Case Studies

Epstein Becker Green Helps Health Insurance Carrier Obtain Reversal of Premium Rate Disapprovals

On August 6, 2010, Epstein Becker Green helped its client Fallon Community Health Plan, Inc. ("FCHP") obtain the reversal of the Massachusetts Division of Insurance ("Division") disapproval of certain of FCHP's premium rate increases. The Division had previously disapproved all premium rate increases filed by FCHP and other health insurance carriers for small business and individual customers that exceeded 7.7 percent — which was 150 percent of the New England Medical CPI for 2009. FCHP and the other affected health insurance carriers filed administrative appeals of the Division's disapprovals of their premium rates. The Massachusetts Attorney General's Office intervened in the administrative hearings on behalf of consumers' interests. Epstein Becker Green, which along with local counsel represented FCHP, presented documentation and testimony justifying FCHP's rates from actuaries, provider contracting executives, and other witnesses.

After examining the evidence, the presiding hearing officers reversed the Division's disapprovals of FCHP's premium rates, finding, among other factors, that FCHP had made reasonable efforts to keep costs down through provider contracting, and utilization control and cost containment programs. The presiding hearing officers also adopted EBG's arguments that the Division's reliance on Medical CPI to reject premium rates was flawed. As a result of the reversals, FCHP was able to implement its filed rate increases through the end of 2010.

Epstein Becker Green and its attorneys Jesse M. Caplan, George B. Breen, and Robert E. Wanerman of the Washington, D.C., office served as co-counsel, along with local counsel Bowditch & Dewey, in representing FCHP.

New Jersey Appellate Court Dismisses Suit Against Medical Claims Administrators

Epstein Becker Green recently achieved a significant appellate victory for Horizon Healthcare Services Inc. ("Horizon") and Magellan Health Services Inc. ("Magellan"). On June 11, 2013, the Superior Court of New Jersey, Appellate Division, reversed a decision by the Chancery Division, Essex County, and dismissed a lawsuit brought by the New Jersey Psychological Association ("NJPA") and two patients. The complaint alleged that Horizon and Magellan had breached their agreement under the State Health Benefit Program ("SHBP"), which insures New Jersey workers, and violated the New Jersey Practicing Psychology Licensing Act ("PPLA") by requiring psychologists to disclose confidential patient treatment information before paying for the patients' mental health services.

The NJPA previously sued Horizon and Magellan in the Chancery Division, Mercer County, for violating the SHBP agreement and the PPLA. In January 2011, the Mercer judge dismissed the suit, claiming that the NJPA lacked standing to bring its claims against Horizon and Magellan because it couldn't prove that the association had suffered any harm. The NJPA filed an appeal, but then withdrew it. In July 2011, the NJPA and two patients, who were covered under SHBP plans and claimed that they were denied treatment by Horizon and Magellan because they refused to disclose confidential information, filed a second lawsuit, but, this time, in the Chancery Division, Essex County. The Essex judge declined to dismiss the suit, and Horizon and Magellan appealed.

In its decision, the Appellate Division pointed out that the plaintiffs in the Essex County suit "raise no new issues and present no new material facts that should change the decision made by the Mercer judge." Accordingly, the Appellate Division dismissed the suit, adding that the Essex judge should not have not considered the case and that the two patient-plaintiffs were required to exhaust their administrative remedies under the SHBP before seeking judicial action.

The Epstein Becker Green team included attorneys James P. Flynn and Amy E. Hatcher.

Epstein Becker Green Successfully Represents Children’s National Medical Center, Greater Southeast Community Hospital, Howard University Hospital, Providence Hospital, and Washington Hospital Center in the Establishment, Operation, and Sale of Capital Community Health Plan, a Medicaid Health Maintenance Organization

On September 19, 1995, Children’s National Medical Center, Greater Southeast Community Hospital, Howard University Hospital, Providence Hospital, and Washington Hospital Center established Capital Community Health Plan, Inc., a Medicaid health maintenance organization, and operated it until its sale to AmeriGroup Maryland, Inc., on March 25, 2002.

The Epstein Becker Green team was led by Clifford E. Barnes and included Robert Reif and Brian Gradle.

Epstein Becker Green Obtains Dismissal of Action Against Health Insurance Plan

On February 5, 2016, Epstein Becker Green litigators obtained summary judgment dismissing an Amended Complaint in its entirety on behalf of client The New York State Catholic Health Plan, Inc., d/b/a Fidelis Care New York (“Fidelis Care”), one of the largest government programs-based health insurance plans in New York State. The case was brought by Ahmed Elkoulily, M.D., P.C., a medical provider, challenging Fidelis Care’s decision to terminate the provider’s health services contract on the basis of a finding that the provider presented a danger of imminent harm to patient care.

After extensive discovery, the New York State Supreme Court (Nassau County) reviewed the submissions of the parties and found that “Fidelis made a searching inquiry of a sample of Dr. Elkoulily’s files, and that its conclusion to terminate him was far from arbitrary,” the standard of review for a determination under New York Public Health Law § 4406-d. On an earlier motion to dismiss, the court had dismissed the provider’s three other claims for breach of contract, intentional infliction of economic harm, and violation of New York Public Health Law § 230(11)(b).

This case is one of the few reported decisions in which a health plan has invoked the right to terminate a provider’s contract without a hearing. The court’s two decisions on the subject present a sound analysis of the proper use of such extreme measures.

The Epstein Becker Green litigators representing Fidelis Care included Peter L. Altieri and Jennifer M. Horowitz.

Epstein Becker Green Assists Two Health Insurers in Defeating Data Breach Class Certification

After more than five years of litigation, on April 26, 2016, a three-judge Superior Court panel in Pennsylvania upheld the denial of a motion for certification of a class action against Epstein Becker Green clients Keystone Mercy and AmeriHealth Caritas Health Plans.

In December 2010, the plaintiff, on behalf of his daughter, filed a lawsuit against the two insurers, claiming that they violated state consumer protection laws by losing a flash drive containing the personal health information (PHI) of more than 283,000 individuals and by failing to live up to their promise to protect and safeguard these individuals’ PHI.

In denying the plaintiff’s class certification motion, the panel found that the trial court had “carefully considered the numerosity, typicality, adequacy of representation, and fair and efficient method of adjudication requirements for class certification under Rule 1702 [('Prerequisites to a Class Action')] and found the class action requirements were not met.” In addition, the panel agreed with the trial court’s ruling that the plaintiff could not properly represent potential class members because he was unable to conclusively link his daughter to the PHI contained on the lost flash drive. Also, the panel left in place the trial court’s finding that, as there was no there was no actual harm associated with the data breach, the plaintiff failed to fulfill the typicality requirements for a class action.

The Epstein Becker Green team was led by Stuart M. Gerson and included Patricia M. Wagner and Tanya Vanderbilt Cramer.

Epstein Becker Green Advises Health System on Forming First-of-Its-Kind Direct-to-Employer Health Care Network and Alliance in California

Epstein Becker Green provided health care transactional and regulatory advice to MemorialCare Health System (“MemorialCare”) pertaining to structuring and developing a five-year arrangement involving a direct contract to provide medical care to Southern California employees of The Boeing Company (“Boeing”) and their families (approximately 37,000 people). The arrangement has been described as the first such customized health plan option in California between a large employer and a health care provider.

The network with MemorialCare for Boeing’s employees includes 2,400 primary care doctors and specialists, nine hospitals, and 71 community-based ambulatory surgery, medical imaging, urgent care, and dialysis centers, among others. The hospitals involved include MemorialCare’s five hospitals that span parts of Los Angeles and Orange Counties in addition to hospitals, physicians, and other facilities through MemorialCare’s related network contracts with UC Irvine Medical Center, Torrance Memorial Medical Center, PIH Health Hospital-Whittier, PIH Health Hospital-Downey, and PIH Health Physicians.

The arrangement is designed to improve health, enhance patient experience, and make health care more affordable for Boeing and those employees who choose it. Also, the arrangement allows MemorialCare direct access to clinical data to better customize and coordinate employees’ health needs.

The Epstein Becker Green team was led by Paul A. Gomez and included Leonard Lipsky and Patricia M. Wagner.