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Pacific Bay treated an individual who was a subscriber to a Blue Shield health plan. It submitted invoices to Blue Shield for payment for the services rendered to the subscriber. Pacific Bay contends it was underpaid and brought suit against Blue Shield to recover the additional amount it claimed to be owed. The court sustained Blue Shield's demurrer to the first amended complaint (FAC) without leave to amend, finding that Pacific Bay had not shown that it was entitled to any payment from Blue Shield. As an out-of-network, nonemergency service provider, Pacific Bay was entitled to payment for treating Blue Shield's subscriber under the terms of the applicable evidence of coverage (EOC). Pacific Bay did not allege Blue Shield paid it improperly under the EOC, nor did it argue that it could allege additional facts to support such a claim. Pacific Bay claimed it was underpaid. Against this backdrop, Pacific Bay's other allegations did not give rise to any valid cause of action. View "Pacific Bay Recovery v. Cal. Physicians' Services" on Justia Law

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Health insurers do not have a broad, unrestricted right of subrogation against third-party tortfeasors who cause injury to their insureds but, rather, are limited to reimbursement rights established by statute. In this personal injury case, the circuit court ruled that Haw. Rev. Stat. 663-10 and/or Haw. Rev. Stat. 431:13-103(a)(1) abrogated Hawai’i Medical Service Association’s (HMSA) contractual and common law rights in subrogation against a third-party tortfeasors responsible for injury to its insured. The Supreme Court affirmed, holding (1) a health insurer does not have equitable subrogation rights against a third-party tortfeasor in the context of personal injures; (2) a health insurer’s subrogation and reimbursement rights are limited by section 663-10 and section 431-13:103(a)(1); (3) any contractual provision that conflicts with section 663-10 is invalid; and (4) section 663-10 takes precedence over HMSA’s subrogation rights. View "Yukumoto v. Tawarahara" on Justia Law

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Only two sections of the Michigan no-fault act mention healthcare providers, MCL 500.3157 and MCL 500.3158, and neither of those sections confers on a healthcare provider a right to sue for reimbursement of the costs of providing medical care to an injured person. Although MCL 500.3112 allows no-fault insurers to directly pay PIP benefits to a healthcare provider for expenses incurred by an insured, MCL 500.3112 does not entitle a healthcare provider to bring a direct action against an insurer for payment of PIP benefits. Covenant Medical Center, Inc., brought suit against State Farm Mutual Automobile Insurance Company to recover payment under the no-fault act for medical services provided to State Farm’s insured, Jack Stockford, following an automobile accident in which Stockford was injured. State Farm denied payment. In the meantime, Stockford had filed suit against State Farm for no-fault benefits, including personal protection insurance (PIP) benefits. Without Covenant’s knowledge, Stockford and State Farm settled Stockford’s claim for $59,000 shortly before Covenant initiated its action against State Farm. As part of the settlement, Stockford released State Farm from liability for all allowable no-fault expenses and any claims accrued through January 10, 2013. State Farm moved for summary judgment under MCR 2.116(C)(7) (dismissal due to release) and MCR 2.116(C)(8) (failure to state a claim). The trial court granted State Farm’s motion under MCR 2.116(C)(7), explaining that Covenant’s claim was dependent on State Farm’s obligation to pay no-fault benefits to Stockford, an obligation that was extinguished by the settlement between Stockford and State Farm. View "Covenant Medical Center, Inc. v. State Farm Mutual Automobile Ins. Co." on Justia Law

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Respondent hired a law firm to investigate a potential malpractice claim against a nursing home. The law firm made a request to the hospital owned by Petitioner for a copy of Respondent’s medical records. Petitioners sent an invoice to the law firm demanding $4,463.43 plus sales tax and shipping costs for the medical records. The law firm paid the invoice. Troubled by the allegedly excessive amount of the invoice, however, the law firm filed suit against Petitioners in the name of the client. The circuit court found that Respondent could pursue a claim for the allegedly excessive costs of the medical records. The Supreme Court granted a writ of prohibition to Petitioners and directed the circuit court to dismiss the lawsuit without prejudice, holding that because Respondent did not pay the invoice and suffered no personal loss caused by the allegedly illegal fee, Respondent could not show an injury in fact. Therefore, Respondent did not have standing to pursue the lawsuit. View "State ex rel. Healthport Technologies, LLC v. Honorable James C. Stucky" on Justia Law

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After plaintiff's son was denied coverage related to gender reassignment services and surgery, plaintiff filed suit against Essentia and the health insurance plan's third party administrator for sex based discrimination in violation of Title VII of the Civil Rights Act of 1964, the Minnesota Human Rights Act (MHRA), and the Affordable Care Act (ACA). The Eighth Circuit held that plaintiff was not discriminated against on the basis of her own sex, and the protections of Title VII and the MHRA do not extend to discrimination based on her son's sex. Therefore, the court affirmed as to this issue. The court reversed the district court's dismissal of plaintiff's ACA claim based on lack of Article III standing, holding that plaintiff has alleged an injury cognizable under Article III because she contends that defendants' discriminatory conduct denied her the benefits of her insurance policy and forced her to pay out of pocket for some of her son's prescribed medication. View "Tovar v. Essentia Health" on Justia Law

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At issue was whether the trial court employed the correct legal standard in determining the reasonable value of appellant's emergency treatment of four patients as an interventional cardiologist. The Court of Appeal agreed with the parties that the court in Children's Hospital Central California v. Blue Cross of California, (2014) 226 Cal.App.4th 1260, correctly applied the governing standard. The Court of Appeal declined to adopt appellant's narrow reading of the case and, instead, held that Children's Hospital supports the decision that the trial court made here to consider a variety of evidence to determine the "reasonable market value" of the services that appellant provided under quantum meruit principles. Accordingly, the court affirmed the judgment of the trial court. View "Sanjiv Goel, M.D., Inc. v. Regal Medical Group" on Justia Law

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Providence Alaska Medical Center terminated Dr. Michael Brandner’s hospital privileges without an opportunity to be heard after determining he had violated hospital policy by failing to report an Alaska State Medical Board order requiring him to undergo an evaluation of his fitness to practice medicine. Brandner unsuccessfully challenged this action through the hospital's hearing and appeal procedures. Brandner thereafter took his cause to court, seeking reinstatement and damages for the alleged due process violations both in the procedures used and in the substantive standard applied in his termination. The superior court found no such violations and that he was not entitled to reinstatement. Brandner appealed. The Alaska Supreme Court affirmed in part and reversed in part, finding that Brandner was not entitled to reinstatement or post-termination-hearing damages. However, the doctor's due process rights were violated when he was not given a hearing following termination of his hospital privileges. The matter was remanded for further proceedings. View "Brandner v. Providence Health & Services" on Justia Law

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The Supreme Court held that “medical assistance” provided to Medicaid recipients includes costs for room and board and other “nonmedical” expenses at nursing facilities, and therefore, those costs can be recovered from the recipient’s estate. In this case, the Nebraska Department of Health and Human Services (DHHS) filed a petition for allowance of a claim for services provided to the decedent while he resided at two different nursing homes. The county court sustained DHHS’ motion for summary judgment, concluding that the services defined as room and board fell within the parameters of services provided under the Medical Assistance Act. The Supreme Court affirmed, holding that DHHS was statutorily authorized to recover the sums it paid for room and board costs and other expenses from the decedent’s estate. View "In re Estate of Vollmann" on Justia Law

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Jeffrey Anderson challenged a district court order placing him in a transitional release program at the Civil Commitment Unit for Sexual Offenders (CCUSO) as a violation of his due process rights. After a jury determined that Anderson was a sexually violent predator, Anderson was civilly committed to CCUSO under the Sexually Violent Predators Act. Anderson was later granted release with supervision but violated the terms of his release-with-supervision plan. The district court revoked Anderson’s release-with-supervision status and ordered him placed at a transitional release program housed at CCUSO. It was this order that Anderson challenged on appeal. The Supreme Court affirmed, holding that the order revoking Anderson’s release-with-supervision status and placing him at the transitional release program at CCUSO did not violate his substantive or procedural due process rights under either the Iowa Constitution or the United States Constitution. View "In re Detention of Jeffrey Anderson" on Justia Law

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An individual’s right to have a judicial officer physically present at hearings held to determine whether the individual may be involuntarily committed to a mental health facility or hospital pursuant to “the Baker Act,” Fla. Stat. 394.467, is denied by the remote appearance of judicial officers at Baker Act hearings. In this case, a single judicial officer of the Twentieth Judicial Circuit instituted a process providing for the remote appearance of judicial officers via an e-mail. The Florida Supreme Court quashed the decision of the panel of the Second District Court of Appeal, which concluded there was no legal duty clearly established in the law that requires judicial officers presiding over Baker Act hearings to be physically present. The Supreme Court remanded the proceedings to the Second District for instructions not inconsistent with this opinion. View "Doe v. State" on Justia Law