From settlements with the federal government over allegations of defrauding health systems to multiple class-action approvals, these are seven recent legal actions taken against payers:
Supreme Court rejects UnitedHealthcare appeal of Medicare Advantage overpayment rule
On June 21, the U.S. Supreme Court declined to hear UnitedHealthcare's appeal of a CMS rule meant to recoup Medicare Advantage overpayments from payers. The federal rule, first implemented in 2014, requires a payer to refund payments to CMS within 60 days if it learns a diagnosis lacks medical record support.
Molina settles claims of MassHealth fraud, improper licensure of healthcare staff for $4.6M
The Justice Department said June 21 that Molina Healthcare and former subsidiary Pathways of Massachusetts have agreed to pay a settlement of $4.625 million over allegations of False Claims Act violations and improper licensure and supervision of healthcare employees.
Texas Supreme Court denies $3M premium tax refund to BCBS
The Texas Supreme Court ruled 5-4 on June 17 that Blue Cross Blue Shield of Texas cannot receive a $3 million tax refund from its stop-loss policies that reimburse self-insured employers because they are a form of health insurance.
Centene to pay $13.7M to settle New Mexico pricing investigation
Centene agreed to pay $13.7 million to settle an investigation into its subsidiaries' pricing and reporting of pharmacy benefits and services to New Mexico's Medicaid program. The payer's subsidiaries were being investigated over concerns they were layering fees and not passing retail discounts on to the state's Medicaid program, the state said June 13.
Judge greenlights class action against Aetna over alleged disability benefits clawbacks
A federal judge in Pennsylvania approved a class-action lawsuit against Aetna on May 25 for allegedly violating the Employee Retirement Income Security Act by forcing disability benefits recipients to return personal injury payments received through legal settlements.
Settlement OK'd in Anthem Blue Cross eating disorder class action
A federal judge in California approved a class-action settlement requiring Anthem Blue Cross to reprocess claims for eating disorder treatments or pay up to $5,500 for denied claims, Bloomberg reported May 25. The class-action lawsuit accuses the payer of wrongly refusing to cover residential eating disorder treatment by relying on medical necessary criteria that conflicted with generally accepted standards of medical practice.
New York attorney general awards $13.6M to consumers denied mental healthcare coverage by UnitedHealthcare
New York Attorney General Letitia James' office announced May 20 that a settlement administrator had completed $13.6 million in payments to consumers who were denied mental healthcare coverage by UnitedHealthcare. The payments come from an agreement between Ms. James and UnitedHealthcare over her federal lawsuit against the payer in August for illegally denying coverage of outpatient psychotherapy to thousands of members.