Diagnostic Associates of N.E. Hou, LLC v. United Healthcare Servs., 2022 WL 214101 (S.D. Tex. 2022)
A COVID-19 testing laboratory alleged that quite a few well being plans and TPAs violated the Households First Coronavirus Response Act (FFCRA) and the Coronavirus Support, Reduction, and Financial Safety Act (CARES Act) by failing to cowl the laboratory’s diagnostic assessments at a publicly disclosed worth of $900 per check. As background, the legal guidelines and associated company steering require group well being plans and insurers to cowl COVID-19 diagnostic testing with out cost-sharing, prior authorization, or different medical administration necessities (see our Checkpoint article). Within the absence of a negotiated price, plans should pay for the testing on the money price posted by the supplier on its public web site.
The courtroom allowed the lawsuit to proceed, discovering that the FFCRA and CARES Act embody an “implied personal proper of motion” that enables the supplier to sue for the required reimbursement. The courtroom additional decided that the supplier may search cost of advantages beneath ERISA on behalf of plan members as a result of it had obtained assignments of advantages from lots of the members who had obtained testing. Lastly, the courtroom allowed the supplier’s claims beneath the Racketeer Influenced and Corrupt Organizations Act (RICO) alleging that the plans and TPAs had engaged in a “calculated and coordinated effort to delay, deny, or scale back the restoration [the provider] may make for its COVID-19 testing companies and to revenue by doing so.”
EBIA Remark: Well being plans face a conundrum beneath the COVID-19 diagnostic testing protection mandate. If plans are unable to achieve settlement with a testing supplier, they’re obligated to pay the supplier’s public money worth. It’s unsure, nonetheless, what recourse is out there when the worth (right here, $900 per check) appears unreasonable. In a footnote to its opinion, the courtroom acknowledged the plan’s assertion that the worth of the testing was too excessive and famous that its ruling didn’t foreclose a counterclaim difficult the propriety of the pricing. For extra data, see EBIA’s Group Well being Plan Mandates guide at Part XVI.C (“COVID-19: Mandated Protection of Diagnostic and Preventive Companies”). See additionally EBIA’s Self-Insured Well being Plans guide at Part XIII.C.11 (“Protection Mandates Referring to the COVID-19 Pandemic”) and EBIA’s Shopper-Pushed Well being Care guide at Part X.H (“COVID-19 Testing and Therapy”).
Contributing Editors: EBIA Workers.