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United States District Court for the Middle District of Florida, Tampa Division
January 5, 2021, Decided; January 5, 2021, Filed
CASE NO. 8:18-cv-2873-T-23SPF
A June 21, 2019 order (1) determines that ERISA completely preempts this action, (2) denies the motion to remand, and (3) dismisses the complaint. An April 7, 2020 order dismisses the amended complaint. Although the plaintiff again amends (Doc. 64) the complaint, the defendants again move (Doc. 68) to dismiss because "a discernable number of federally-governed plans continue to pervade Plaintiff's causes of action, which thus remain preempted." (Doc. 68 at 4) Resolution of the motion requires another slog through the law of Employee Retirement Income and Security Act, 29 U.S.C. § 1001 (ERISA); the Federal Employee Health Benefits Act, 5 U.S.C §§ 8901-14 (FEHBA); and the Social Security Act, 42 U.S.C. § 1395 (Medicare).
As recounted in both the June [**2] 21, 2019 order and the April 7, 2020 order, the defendants administer health insurance and some of the defendants' insureds are enrolled in health benefit plans regulated by ERISA, FEHBA, or Medicare. The plaintiff entered into a "Preferred Patient Care Hospital Agreement" (PPC Agreement) with one defendant, Florida Blue, and a "Hospital Services Agreement" (HO Agreement) with the other defendant, Health Options. These "Provider Agreements," which the parties frequently renew and amend, establish both the terms under which the plaintiff provides "hospital services" to the defendants' members and the terms under which the defendants pay for those services. The plaintiff alleges, among other things, that the defendants breached the Provider Agreements by using improper methods of payment.
Count I asserts that Florida Blue improperly paid for hospital services provided to Blue Select Members by, for example, implementing a "split-billing" policy that allegedly violates the PPC Agreement. Count II alternatively alleges that if the Blue Select plan "is not payable under the PPC Agreement," the defendants violated Section 641.513, Florida Statutes, and Section 627.64194, Florida Statutes. In Counts III and IV, the plaintiff alleges that the defendants breached [**3] the "anti-steerage" [*1244] provisions of the Provider Agreements by "advising, steering, and providing incentives to [plan] members to seek hospital services from other hospital providers" and by excluding from the defendants' directories "certain of Hospital's facilities." (Doc. 64 at 23-4)
Counts IV and V allege that the defendants breached the Provider Agreements by underpaying the contractually required amount to the plaintiff either for services provided after the receipt of an authorization or for services provided when no authorization was required. Counts VII and VIII assert that the defendants breached the Provider Agreements by employing third parties to deny claims for payment.1 In Count IX, the plaintiff alleges that Florida Blue breached the PPC Agreement by underpaying for hospital services provided to Medicare Advantage Blue Card members. And finally, Counts X and XI allege that the defendants underpaid for emergency services by failing to apply the "prudent layperson standard" and by "retrospectively denying payment of the contractually required amount . . . for reasons not permitted by the P[rovider] Agreement[s]." (Doc. 64 at 47)
Full case includes Shepard's, Headnotes, Legal Analytics from Lex Machina, and more.
511 F. Supp. 3d 1240 *; 2021 U.S. Dist. LEXIS 926 **; 2021 WL 37605
SARASOTA COUNTY PUBLIC HOSPITAL BOARD, Plaintiff, v. BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., et al., Defendant.
Prior History: Sarasota Cty. Pub. Hosp. Bd. v. Blue Cross & Blue Shield of Fla., Inc., 2019 U.S. Dist. LEXIS 104146, 2019 WL 2567979 (M.D. Fla., June 21, 2019)
provider, preemption, preempted, contracted, defendants', second amended complaint, plaintiff's claim, exhaustion, coverage, benefit plan, Rehabilitation, benefits, alleges, insurer, challenges, state law, reimbursement, parties, cause of action, contractually, noncontract, plans, exhaustion of administrative remedies, healthcare provider, hospital service, disputes, Counts, authorization, third-party, coverage determination