Premier Comp Solutions LLC v. UPMC

• Decision Date: 27 March 2019
• Docket Number: 2:15cv703
• Citation: 377 F.Supp.3d 506
• Parties: PREMIER COMP SOLUTIONS LLC, Plaintiff, v. UPMC, a Pennsylvania non-profit non-stock corporation, UPMC Benefit Management Services, Inc., d/b/a UPMC WorkPartners, UPMC Health Benefits, Inc., d/b/a UPMC WorkPartners, and, MCMC, LLC a wholly-owned subsidiary of York Risk Management, Defendants.
• Court: U.S. District Court — Western District of Pennsylvania

377 F.Supp.3d 506

PREMIER COMP SOLUTIONS LLC, Plaintiff,

v.UPMC, a Pennsylvania non-profit non-stock corporation, UPMC Benefit Management Services, Inc., d/b/a UPMC WorkPartners, UPMC Health Benefits, Inc., d/b/a UPMC WorkPartners, and, MCMC, LLC a wholly-owned subsidiary of York Risk Management, Defendants.

2:15cv703

United States District Court, W.D. Pennsylvania.

Filed March 27, 2019

Stanley M. Stein, Stanley M. Stein, PC, Pittsburgh, PA, Jeffrey S. Jacobovitz, Arnall Golden Gregory LLP, Washington, DC, for Plaintiff.

Daniel K. Oakes, Richard B. Dagen, Axinn, Veltrop & Harkrider LLP, Washington, DC, Thomas G. Rohback, Axinn, Veltrop & Harkrider, LLP, Hartford, CT, Peter S. Wolff, Pietragallo Gordon Alfano Bosick & Raspanti, LLP, Alaura R.M. Perdzock, Jones Day, Curtis M. Schaffner, Paul S. Mazeski, Stephenie G. Anderson, Buchanan Ingersoll & Rooney PC, Pittsburgh, PA, for Defendants.

MEMORANDUM OPINION

David Stewart Cercone, United States District Judge

I. INTRODUCTION

Plaintiff, Premier Comp Solutions, LLC ("Premier" or "Plaintiff"), initiated this action by filing a seven (7) count Amended Complaint against Defendants, UPMC ("UPMC"), UPMC Benefit Management Services, Inc. ("UPMC-BMS"), UPMC Health Benefits, Inc.¹ ("UPMC-HB") (collectively the "UPMC Defendants"), and MCMC, LLC ("MCMC") (collectively the "Defendants"), alleging (1) violation of Section 2 of the Sherman Act, 15 U.S.C. §§ 1 et seq. , attempted monopolization against UPMC (Count I); (2) violation of Section 1 of the Sherman Act, group boycott, against the UPMC Defendants (Count II); (3) violation of Section 2 of the Sherman Act, attempted monopolization against UPMC (Count III); (4) violation of Section 1 of the Sherman Act, exclusive dealing, against all Defendants (Count IV); (5) violation of Section 1 of the Sherman Act, restraint of trade, against all Defendants (Count V); (6) violation of Section 2 of the Sherman Act, attempted monopolization against UPMC and WorkPartners (Count VI); (7) common law Unfair Competition against all Defendants (Count VII). Premier contends, inter alia , that the Defendants conspired to drive Premier from the market in workers' compensation cost containment services. The UPMC Defendants and MCMC have filed Motions for Summary Judgment, Premier has responded and the matter is now before the Court.

II. STATEMENT OF THE CASE

Premier is a limited liability company organized under the laws of the Commonwealth of Pennsylvania, located in Allegheny County, Pennsylvania. UPMC Concise Statement of Undisputed Material Facts ("UPMC CSUMF") ¶¶ 1 & 2. Premier provides cost containment services to workers' compensation insurers and third party administrative ("TPA") service providers in twenty-one (21) states including Pennsylvania. Am. Compl. ¶¶ 20, 21 & 25; UPMC CSUMF ¶ 10; Premier's Response to UPMC Concise Statement of Undisputed Material Facts ("Premier Resp.") ¶ 10. The services provided by Premier include:

(1) Medical Bill Review and Repricing – Preferred Provider Organization ("PPO") discount network access, electronic data interface ("EDI") transfer services, and the issuance of savings reports to clients on a monthly, quarterly, and/or annual basis;

(2) Physical Therapy ("PT") and Diagnostic ("MRI") discount network access – Scheduling of all PT/MRI appointments, verification and tracking of attendance for all appointments, PT utilization review services, obtaining all PT treatment notes and MRI imaging reports, tracking PT appointments and treatment compliance, issuance of detailed PT utilization reports for all active and discharged patients as well as PT outcomes by body part on a monthly, quarterly, and/or annual basis and the issuance of network savings reports to clients on a monthly, quarterly, and annual basis;

(3) Panel Development - Investigation and vetting of potential panel providers for qualifications, licensing, and quality of care, providing ongoing panel maintenance, panel implementation, and verification of the accuracy of the panel provider information of all panels every six months and/or when demographic (address, phone number, etc.) changes occur, providing customer service and receiving feedback regarding client satisfaction with all PCS services through the use of written customer surveys;

(4) Injury Management – Scheduling of all physician, PT and MRI appointments for managed panel clients, obtaining work status information after every appointment and forwarding it to adjuster and/or employer.

UPMC CSUMF ¶ 10; Premier Resp. ¶ 10.

UPMC BMS (d/b/a WorkPartners) is a licensed TPA in Pennsylvania that originally began providing workers' compensation TPA services to UPMC entities in 1997, and later began providing workers' compensation TPA (and other) services to other public and private employers. UPMC CSUMF ¶ 40. UPMC HB (d/b/a WorkPartners) is licensed to provide workers' compensation insurance in the Commonwealth of Pennsylvania, and began selling workers' compensation insurance in Pennsylvania in 2010. UPMC CSUMF ¶¶ 42 & 43. WorkPartners uses vendors to provide inter alia medical bill repricing and panel generation services to its clients. MCMC Concise Statement of Undisputed Material Facts ("MCMC CSUMF") ¶ 5. Both UPMC BMS and UPMC HB are wholly owned subsidiaries of UPMC. UPMC CSUMF ¶ 44.

Medical bill review and repricing is the process by which a company reviews medical bills to ensure there are no errors in the billing and to reduce provider charges. Bills from healthcare providers for services rendered to workers' compensation claimants are reviewed to assure the providers' documentation supports their billed charges, and billed charges in excess of the amounts allowed under the appropriate state's workers' compensation fee schedule are disallowed and reduced accordingly. The repricing company then reprices the bill and generates Explanation of Reimbursement ("EOR") forms which reflect the providers' billed charges, workers' compensation fee schedule reductions, medical bill review reductions, PPO discounts, and amounts payable to the provider. The repricing company transmits the EORs to their clients and the clients remit payment to the providers with copies of the EORs. UPMC CSUMF ¶ 15; MCMC CSUMF ¶ 2(b).

Premier performs repricing services for clients in Pennsylvania and twenty-one (21) states outside of Pennsylvania, according to the workers' compensation laws and fee schedules of those states, including the states with the largest volume, New Jersey, Maryland, Delaware, Ohio, and Utah. UPMC CSUMF ¶ 19. Premier has a PPO network access contract with the Coventry Health Care ("Coventry") workers' compensation PPO network, which is the largest such network in the nation. UPMC CSUMF ¶ 16. Premier also accesses the Prime Health Services Network ("Prime") PPO, located in Brentwood, Tennessee, which includes more than 700,000 medical service providers throughout the United States. UPMC CSUMF ¶ 17. In 2014, approximately 6.84% of Premier's overall revenue was derived from its medical bill review and repricing services. UPMC CSUMF ¶ 21.

MCMC provides medical bill review and repricing services to, among other types of customers, workers' compensation insurers, workers' compensation TPA services providers and self-insured employers. UPMC CSUMF ¶ 53. Medical bill review and repricing services for UPMC WorkPartners have always been provided by MCMC, except that Premier provided bill review and repricing for four (4) of WorkPartners' TPA clients relevant here: (1) the City of Pittsburgh; (2) Port Authority of Allegheny County; (3) Pennsylvania Turnpike Commission and (4) Allegheny County. UPMC CSUMF ¶ 55; Premier Resp. ¶ 55; MCMC CSUMF ¶¶ 7, 9 & 10. MCMC is not a panel provider and has provided no panel generation services to WorkPartners. MCMC CSUMF ¶ 11.

Though WorkPartners contends that it does not engage in or sell medical bill review and repricing services of workers' compensation medical bills, UPMC CSUMF ¶ 48, Premier contends that WorkPartners bundles services in their TPA bids to include repricing services. Premier Resp. ¶ 48. In that regard, WorkPartners does not give the employer the option to carve out the repricing services to an independent repricing vendor such as Premier. Id.

With regard to Premier's physical therapy and diagnostic network, Premier entered into direct discount contracts with a large number of outpatient healthcare providers who render services in the fields of physical therapy and diagnostic imaging (e.g. MRI and CT). UPMC CSUMF ¶ 23. These direct contract relationships form what Premier called its "PT Network" and "MRI Network" which is also referred to as its "PT/MRI Network." UPMC CSUMF ¶ 24. Premier has the largest and most extensive PT/MRI network in Pennsylvania, containing over 995 PT providers and 265 diagnostic imaging providers across the Commonwealth of Pennsylvania. UPMC CSUMF ¶ 25.

Panel development and maintenance, as practiced by Premier, is the process by which Premier develops functional and customized panel listings of healthcare providers to be utilized by employees who incur work-related injuries and illnesses. Premier assists the employer to implement a panel in compliance with Pennsylvania's Workers' Compensation Act and to understand the proper use of the panel. The panels are posted at the employer's workplace and are comprised of healthcare providers who are geographically located near the place of employment and who provide the medical services most likely to be needed by the employees of the particular employer. Premier updates and reissues the employer panels when provider demographics change and at the request of the employer. Premier verifies the accuracy of panel provider information for all its clients' panels every six months and communicates any changes to their employer and insurance carrier clients. Premier also investigates and vets potential panel providers for qualifications, current licensing and quality of care. Premier Resp. ¶ 29....