a motion to dismiss a lawsuit out of Nashville, Tenn., that accused Clover Health of misleading investors, according to a Feb. 28 court order. The initial 150-page amended complaint emphasizes five ways the payer allegedly misled investors, and noted that the payer's flagship platform, Clover Assistant, would "nudge" physicians to increase patient risk scores.
2. A federal judge in New York denied Anthem's motion to dismiss a lawsuit over its mental health coverage criteria, according to a Feb. 24 ruling. The payer is being sued by members of its employee-sponsored plans, who accuse Anthem of adopting mental health coverage criteria that are "far more restricted" than "generally accepted standards" after being denied residential psychiatric treatment.
3. A Kentucky judge ruled in favor of Anthem BlueCross & BlueShield after a transgender member accused the payer of unjustly denying coverage of gender-affirming facial surgery. The court ruled Feb. 23 that while gender affirming procedures related to urology or gynecology are covered by the member's plan, facial surgery and other procedures that are deemed cosmetic do not fall under that umbrella because they are not medically necessary.
4. UnitedHealthcare dodged a Texas court order that could have required it to disclose rates it negotiated with providers. A UnitedHealthcare member involved in a lawsuit over a car accident filed a motion that would require the payer to share its reimbursement rates with nine providers, which the judge denied as a violation of Texas Rules of Civil Procedure.
5. Health Care Services Corp., a Blue Cross Blue Shield affiliate, is suing Jazz Pharmaceuticals over narcolepsy drug Xyrem. The federal lawsuit, filed Feb. 17 in the Northern District of California, accuses the drugmaker of a "scheme to restrain competition for branded Xyrem" and its generic equivalents. The payer claims Jazz's actions violate antitrust and consumer protection laws.