Private Insurers

On March 11, the U.S. Department of Justice and U.S. Attorney’s Office announced that Aetna, a national health insurer, has agreed to pay $117,700,000 to settle alleged violations of the False Claims Act (FCA). The government was investigating Aetna for submitting inaccurate and untruthful diagnosis codes for its Medicare Advantage Plan beneficiaries, which increased Aetna’s…

Westside Behavioral Care Inc., a Colorado mental health clinic, recently sued Kaiser Foundation Health Plan of Colorado for prematurely terminating its participation agreement. Kaiser terminated the agreement in an effort to increase the provision of services through a less costly telehealth model.

The clinic is alleging that the early termination disrupted care for more than…

On Thursday, September 18, in the next installment of Rivkin Radler’s Health Law Executive Briefings, Chris Kutner and Ashley Algazi will present “How to Handle Payer Record Request and Subsequent Demand for Alleged Overpayments.”

The presentation will provide a comprehensive review of the issues and best practices for responding to, and defending against, payer audits.

The New York Attorney General’s office recently announced an agreement with MVP Health Care under which the insurer will pay $250,000 in penalties, fees, and costs to the state for maintaining an inaccurate mental health provider directory. The settlement is the first arising out of an investigation of so-called “ghost networks” by Attorney General Letitia…

The U.S. Department of Justice recently issued a press release concerning a Statement of Interest that shields small businesses from being forced to provide medical coverage for gender dysphoria.

In Bernier v. Turbocam et al., the Plaintiff, who identifies as a woman and has been diagnosed with gender dysphoria, claims denial of “medically necessary”…

Cigna filed a lawsuit on June 24 in Manhattan federal court accusing Bristol Myers Squibb of unlawfully blocking generic versions of its blood cancer drug, Pomalyst, from entering the market. The suit also names Celgene, a Bristol Myers subsidiary that originally developed and marketed the drug. Cigna alleges that Celgene violated U.S. antitrust laws by…

On April 30, the Federal Bureau of Investigation (FBI) released a Public Service Announcement warning consumers about fraudulent discount medical scams. These scams typically involve deceptive offers for health insurance plans that, in reality, provide little to no legitimate coverage. Scammers are contacting people through text messages, phone calls, or emails falsely claiming to represent…

On May 1, a whistleblower filed a complaint under the federal False Claims Act (FCA) against Aetna, Elevance Health (formerly Anthem) and Humana alleging that the insurers paid hundreds of millions of dollars in illegal kickbacks to induce brokers including GoHealth, eHealth and SelectQuote (the “Brokers”) to steer beneficiaries to their Medicare Advantage plans. While…

On October 31, Elevance Health filed suit against the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) to challenge the 2025 Star Ratings system used for Medicare Advantage and Part D plans. CMS published the final Star Ratings to the public on October 10 through the…

Rivkin Radler Partner Eric Fader co-authored an article in the March-April issue of SpineLine, the magazine of the North American Spine Society (NASS). The article, “OIG Advisory Opinion Cautions Against ‘Surgeon Deals’ in Neuromonitoring,” was written with Rich Vogel, PhD, DABNM, FASNM, the current President of the American Society of Neurophysiological Monitoring…