Anand v. Independence Blue Cross, 20-6246
| Decision Date | 23 July 2021 |
| Docket Number | 20-6246 |
| Parties | NEIL ANAND, Plaintiff, v. INDEPENDENCE BLUE CROSS, Defendant. |
| Court | U.S. District Court — Eastern District of Pennsylvania |
Plaintiff Dr. Neil Anand (“Anand”) brings this pro se action against an insurance company, Defendant Independent Blue Cross, LLC (“IBC”). Anand's Amended Complaint is more than one thousand paragraphs long and includes sixty-four claims against IBC. Presently before the Court is the Defendant's Motion to Dismiss, in which it argues that the Court must dismiss this case, first, for lack of subject matter jurisdiction and, secondly, for failure to state a claim upon which relief can be granted. For the following reasons, the Court will take the unusual step of dismissing the entire Amended Complaint sua sponte for failure to adhere to Fed.R.Civ.P. 8., while at the same time addressing at some length the Motion to Dismiss and making some rulings thereon both with and without prejudice while trying to comprehend the incomprehensible and to give the pro se plaintiff guidance and an opportunity to restructure and set forth viable claims in an attempt to avoid a further dismissal with prejudice.[1] With this approach in mind, the Court will also grant in part and deny in part the Defendant's Motion to Dismiss under Fed.R.Civ.P. 12(b)(6) without prejudice to the Defendant to file a full and comprehensive Motion to Dismiss if and when a comprehensive Second Amended Complaint is filed. The Court previously addressed these issues with the Amended Complaint in its current form with the Plaintiff at Oral Arguments on the Motions to Dismiss which the court combined with a Pre-trial conference in an attempt to bring some semblance of order and practical reality to the pleadings. Plaintiff may file an Amended Complaint curing the deficiencies identified herein and has until August 13, 2021 to do so.
Plaintiff Anand is an anesthesiologist who has been employed by Atlantic Health Care PLLC (AHC), a medical practice partnership formed in 2013, and/or Institute of Advanced Medicine and Surgery PLLC (IAMS), a medical practice formed in September of 2014 by Anand and two other medical doctors. Amended Complaint ( ) ¶ 1, Neil Anand v. Independence Blue Cross, No. 20-6246 (March 24, 2021), ECF No. 22. Anand also formed a separate partnership in 2015 with Dr. Paul Soccio. Id. Defendant IBC is a health insurance company that entered into agreements with Anand, as an individual, and with IAMS. Id. ¶ 2. On or around March 31, 2013, Anand entered into a written agreement with IBC. Id. Under the terms of the agreement, Anand became an in-network provider who could treat IBC members and obtain reimbursement for services provided at a discounted rate. Id. ¶ 8. One alleged key term of the agreement was that IBC would not penalize Anand's advocacy on behalf of his patients to obtain coverage for what he determined to be appropriate and necessary health services. Id. ¶ 147. Additionally, the provider agreement required IBC to reimburse Anand for services provided to IBC's members. Id. ¶ 8. Anand's claims against IBC appear to involve four general disputes: Anand's advocacy for his patients, issues with IBC's reimbursement and coding processes, IBC's statements about Anand to third parties, and IBC's use of software to monitor controlled substances prescriptions.
When an IBC member sought treatment from Anand, the patient would “sign contracts with AHC, BCPPM, and IAMS, ” “including but not limited to Assignment of Benefits from IBC to either Anand or the Companies.” Amen. Compl. ¶¶ 9, 10, 18. Anand does not specifically identify which or how many of his patients were covered by IBC insurance policies, but he indicates that some of his patients were covered by IBC insurance policies within the Employment Retirement Income Security Act (ERISA). Id. ¶ 20. These assignment-of-benefits contracts, when forwarded to IBC network coordinators, gave Anand the right to obtain reimbursement for the treatment provided to IBC members. Id. ¶¶ 11, 19. To obtain reimbursement for the treatment, Anand would submit a claim to IBC, identifying the procedure provided with treatment “codes developed by the American Medical Association.” Id. ¶ 12. IBC uses a computer program to process these claims that “is programmed to reduce costs (where appropriate) by ‘down coding' (reading certain CPT codes as requests for less expensive service) and ‘grouping' (combining certain CPT codes as if they were a single procedure).” Id. ¶¶ 13, 14.
Although the timeline of events is not clear from the Amended Complaint, it appears that Anand's first issue occurred in January 2015, when Anand appealed to IBC's denial of coverage for his proposed treatment plan of an IBC member, “patient K.T.” Amen. Compl. ¶¶ 58-63. At this time, Anand learned that IBC “initiates investigations on doctors who file multiple appeals on behalf of patients” and was told that IBC “would retaliate against him if [he] dared to file another appeal on behalf of patient K.T.” Id. ¶¶ 62, 63. IBC allegedly directed K.T. to file an
“incorrect and unsubstantiated complaint against Anand” with the Commonwealth of Pennsylvania Department of State Professional Compliance Office, after which Anand stopped receiving business from the “pain group” that referred patient K.T. to him. Id. ¶¶ 63, 64.
In June 2015, Anand hired Paul Soccio to join his medical practice. Amen. Compl. ¶ 36. Relying on Soccio's false representation that he was an IBC-credentialed healthcare provider, Anand let Soccio treat his patients. Id. ¶¶ 36, 39, 43. In or around August 2015, Anand learned that Soccio lied about his credentials to bill with IBC. Id. ¶ 47. As a result, most of the claims submitted to IBC in mid-2015 had to be returned and resubmitted because IBC would not reimburse the practice for uncredentialed billing. Id. ¶ 51. Soccio terminated his relationship with Anand and Anand's medical practices by May 2016. Id. ¶ 65. Before leaving, Soccio obtained confidential information from Anand, including patient lists, fee schedules, physician dispensing programs, and Dr. Chrono templates. Id. ¶¶ 66-69.
Although Anand addressed the errors that Soccio created, after 2015, IBC began denying newly submitted claims, retracting old claims, and offsetting future claims. Amen. Compl. ¶ 55. These issues escalated when Lorraine Stewart, who had been assigned as Anand's IBC network coordinator, began denying many of Anand's claims. Id. ¶ 82. Anand's claims were coded as “physical therapy and other services not normally billed by an Anesthesiologist, ” prompting Stewart to deny the claims and refer him for an audit because she determined that he was “not credentialed to perform and bill” these treatments. Id. ¶¶ 84-87. After IBC audited Anand's billing, it “flagged” him in the system and “blacklisted” him from treating patients. Id. ¶ 95. IBC initially acknowledged several computer errors responsible for these problems, but it failed to correct the issues. Id. ¶ 57.
Anand's ongoing issues with IBC's billing and claims processing escalated in April 2016, when Anand began advocating for his patient, W.S., to receive pain medication for bladder cancer. Amen. Compl. ¶ 96. Victor Carabello, IBC's senior director of quality management, told Anand that “IBC doesn't care about or desire the treatment of cancer pain of their Members” in reference to the expensive medication that Anand thought W.S. should receive. Id. ¶ 97. Carabello also indicated that Anand's notes about the patient's history were inadequate and attempted to force Anand to amend W.S.'s medical chart. Id. ¶¶ 96, 99. On August 10, 2016, Anand received a letter from Caraballo telling Anand that he was removed from the IBC network “due to [his] failure to comply with the term of a corrective action plan.” Id. ¶ 99. The letter apparently also suggested that Carabello's objections to Anand's notes were meant to cover up IBC's real issue-that Anand “was serially appealing for expensive pain medications that IBC did not want to pay for.” Id. ¶ 99. On the same day, Caraballo sent a separate letter to Soccio indicating that Anand was prohibited from professionally treating IBC members and that Anand's existing IBC-member patients needed to be transferred to another credentialed physician. Id. ¶ 101.
On November 9, 2016, IBC officially removed Anand from its network and terminated the Provider Agreement. Amen. Compl. ¶ 103. Anand believes that he was “terminated solely for zealously advocating for his patient.” Id. ¶ 104. Although no written contract existed between the parties after November 9, 2016, Anand continued to treat IBC's members as an “out-of-network provider.” Id. ¶ 28. IBC's computer system, however, continued to improperly reimburse his claims at the lower, in-network provider rate. Id. Anand alleges that IBC “continued to ‘bully' and threaten [him]” and that it conspired with other insurance companies, his business partners, and third parties. Id. ¶ 35. Specifically, he alleges that IBC attempted to dissuade patients from seeking treatment from Anand, by making “unsolicited phone calls” to get patients to terminate their contracts with Anand. Id. ¶ 134. Several patients filed complaints against IBC with the Pennsylvania Insurance Department about IBC's communications. Id. At some point after this incident, IBC “deliberately erased Anand's profile out of their database” and stopped reimbursing his treatment of IBC's members. Id. ¶¶ 128-29. Although IBC refused to reimburse Anand for treatment provided to its members, IBC employees allegedly informed some of Anand's patients that he was still an in-network provider and that the insurance plan would cover treatment...
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