Surgery Ctr. of Viera v. UnitedHealthcare Ins. Co.

• Decision Date: 17 February 2023
• Docket Number: 6:22-cv-793-PGB-DAB
• Parties: SURGERY CENTER OF VIERA, LLC, Plaintiff, v. UNITEDHEALTHCARE INSURANCE COMPANY, Defendant.
• Court: U.S. District Court — Middle District of Florida

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SURGERY CENTER OF VIERA, LLC, Plaintiff, v. UNITEDHEALTHCARE INSURANCE COMPANY, Defendant.

No. 6:22-cv-793-PGB-DAB

United States District Court, M.D. Florida, Orlando Division

February 17, 2023

ORDER

PAUL G. BYRON, UNITED STATES DISTRICT JUDGE

This cause comes before the Court on Defendant's Motion to Dismiss(Doc. 19(the “Motion”)) and Plaintiff's response thereto (Doc. 25).Upon consideration, the Motion is due to be granted in part and denied in part.

I.BACKGROUND^[1]

This case flows from a medical billing dispute.PlaintiffSurgery Center of Viera, LLC is a medical provider which served P.M (the “Patient-Insured”) for cervicalgia, cervicobrachial syndrome, and cervical radiculopathy.(Doc. 17, ¶¶ 1, 11).After some alternative but ultimately unsuccessful treatments, Plaintiff provided surgical care for the Patient-Insured on September 25, 2018.(Id.¶ 11).The Patient-Insured maintained health insurance with DefendantUnitedHealthcare Insurance Company through his employer, and the PatientInsured provided the relevant insurance plan documentation (the “Plan”) to Plaintiff to cover his care.(Id.¶¶ 1, 4, 8-9).The Plan's underlying insurance contract is governed by the Employee Retirement Income Security Act(“ERISA”).(Id.¶ 20).The Plan provides that payment of benefits will unfold pursuant to a “Reasonable and Customary Charges” analysis.(Id.¶ 26).Prior to surgery, Plaintiff obtained pre-surgery authorization for a medically necessary procedure from Defendant.(Id.¶¶ 10, 11).Moreover, “at all material times,”Plaintiff“was the authorized representative of” the Patient-Insured with regard to the Plan as the Patient-Insured assigned his benefits under the Plan to Plaintiff.(Id.¶ 2).

After the conclusion of care for the Patient-Insured, Plaintiff submitted a corresponding claim for $193,348.00 (the “Claim”) to Defendant as the Plan insurer.(Id.¶ 13).Defendant made a partial payment of $46,164.46 to Plaintiff based on the Claim.(Id.¶¶ 16, 19).Plaintiff requested documentation pursuant to its understanding of ERISA's document production statutory requirements to further understand on what basis its claim payment was adjusted downward, but Defendant did not produce documentation sufficient to obviate Plaintiff's concerns.(Id.¶¶ 18, 21-24).

Plaintiff now brings suit to remedy the partial payment of its Claim.(Id.¶¶ 31-59).However, Plaintiff alleges that Defendant's partial payment of its Claim does not violate the Plan's underlying contractual terms; instead, the partial payment violates a separate repricing agreement for discounted billing rates (the “Repricing Agreement”), which non-party Preferred Medical Claim Solutions (“PMCS”) secured from Plaintiff on behalf of Defendant.(Id.¶¶ 9, 13-16, 27-29, 38, 44-45, 52).At the same time, Plaintiff alleges the “Reasonable and Customary Charges” analysis “squares with what” the Repricing Agreement established as a rate of payment.(Id.¶¶ 26-27).

The Repricing Agreement established a pre-set reimbursement rate formula that would have reduced Plaintiff's Claim to an amount no less than $162,416.80- at least according to Plaintiff's interpretation of the Repricing Agreement's terms.(Id.¶¶ 32, 37-39).As such, Plaintiff seeks at least $116,252.34 in compensatory damages for Defendant's alleged breach of the Repricing Agreement.(Id.¶¶ 32, 41-42).

Plaintiff twice amended its complaint and currently alleges the following three causes of action in the Second Amended Complaint: breach of contract (Count I); unjust enrichment (Count II); and quantum meruit (Count III).(Docs. 1, 9, 17).Defendant moved to dismiss the Second Amended Complaint for failure to state a claim (Doc. 19), and after Plaintiff responded (Doc. 25), this matter is ripe for review.

II.STANDARD OF REVIEW

To survive a Rule 12(b)(6) motion to dismiss, the complaint “must contain sufficient factual matter, accepted as true, to ‘state a claim to relief that is plausible on its face.'”Ashcroft v. Iqbal, 556 U.S. 662, 678(2009)(quotingBell Atl. Corp. v. Twombly, 550 U.S. 544, 570(2007)).A claim is plausible on its face when the plaintiff“pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.”Id.Legal conclusions and recitation of a claim's elements are properly disregarded, and courts are “not bound to accept as true a legal conclusion couched as a factual allegation.”Papasan v. Allain, 478 U.S. 265, 286(1986).Courts must also view the complaint in the light most favorable to the plaintiff and must resolve any doubts as to the sufficiency of the complaint in the plaintiff's favor.Hunnings v. Texaco, Inc., 29 F.3d 1480, 1484(11th Cir.1994)(per curiam).

In sum, courts must: reject conclusory allegations, bald legal assertions, and formulaic recitations of the elements of a claim; accept well-pled factual allegations as true; and view well-pled allegations in the light most favorable to the plaintiff.Iqbal, 556 U.S. at 679.

III.DISCUSSION

Defendant puts forward three main arguments in support of the Motion.First, Defendant argues each state-law claim “relates to” the administration of a self-funded health plan and is therefore defensively preempted by ERISA's express preemption provision in 29 U.S.C. § 1144(a).(Doc. 19, pp. 2-15).Second, Defendant contends that, apart from the preemption of Florida state law, Plaintiff has not sufficiently alleged that Defendant breached or was party to the Repricing Agreement.(Id. at pp. 15-17).Third, Defendant maintains that, in any event, Plaintiff has failed to state plausible equitable claims for relief against the claims administrator of an employee-sponsored health insurance plan.(Id. at pp. 17-19).The Court addresses each argument in turn.

A.Defensive ERISA Preemption

29 U.S.C. § 1144(a) provides that ERISA“supersede[s] any and all State laws insofar as they may now or hereafter relate to any employee benefit plan.”(emphasis added).The statutory text “relate to” is “given its broad, common-sense meaning, such that a state law ‘relates to' a benefit plan in the normal sense of the phrase-that is, if it has a connection with or reference to such a plan.”Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 47(1987);see alsoJones v. LMR Int'l, Inc., 457 F.3d 1174, 1179(11th Cir.2006).“A party's state law claim ‘relates to' an ERISA benefit plan for purposes of ERISA preemption whenever the alleged conduct at issue is intertwined with the refusal to pay [ERISA] benefits.”Garren v. John Hancock Mut. Life Ins. Co., 114 F.3d 186, 187(11th Cir.1997)(citation omitted).At the same time, conduct independent of an ERISA plan can be “too tenuous, remote, or peripheral” from the plan to be defensively preempted, including some conduct giving rise to medical providers suing plan administrators or their claims administrators.SeeLordmann Enters., Inc. v. Equicor, Inc., 32 F.3d 1529, 153334(1994)(quotingShaw v. Delta Air Lines, Inc., 463 U.S. 85, 100 n.21(1983));see alsoIn re Managed Care Litig., 595 F.Supp.2d 1349, 1357(S.D. Fla.2009)(notingERISA does not defensively preempt independent causes of action by medical providers against plan insurers if they arose independently from an ERISA plan.).For example, a medical provider's suit against an insurer can escape ERISA preemption when there is an independent basis for the claim beyond the ERISA plan such that an insurer's “failure to pay for the medical services violates a completely different non-ERISA agreement” which is “separate and distinct[] from the ERISA plan.”Surgery Ctr. of Viera, LLC v. UnitedHealthcare, Inc., 465 F.Supp.3d 1211, 1222(M.D. Fla.2020)(emphasis added).

Here Plaintiff might be able to allege an independent basis for its state law claims.Namely, the Repricing Agreement allegations, when interpreted in the light most favorable to Plaintiff, may establish an independent basis for suit that is separate and distinct from the Plan.(Doc. 17, ¶¶ 9, 13-16, 27-29, 38, 44-45, 52).Plaintiff further alleges, however, that a “Reasonable and Customary Charges” analysis under the Plan “squares with what” the Repricing Agreement established as a rate of payment.(Id.¶¶ 26-27).If Defendant's alleged underpayment connects to the Plan as it somehow is not a “Reasonable and Customary Charge”-even if one that simply “squares with” the Repricing Agreement-it is unclear to the Court how the Repricing Agreement is “separate and distinct” or “completely different” from the Plan.UnitedHealthcare, 465 F.Supp.3d at 1222;see alsoLordmann, 32 F.3d at 1533;(Doc. 17, ¶¶ 26-27).Moreover, Plaintiff further alleges that Defendant failed to comply with the “pre-suit remedies process (which such presuit mechanisms ERISA designed to try to avoid lawsuits like this)” as Plaintiff attempted to ascertain how Defendant arrived at its adjusted Claim payout amount, so the Court is at a loss to understand why Defendant is both obligated to comply with ERISA's document production requirement due to inquiries regarding the Claim and yet Plaintiff's cause of action is somehow “separate and distinct” from the ERISA Plan.(Doc. 17, ¶¶ 20-24).Nevertheless, Plaintiff may be able to clarify this ambiguity by amending the complaint, so Counts I-III are due to be dismissed without prejudice.^[2]The Court cautions Plaintiff and its counsel that any re-pled claims must establish a factual basis for its contractual claims which are independent of the Plan.SeeIn re Managed Care Litig., 595 F.Supp.2d at 1356-57(findingplaintiff's state law claims were defensively preempted because they necessarily must be read in conjunction with and “have a definite connection with” the ERISA...