We won summary judgment on all claims by a national health insurer against a Houston-based hospital. The insurer was seeking to recover $15 million in claims payments for emergency care, alleging that it had been defrauded because freestanding emergency departments were not “hospital-based” for purposes of claim reimbursement.
The case was a David v. Goliath brought against our client by one of the nation’s leading insurers, mirroring a number of similar cases concerning a Texas law that allows freestanding emergency departments affiliated with hospitals to bill as hospital-based facilities. The practical effect of this law requires insurers to pay for emergency treatment at the reasonable and customary rate whether or not the facility is “in network.”
The case was a David v. Goliath brought against our client by one of the nation’s leading health insurers.
Our lawyers successfully invoked Buckman Co. v. Plaintiffs Legal Committee, also known as the Buckman preemption, to argue that the insurer’s claims—which were based on alleged misrepresentations to Medicare—were precluded by our client’s Medicare designation as a provider-based entity (PBE). While previous cases brought by other insurers reached confidential settlements, this one was dismissed in its entirety.