Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 1 of 92
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`Matthew M. Lavin, Esq. (pro hac vice)
`mlavin@napolilaw.com
`Wendy A. Mitchell, Esq. (CA SBN 158553)
`wmitchell@napolilaw.com
`NAPOLI SHKOLNIK, PLLC
`5757 W. Century Boulevard, Suite 680
`Los Angeles, CA 90045
`Telephone: (212) 397-1000
`Facsimile: (646) 843-7603
`
`David M. Lilienstein, Esq. (CA SBN 218923)
`david@dllawgroup.com
`Katie J. Spielman, Esq. (CA SBN 252209)
`katie@dllawgroup.com
`DL LAW GROUP
`345 Franklin St.
`San Francisco, CA 94102
`Telephone: (415) 678-5050
`Facsimile: (415) 358-8484
`
`Attorneys for Plaintiffs and Putative Class
`
`UNITED STATES DISTRICT COURT
`
`NORTHERN DISTRICT OF CALIFORNIA
`
`
`Case No.: 4:20-cv-02249-YGR
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`FIRST AMENDED CLASS ACTION
`COMPLAINT
`
`JURY TRIAL DEMANDED FOR ALL
`ISSUES SO TRIABLE
`
`PACIFIC RECOVERY SOLUTIONS d/b/a
`WESTWIND RECOVERY, MIRIAM
`HAMIDEH PHD CLINICAL
`PSYCHOLOGIST INC. d/b/a PCI
`WESTLAKE CENTERS, BRIDGING THE
`GAPS, INC., SUMMIT ESTATE
`RECOVERY CENTER, INC., on behalf of
`themselves and all others similarly situated,
`
`
`Plaintiffs,
`
`
`vs.
`
`
`UNITED BEHAVIORAL HEALTH, a
`California Corporation, and MULTIPLAN,
`INC., a New York Corporation,
`
`
`Defendants.
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`PRS, et al. v. United, et al. – FIRST AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 2 of 92
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`Table of Contents
`Table of Contents .......................................................................................................................... i
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`Introduction .................................................................................................................................. 1
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`Summary of Claims ..................................................................................................................... 3
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`Parties ........................................................................................................................................... 6
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`Plaintiffs ................................................................................................................................. 6
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`Defendants ............................................................................................................................. 6
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`Jurisdiction and Venue ................................................................................................................. 7
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`Facts ............................................................................................................................................. 8
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`Summary of the Facts ............................................................................................................ 8
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`Usual, Customary, and Reasonable Rate (“UCR”) .............................................................. 10
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`Intensive Outpatient Program Treatment ............................................................................. 11
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`Federal RICO Allegations.................................................................................................... 13
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`The Ingenix Precursor .................................................................................................... 13
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`The RICO Enterprise ........................................................................................................... 16
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`The Defendants formed a RICO Enterprise to Fraudulently Avoid Paying the Usual,
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`Customary, and Reasonable Rates for Reimbursements for IOP Services .............. 16
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`The FAIR Health Database ............................................................................................ 19
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`The Underpayment Scheme’s Mechanics ...................................................................... 22
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`Claims submission ......................................................................................................... 26
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`Rates of Payment ........................................................................................................... 27
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`Viant’s Methodology ..................................................................................................... 28
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`Viant Facility Outpatient Review: “Viant OPR” ........................................................... 29
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`Standard Analytical Files ............................................................................................... 29
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`Target Pricing: Meet or Beat .......................................................................................... 30
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`MultiPlan and the Viant Methodology .......................................................................... 32
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`MultiPlan’s Secret Annual Events ................................................................................. 32
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`MultiPlan’s Secret Road Shows..................................................................................... 34
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`The Secret Internal Whitepapers .................................................................................... 35
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`The Network Access Agreement ................................................................................... 36
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`RICO Predicate Acts ............................................................................................................ 36
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`Pacific Recovery Solutions ............................................................................................ 36
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`PCI Westlake ................................................................................................................. 43
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`Bridging The Gaps ......................................................................................................... 49
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`Summit Estate ................................................................................................................ 55
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`RICO Proximate Cause ........................................................................................................ 62
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`PRS, et al. v. United, et al. – AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 3 of 92
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`The Continuing Nationwide Pattern and Other Victims Affected ....................................... 62
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`Facts Specific to Anti-Trust Claims ..................................................................................... 63
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`The Relevant Market...................................................................................................... 64
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`Price Fixing .................................................................................................................... 65
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`Anti-Competitive Harm ................................................................................................. 68
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`General Allegations to All Counts ....................................................................................... 69
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`The Direct Harm Caused to the Plaintiffs and Class ........................................................... 69
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`Class Action Allegations............................................................................................................ 70
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`The Plaintiff Class................................................................................................................ 70
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`Rule 23(a)............................................................................................................................. 70
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`Numerosity ..................................................................................................................... 70
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`Commonality.................................................................................................................. 71
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`Typicality ....................................................................................................................... 72
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`Adequacy ....................................................................................................................... 73
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`Rule 23(b) ............................................................................................................................ 73
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`Causes of Action ........................................................................................................................ 74
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`COUNT I: Violation of RICO, 18 U.S.C. § 1962(c) ........................................................... 74
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`COUNT II: Violation of RICO Conspiracy, 18 U.S.C. § 1962(d) ...................................... 75
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`COUNT III: Violation of California Business & Professions Code §§ 17200 et seq.
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`(Unfair and Unlawful Business Practices of United) ..................................................... 76
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`COUNT IV: Violation of California Business & Professions Code §§ 17200 et seq.
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`(Unfair and Unlawful Business Practices of MultiPlan) ................................................ 78
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`COUNT V Intentional Misrepresentation/Fraudulent Inducement ..................................... 80
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`COUNT VI: Negligent Misrepresentation ........................................................................... 81
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`COUNT VII: Civil Conspiracy ............................................................................................ 82
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`COUNT VIII: Breach of Oral and/or Implied Contract....................................................... 83
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`COUNT IX: Promissory Estoppel ....................................................................................... 85
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`COUNT X: Violations of Section One of the Sherman Act ................................................ 86
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`Effects ............................................................................................................................ 87
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`Fraudulent Concealment ................................................................................................ 87
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`Damages to Plaintiffs ..................................................................................................... 87
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`Demand for Jury Trial ................................................................................................................ 88
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`PRS, et al. v. United, et al. – AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 4 of 92
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`FIRST AMENDED CLASS ACTION COMPLAINT
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`Plaintiffs Pacific Recovery Solutions d/b/a Westwind Recovery, Miriam Hamideh PhD
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`Clinical Psychologist Inc. d/b/a PCI Westlake Centers, Bridging the Gaps, Inc., Summit Estate
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`Recovery Center, Inc., bring this action on behalf of themselves and all other similarly situated
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`out-of-network behavioral health providers (collectively, the “Plaintiffs”) that provide Intensive
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`Outpatient Program treatment (“IOP”) against defendants United Behavioral Health, Inc.,
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`(“United”) and MultiPlan, Inc. (“MultiPlan”) and allege the following:
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`Introduction
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`1.
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`Plaintiffs bring this class action on behalf of themselves and all those similarly
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`situated out-of-network behavioral health providers that provide IOP treatment services (the
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`“Plaintiff Class”) and who were directly injured by United and MultiPlan’s scheme to underpay
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`valid, medically necessary claims.
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`2.
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`Each Plaintiff is a behavioral healthcare provider treating patients suffering from
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`mental health and/or substance use disorders (“MH/SUD”). Each is a duly licensed, accredited
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`provider.
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`3.
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`4.
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`Plaintiffs provide medically necessary services for MH/SUD treatment.
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`The Defendant, United Behavioral Health is one of more than 1,200 ‘United’
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`Companies. The United companies are not independent, rather they act in concert to maximize
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`profits for the shareholders of United Corporation. MultiPlan, Inc. is a ‘cost management’
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`company. Together, United and MultiPlan have formed an enterprise that furnishes a vehicle to
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`deny proper payment for the IOP treatment services that Plaintiffs provided.
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`5.
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`United and MultiPlan have also conspired together to withhold proper payment
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`for IOP treatment services from Plaintiffs.
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`6.
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`United underpaid all of the claims for medically necessary treatment at issue in
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`this litigation and amounts are still outstanding and owed directly to Plaintiffs, to whom the
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`payments were promised by United.
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`7.
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`Plaintiffs seek monetary and injunctive relief.
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`PRS, et al. v. United, et al. – AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 5 of 92
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`8.
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`All Plaintiffs in this case are aware that their attorneys also represent patients in
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`the related case before this court styled, L.D., et al. v. United, et al., Case No. 4:20-cv-02254-
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`YGR. The Plaintiffs in both matters have waived any perceived or potential conflict.
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`9.
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`United is the largest health insurer in the United States, reporting $6.7 billion in
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`profits for the second quarter of 2020, a 97 percent increase from the same period in 2019.1
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`United insures approximately 80 million people and controls 14.1% of the commercial
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`healthcare marketplace with annual premiums paid to it totaling $107 billion dollars.
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`10.
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`United also controls a large percentage of the commercial healthcare marketplace
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`in the geographic areas where the Plaintiffs reside.
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`11. MultiPlan is a private, ‘cost-management’ company that partners with insurers to
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`reduce the amounts they pay doctors and hospitals.
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`12.
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`Together, United and MultiPlan created, developed, managed, and administered
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`the scheme to underpay Plaintiffs and the class.
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`13.
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`Every claim at issue in this litigation was required to be paid at a percentage of
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`the usual and customary rate (“UCR”); the rate charged by similar providers of the same services
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`in the same geographic location.
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`14.
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`15.
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`16.
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`17.
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`Each of the claims at issue in this litigation was underpaid.
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`The underpayment directly and proximately damaged Plaintiffs.
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`The underpayment arose out of the fraudulent scheme of United and MultiPlan.
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`United and MultiPlan’s fraudulent scheme used the wires and mail to fraudulently
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`represent that the claims would be and were paid at the usual and customary rate.
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`18.
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`This scheme has been ongoing and continuous for more than two years.
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`19. Without Court intervention, this scheme will continue and continue to damage
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`Plaintiffs and the class.
`
`
`1 U.S.’ Largest Health Insurer Reports $6.7B In Profits Amid COVID, As N.Y. Cuts State
`Rates, Newsweek, August 14, 2020, https://www.newsweek.com/us-largest-health-insurer-
`reports-67b-profits-amid-covid-ny-cuts-state-rates-1525210 (last visited September 14, 2020).
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`PRS, et al. v. United, et al. – AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 6 of 92
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`20.
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`This scheme injured the Plaintiffs and the class in their persons and property as
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`Plaintiffs’ and the class have a well-established property interest in their claims for services
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`rendered to patients that is directly and proximately damaged by underpayment of the claim.
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`Summary of Claims
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`21.
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`This action asserts claims under the Federal Racketeer Influenced and Corrupt
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`Organizations (“RICO”) Act, the federal Sherman Acts, California state law claims, and seeks
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`monetary, injunctive, and declaratory relief.
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`22.
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`Plaintiffs’ federal RICO action is brought pursuant to 18 U.S.C. § 1962(c) and 18
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`U.S.C. § 1962(d).
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`23.
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`Plaintiffs’ antitrust claims are brought pursuant to the Sherman Act and other
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`federal anti-trust law.
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`24.
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`Together, and as explained more fully in the following sections, United and
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`MultiPlan have formed a federal RICO enterprise (the “Enterprise”).
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`25.
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`The Enterprise is an ongoing, informal organization with the common purpose of
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`engaging in the fraudulent scheme to underpay MH/SUD providers who do not participate in
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`United’s network.
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`26.
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`The Enterprise functions as a continuing unit and it came into being on or about
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`January 1, 2015.
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`27.
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`The Enterprise furnishes the vehicle through which the acts of racketeering
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`activity are committed.
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`28.
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`The acts of racketeering activity, as detailed in later sections, are the development
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`and implementation of the scheme to defraud and use of mail and interstate wire communications
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`in furtherance of that scheme. Pursuant to the scheme, Defendants sought, and did, under-
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`reimburse Plaintiffs for medically necessary IOP services provided to patients, injuring Plaintiffs
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`in their business and property.
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`29.
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`The relationships between United and MultiPlan are not merely standard,
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`commercial, contracts; instead, United and MultiPlan exploit their contractual arrangements to
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`provide a fig leaf of legitimacy for their racketeering activity.
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`PRS, et al. v. United, et al. – AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 7 of 92
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`30.
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`The Enterprise has operated continually since 2015 as reflected in the thousands
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`of underpaid claims at issue in this litigation and in the tens of thousands, or more, of underpaid
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`claims to other IOP treatment providers in California and across the country.
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`31.
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`Plaintiffs’ state law claims rely upon the same facts as Plaintiffs’ federal RICO
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`and antitrust claims.
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`32.
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`Plaintiffs assert supplemental state law claims for violations of the California
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`Business & Professions Code § 17200, et seq, intentional misrepresentation and fraudulent
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`inducement, negligent misrepresentation, civil conspiracy, breach of oral and/or implied contract
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`and promissory estoppel. breach of implied-in-fact contract, unjust enrichment, and declaratory
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`relief.
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`Plaintiffs Supplemental State Law Claims are Not Pre-Empted by ERISA
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`33.
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`Plaintiffs do not bring a cause of action under ERISA as the state law claims do
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`not arise under and are not preempted by ERISA. A large percentage of the claims which underlie
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`this lawsuit do not involve ERISA plans.
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`34.
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`Plaintiffs’ RICO causes of action are not preempted by ERISA, the McCarran-
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`Ferguson Act, or any other statute.
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`35.
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`Plaintiffs’ state law causes of action are not preempted by ERISA. The U.S.
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`Supreme Court has established a clear test for determining whether a state-law claim is
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`completely preempted by ERISA in Aetna Health Inc. v. Davila, 542 U.S. 200 (2004). Under
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`Davila, there is no preemption as Plaintiffs have no inherent ability to bring a claim directly
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`against UBH absent an independent cause of action. Additionally, Plaintiffs’ causes of action
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`arise under state law tort law, contracts law (oral and/or implied), equities law and federal
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`statutory law other than ERISA. For out of network providers amounts due under state law
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`duties do not satisfy the Davila test. See Marin Gen. Hosp. v. Modesto & Empire Traction Co.,
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`581 F.3d 941, 948 (9th Cir. 2009).
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`36.
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`Nor are Plaintiffs’ state law claims conflict preempted. It is well established that
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`third-party providers such as Plaintiffs may sue on their own behalf for breach of duties owed to
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`them. See Catholic Healthcare W.-Bay Area v. Seafarers Health & Benefits Plan, 321 F. App'x
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`PRS, et al. v. United, et al. – AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 8 of 92
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`563, 564 (9th Cir. 2008) (“where a third party medical provider sues an ERISA plan based on
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`contractual obligations arising directly between the provider and the ERISA plan (or for
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`misrepresentations of coverage made by the ERISA plan to the provider), no ERISA-governed
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`relationship is implicated and the claim is not preempted”); Port Med. Wellness, Inc. v.
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`Connecticut Gen. Life Ins. Co., 233 Cal. Rptr. 3d 830, 848–49 (Ct. App. 2018) (“where a plan
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`assures a provider that a proposed treatment is covered under the plan but later determines it is
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`not covered, the provider may sue based upon the plan's independent promise to the provider to
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`pay for the services rendered.”). Also, that payment may come from an ERISA plan is
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`insufficient for complete preemption or to satisfy the “relates to” requirement under ERISA §§
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`502 or 514. See Ramin M. Roohipour, M.D., Inc., v. ILWU-PMA Welfare Plan et al., 2020 WL
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`472921 (C.D. Cal. Jan. 28, 2020)
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`37.
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`In analyzing state law claims, this Court has recently ruled on the same and
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`similar state law causes of action asserted by Plaintiffs here and found that they were not
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`preempted. See Summit Estate, Inc. v. United Healthcare Ins. Co., No. 4:19-CV-06724-YGR,
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`2020 WL 5436655 (N.D. Cal. Sept. 10, 2020) (“the Court does not find that Summit Estate's
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`state-law claims depend on either the existence or the terms of an ERISA plan.”) Summit Estate
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`is a Plaintiff in the present matter as well. The claims in the present case do not overlap with
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`those of the Summit Estate case because they involve different periods of time and different
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`levels of behavioral healthcare services authorized by United.
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`38.
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`This case asserts claims similar to Doctors Med. Ctr. of Modesto, Inc. v. The
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`Guardian Life Ins. Co. of Am., 2009 WL 179681 (E.D. Cal. Jan. 26, 2009) where the court found
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`that the plaintiff-provider’s claims asserted against Viant, a MultiPlan subsidiary, were not
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`ERISA preempted. The court found that the claims asserted against Viant arose out of
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`independent obligations. After a lengthy analysis, the court held that when a claim arises out of
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`independent obligations, “[t]he authorities discussed above amply explain how a claim can arise
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`out of a transaction that involves an ERISA benefit plan while nevertheless not be “related” to
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`that plan for purposes of preemption.” Id. at *6. That is precisely the case here, even though
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 9 of 92
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`some claims will involve an ERISA benefit plan, the claims are not “related” to that plan for
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`purposes of preemption.
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`39.
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`Plaintiffs here are seeking damages based on the amount of underpayment for
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`each claim and for injunctive relief to prevent Defendants from continuing to operate their
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`fraudulent scheme.
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`Parties
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`Plaintiffs
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`40.
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`Plaintiff, Pacific Recovery Solutions d/b/a Westwind Recovery (“Westwind”), is
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`a California Limited Liability Company and a duly licensed behavioral health treatment provider
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`with a primary place of business at 7966 Beverly Blvd Suite 200, Los Angeles, CA 90048.
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`41.
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`Plaintiff, Miriam Hamideh PhD Clinical Psychologist Inc. d/b/a PCI Westlake
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`Centers (“PCI Westlake”), is a California corporation and a duly licensed behavioral health
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`treatment provider with a primary place of business 37794 La Baya Dr. # 201, Westlake Village,
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`CA 91362.
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`42.
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`Plaintiff Bridging the Gaps, Inc. (“BTG”), is Virginia corporation and a duly
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`licensed behavioral health treatment provider with a primary place of business at 31 South
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`Braddock Street, Winchester, VA 22601.
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`43.
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`Plaintiff, Summit Estate Recovery Center, Inc. (“Summit”), is a California
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`corporation and duly licensed behavioral health treatment provider with a primary place of
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`business at 20640 3rd Street Suite 350, Saratoga, CA 95070.
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`Defendants
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`44.
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`Defendant United Behavioral Health (“United”) is a California corporation, with
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`its principal place of business at 425 Market Street, 14th Floor, San Francisco, CA 94105. United
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`is a “provider of mental health2” and manages behavioral health services for UnitedHealth Group.
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`It is responsible for payment of claims related to behavioral services covered under health plans
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`sponsored or administered by UnitedHealth Group Incorporated or its many wholly owned and
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`
`2 2018 Statement of Information of United Behavioral Health, Document G063267, Filed
`September 26, 2018.
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`PRS, et al. v. United, et al. – AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 10 of 92
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`controlled subsidiaries, including United Healthcare. None of the subsidiary companies are
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`independent, rather they all act in concert to maximize profits for the shareholders of
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`UnitedHealth Group.
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`45.
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`Defendant MultiPlan, Inc. is a New York Corporation with its principle place of
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`business located at 115 5th Avenue, New York, NY 10003. Viant, Inc., is a Nevada corporation
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`and wholly owned subsidiary of MultiPlan. MultiPlan has several wholly owned and controlled
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`subsidiaries, including Viant, all of which act in concert to maximize profits for MultiPlan.
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`Jurisdiction and Venue
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`46.
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`At least one Plaintiff is diverse from the Defendants and the amount in
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`controversy exceeds $5,000,000. Therefore, this Court has subject matter jurisdiction over this
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`action pursuant to 28 U.S.C. § 1332(d) as the matter in controversy exceeds the sum or value of
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`$5,000,000, exclusive of interest and costs, and is a class action where at least one member of a
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`class of plaintiffs is a citizen of a State different from any defendant.
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`47.
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`The claims asserted involve matters of interstate and national interest, and several
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`of the claims at issue arise under federal law.
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`48.
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`The Court has supplemental jurisdiction over the state law claims pursuant to 28
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`U.S.C. § 1367 as the other claims are so related that they form part of the same case or
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`controversy.
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`49.
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`This court has personal jurisdiction over Defendants because United and/or its
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`subsidiaries maintain offices and transact business across the State of California, including at
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`corporate offices within this jurisdiction. United transacts business in California in such volume
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`that it is at home in this jurisdiction, and subject to the personal jurisdiction of this court.
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`50.
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`This court has personal jurisdiction over MultiPlan because MultiPlan and/or its
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`subsidiaries transact business so frequently and with such regularity in Northern California that
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`they avail themselves to the protections of California’s laws, are at home in this jurisdiction, and
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`subject to the personal jurisdiction of this court.
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`51.
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`This Court is the proper venue for this action pursuant to 28 U.S.C. § 1391(b) and
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`18 U.S.C. § 1965: a substantial part of the events or omissions giving rise to the claims alleged
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`PRS, et al. v. United, et al. – AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 11 of 92
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`herein occurred in this Judicial District and one or more of the Defendants conducts a substantial
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`amount of business in this Judicial District.
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`Facts
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`Summary of the Facts
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`52.
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`Plaintiffs are behavioral healthcare providers who provide, among other services,
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`intensive outpatient treatment (or, “IOP”) to patients with mental health and/or substance use
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`disorders (“MH/SUD”).
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`53.
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`Plaintiffs have no pre-existing contract with either United or MultiPlan that
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`establishes the rate that they will be paid for providing IOP treatment to patients.
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`54.
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`55.
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`56.
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`All of the IOP treatment provided was medically necessary.
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`All of the IOP treatment was under-paid.
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`United was required to pay Plaintiffs for the treatment provided based on the
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`usual and customary rate (“UCR”). UCR is a commonly accepted term in the healthcare industry
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`and means generally, the rate charged by similar providers of the same specialty in the same
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`geographic area.
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`57.
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`The FAIR Health database, described in more detail in the following sections,
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`allows the public, including Plaintiffs and their patients, to estimate the UCR for IOP treatment
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`in a specified geographic area.
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`58.
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`United, for many years, until on or about 2015, was legally required to use the
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`FAIR Health database to calculate UCR in its payment of claims, for reasons discussed below.
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`59.
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`The significant differences between the publicly available FAIR Health estimates
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`and actual payments provide compelling evidence that the Plaintiffs were not paid based on the
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`UCR for IOP treatment they provided.
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`60.
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`The fairly uniform under-payments received by Plaintiffs, all in different
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`geographic locations, provide compelling evidence that geographic location was not considered
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`in the payment received by Plaintiffs.
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`61.
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`Geographic location is part of what determines the UCR.
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`PRS, et al. v. United, et al. – AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 12 of 92
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`62. Most patients cannot shoulder the full costs of MH/SUD treatment and, in the
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`vast majority of cases, the provider bears the full cost of treatment services until they are paid
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`by a commercial payer such as United.
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`63.
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`64.
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`Such is the case with the claims at issue in this litigation.
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`For all the claims here, the Plaintiffs have received from United less than the UCR
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`based amount they were promised by the provider and are properly owed.
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`65.
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`For all healthcare claims relevant to this action the amount of the underpayment
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`remains due and owing to the providers from the Defendants.
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`66.
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`After providing services, the Plaintiffs’ billing departments transcribed patients’
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`medical charts into standardized billing codes, created invoices with standard charges, medical
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`coding, patient demographics, and submitted the invoices electronically to United via interstate
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`wire communications.
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`67.
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`68.
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`69.
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`Detailed examples for each Plaintiff are provided in the following sections.
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`Every claim at issue was approved for payment.
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`Every claim at issue received an underpayment. Examples of underpayments to
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`each Plaintiff are set forth in the following sections.
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`70.
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`Instead of paying a “reasonable” rate to Plaintiffs, the Defendants utilized Viant’s
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`methodology to fabricate a fraudulent UCR rate and withhold a substantial part of the payment
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`owed to Plaintiffs.
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`71.
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`Both United and MultiPlan had management and control over how Viant’s
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`methodology was employed to underpay the Plaintiffs as set forth in more detail in the following
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`sections.
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`72.
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`For every claim at issue, the Plaintiffs were paid at a rate that was well below
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`UCR.
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`73.
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`The federal RICO enterprise formed between United and MultiPlan used Viant’s
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`methodology to justify the fraudulent withholding of most of the payment owed on each and
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`every claim at issue, thereby directly and proximately injuring Plaintiffs in their business and
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`property.
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`PRS, et al. v. United, et al. – AMENDED CLASS ACTION COMPLAINT
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`Case 4:20-cv-02249-YGR Document 62 Filed 09/24/20 Page 13 of 92
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`74.
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`United and MultiPlan exercised management and control over the enterprise as
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`set forth in more detail in the following sections.
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`75.
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`Defendants used the enterprise to fraudulently represent to Plaintiffs and others
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`that the rate paid was the UCR rate, using the wires for telephone calls and other communications
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`and the mail by sending explanation of benefits (“EOBs”) and electronic data interchange
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`(“EDI”) versions of EOBs to through an electronic remittance advice (“ERA”).
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`76.
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`It was represented to Plaintiffs that they were paid the UCR rate, that the rate was
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`commensurate with the rates paid similar providers in the same geographic area.
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`77. Multiple acts of racketeering activity were committed by Def