On November 18, 2024, Owens & Minor, Inc. (OMI), a business that sponsors a self-funded healthcare plan for its employees, filed suit against Anthem Health Plans of Virginia, in its role as third-party administrator (TPA), claiming Anthem withheld information and engaged in financial misconduct, and challenging the function of the BlueCard program.  On April 22, 2025, Chief U.S. District Judge R. David Proctor issued an injunction stopping the case due to the settlement terms of a previous class action antitrust lawsuit against Blue Cross Blue Shield (BCBS). Lawsuits like the […]

On April 1, 2025, the Federal Trade Commission (FTC) filed for a stay in a case against three Pharmacy Benefit Managers (PBMs), not because of any lack of evidence, but rather because there was no one left at the FTC to pursue the case due to recent firings by the current administration. When the suit was filed, it was supported by the three Democrat Commissioners, and the two Republican Commissioners recused themselves. A last-minute reversal of a previous recusal may have put the suit back into motion, but the entire […]

Department of Justice Looking Into United Health On February 21, 2025, the Wall Street Journal reported that the Department of Justice (DOJ) has launched a civil fraud investigation against UnitedHealth.  The investigation is centered on Medicare billing practices, with sources saying that UnitedHealth-employed physicians were trained to document higher revenue-generating diagnoses, even if that was not what patients were being treated for.  Additionally, the investigation is apparently looking into claims that UnitedHealth used software to suggest additional codes and offered bonuses to clinicians who coded for these additional diagnoses.  If […]

On December 23, 2024, Aetna (part of CVS Health) filed a lawsuit against Radiology Partners and its private equity backers in the U.S. District Court for the Middle District of Florida – Jacksonville Division.  The suit claims Radiology Partners, one of the nation’s largest imaging groups, manipulated the No Surprises Act (NSA) and its dispute resolution process to boost payments improperly.  Aetna’s filing called this a “multiphase healthcare fraud scheme” that defrauded Aetna of “tens of millions” of dollars. Update: On February 25, Radiology Partners filed two motions: one to […]

In November of 2024, three lawsuits were filed by pharmaceutical manufacturers against the Department of Health and Human Services (HHS) and the Health Resources and Services Administration (HRSA), challenging how HRSA oversees the Federal 340B Drug Pricing Program.  (HRSA is the sub-agency within HHS that administers the 340B Program). The potential impact of the lawsuits on the 340B Program is significant in its own right, but the outcome of the lawsuits could also have an indirect effect on merger and acquisition activity.  Research has indicated that the merger and acquisition […]

Healthcare market oversight at the federal level is primarily done through litigation brought by the Federal Trade Commission (FTC) or the Department of Justice (DOJ).  Any change in administration in Washington will change the focus and priority of these agencies.  Nonetheless, the second Trump administration has indicated that it will make wholesale changes to federal agencies, including the FTC and DOJ, that exceed those that are typical during a change in administration.  These indications raise many questions about the new role of the FTC and DOJ in healthcare markets: How […]

On October 18, 2024, the North Carolina Supreme Court unanimously ruled to send a case challenging the states Certificate of Need (CON) law back to a lower court.  Certificate of Need laws require healthcare providers and facilities to get permission from the state government before adding or expanding healthcare services, equipment, or facilities.  To get this permission, the provider must show that the new service is needed, hence the name. The case in North Carolina originated in April 2020 when Dr. Jay Singleton, an eye surgeon, filed suit against legislative […]

On September 23, 2024, Particle Health, a startup that aggregates and shares data among healthcare providers and health technology companies, filed suit in the U.S. District Court for the Southern District of New York against Epic Systems, the nation’s largest vendor of electronic health records.  The suit alleges that Epic is using its market power to destroy competition and represents a challenge to Epic’s dominance in the patient data marketplace. Parties to the Suit Epic is a software company that provides electronic health record (EHR) resources for hospitals and health […]

New laws and rules requiring greater transparency into the behaviors and reimbursements of insurers have given employees and employers a clearer picture of where their healthcare dollars are going.  For example, the “Transparency in Coverage” rule, implemented in October 2020, required health plans and insurers to post rates they negotiate with providers and develop price transparency tools related to cost-sharing.  The “Consolidated Appropriations Act”, passed in 2021, requires Third Party Administrators (TPAs) to provide notice of other compensation they receive to plan sponsors and restricts “gag clauses” that would otherwise […]

No Decision in AAEM-PG v. Envision Case: A Potential Precedent-Setting Corporate Practice of Medicine and Private Equity Case is Avoided  A decision in the long-anticipated case, the American Academy of Emergency Medicine Physician Group (AAEM-PG) v. Envision Healthcare, will not come to pass, as Envision, a private equity-backed emergency physician staffing company, choose to exit the California market.  In a press release, AAEM-PG stated a concern about whether a California court could retain jurisdiction over the case after Envision exited, and noted that a confidential settlement had been made.   Experts, […]