Health Plan & Provider Report Index Summary

OBESITY

– Diabetics, Medicare covers some bariatric procedures, 181
– N.C. state health plan, smokers and overweight workers will pay more, 534
– Overweight infants, Rocky Mountain Health Plans of Grand Junction reverses policy of denying coverage, 2026
– Surgery to remove excess skin after weight loss, plan administrator properly denied coverage (6th Cir.), 262

OFF-LABEL USE

– RICO, no cause of action against drug maker over promotions (C.D. Cal.), 38

OHIO

– Breach of contract, attorneys' fees award for sponsor upheld when ERISA plan's third-party administrator removed state law action to federal court (6th Cir.), 12
– Medical records, patient consent allows insurer review (Ohio), 675
– Nonprofit hospitals, Health Alliance of Greater Cincinnati settlement agreement, 73

OKLAHOMA

– Uninsured persons, house approves coverage expansion bill, 296; revised bill passed, 317; sent to governor, 533; new law, In Brief, 569

OREGON

– Brain injuries, new law requires treatment coverage, 746
– Clinical trials, bill passed requiring cost coverage, 680; new law, In Brief, 747
– Health insurance, new law allows payments for healthy lifestyles enrollees, 776
– Mandated benefits

– – Hearing aids for children, In Brief, 803
– – HPV vaccine for young women, In Brief, 803
– – Tobacco use cessation programs, In Brief, 803

– Provider tax to fund health coverage expansion, no consensus for hospitals and governor, 193; legislative panels approve bills, 681
– Regence BCBS, premiums increase approved, 595
– SCHIP, new laws expand coverage, 954
– State agencies restructured under new laws, 954
– Telemedicine, bill passed requiring services coverage, 680; new law, 746

ORGAN TRANSPLANTS

– Kidney patients, Kaiser settles for $1 million, 494

OUT-OF-NETWORK CARE

– BCBS

– – ERISA no bar to claim over patient incentives to change surgical services providers (D.N.J.), 530
– – Hospitals

– – – Anthem sues over use of manipulated data to underpay (Cal. Super. Ct., C.D. Cal.), 921
– – – Insurer sues over waiver of patient costs (N.J. Super. Ct.), 677

– – Medicare Secondary Payer Act, plan did not violate by reimbursement for dialysis at lower rates (N.D. Ga.), 261

– Databases and data banks

– – CIGNA and Aetna, AMA and state medical societies file class actions alleging knowing underpayment (D.N.J.), 184
– – Hospitals, Anthem BCBS sues over use of manipulated information to underpay (Cal. Super. Ct., C.D. Cal.), 921
– – UnitedHealth Group and N.Y. attorney general reach agreement on system revision, 57; similar agreement reached with WellPoint and CIGNA, 221; 2 more insurer agreements, 295; greater transparency needed, hearing, 369; group plans must adjust, consulting firm says, 390; Rockefeller (D-WVa) calls for probe of industry calculation methods, 405; Health Net pays to settle, 746
– – WellPoint sued over use of Ingenix data (C.D. Cal.), 381

– Dental care, ERISA claims over payment proceed against Wellpoint (S.D. Fla.), 126
– Fla., new direct payments law, 711
– Health care reform, federal debate should address high fees, report, 968
– Investigations

See INVESTIGATIONS

– Medically necessary services, denial proper where Medicare beneficiary did not prove surgery was superior to procedure plan covered (9th Cir.), 261; subpoenas ruling by administrative law judge (U.S., rev sought), 1157; (rev den), 2020
– Medicare coverage for liver resection surgery performed out of plan without prior authorization, denial affirmed (D. Haw.), 1099
– Mental health, claim over denial of residential treatment for dependent's eating disorder barred (S.D.N.Y.), 347
– Physicians

– – AMA class action challenging UnitedHealth reimbursement system settled (S.D.N.Y.), 57; trial court delays accord approval, 649
– – Negligent misrepresentation, ERISA no bar to claim doctor stated knee treatment would be covered by plan (S.D. Ohio), 675

– Provider reimbursement

– – Capital District Physician's Health Plan, N.Y. attorney general to sue, 161; settlement, 189
– – Hospitals, ERISA plan participant not entitled to full coverage (N.D. Cal.), 126
– – Neutral rate-setting, Guardian Life Ins. funds N.Y. group, 294
– – N.Y. attorney general probe of student health plans, Aetna pays millions to settle, 129
– – Tex. students, Aetna pays to settle state probe (Tex. Dist. Ct.), 191

OUT-OF-POCKET EXPENSES

– High copayments and treatment delays linked, study, 537
– Individual coverage not affordable, study, 899
– Medicare Advantage, less protection than Medigap, studies, 339
– Underinsured persons, House subcommittee hearing, 2010

OUTCOMES

– CalPERS pilot, risk sharing to cut costs and improve results, 503
– Hospitals, increased use of information technology cuts death rates and saves money, study, 133
– PPOs, value-based benefit designs improve, study, 196

OVERPAYMENTS

– BCBS

– – Omega Hosp., trial over Mich. plan reimbursement proceeds (E.D. La.), 376
– – State medical association sues contractor (Tenn. Ch. Ct.), 744

– Medicare, imposition of over $904,000 in interest not unfair to Kaiser (N.D. Cal.), 826
– N.Y. workers plan, outpatient consultant services and facility fees overpayment fraud recovery $9 million in 2008, report, 315
– Recovery of payments made in error to health care providers by insurance entities, Tenn. attorney general says changes to law constitutional, 1104