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Case 3:20-cv-01675-JBA Document 29 Filed 03/24/21 Page 1 of 38
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`Docket No. 20 Civ. 1675 (JBA)
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`AMENDED COMPLAINT
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`JURY TRIAL DEMANDED
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`UNITED STATES DISTRICT COURT
`DISTRICT OF CONNECTICUT
`- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - x
`MURPHY MEDICAL ASSOCIATES, LLC;
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`DIAGNOSTIC AND MEDICAL SPECIALISTS
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`OF GREENWICH, LLC; NORTH STAMFORD
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`MEDICAL ASSOCIATES, LLC; COASTAL
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`CONNECTICUT MEDICAL GROUP, LLC; and
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`STEVEN A.R. MURPHY, M.D.,
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`- -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - x
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`Plaintiffs,
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`vs.
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`CIGNA HEALTH AND LIFE INSURANCE
`COMPANY and CONNECTICUT GENERAL
`LIFE INSURANCE COMPANY,
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`Defendants.
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`Plaintiffs, Murphy Medical Associates LLC; Diagnostic and Medical Specialists of
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`Greenwich, LLC; North Stamford Medical Associates, LLC; (collectively, “Murphy
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`Practice”); and Steven A.R. Murphy, M.D. (“Dr. Murphy”), by their attorneys, Garfunkel
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`Wild, P.C., for their Amended Complaint against the Defendants, CIGNA Health and Life
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`Insurance Company and Connecticut General Life Insurance Company (collectively,
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`Cigna), allege as follows:
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`INTRODUCTION
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`1.
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`This case is brought because CIGNA, a Fortune 500 health insurance
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`company, is blatantly defying federal law by unjustifiably refusing to provide healthcare
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`coverage for public health measures – COVID-19 testing and related services - that
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`federal law requires CIGNA to cover. Since the onset of the COVID-19 pandemic Plaintiff
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`the Murphy Practice has provided CIGNA members and beneficiaries with thousands of
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`COVID-19 diagnostic tests, as well as related medically necessary testing and services.
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`Congress has twice specifically passed statutes requiring all insurers, including CIGNA,
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`to cover such tests and services, regardless of whether they are provided by in-network
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`or out-of-network providers. Such coverage must be complete: copayments, deductibles,
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`coinsurance and limits on coverage are not permitted.
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`2.
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`Nevertheless, CIGNA has only reimbursed the Murphy Practice a fraction
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`of the cost of the services provided to CIGNA beneficiaries. Instead, CIGNA has issued
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`improper requests for medical records in every case, and, even after records have been
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`provided, CIGNA has continued to refuse to pay for the services. At last count, CIGNA
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`owed the Murphy Practice over $6 million.
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`3.
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`By this Action, the Murphy Practice seeks to hold CIGNA accountable for
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`its illegal practices.
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`JURISDICTION AND VENUE
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`4.
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`This Court has jurisdiction over this dispute under 28 U.S.C. § 1331
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`because the Murphy Practice and Dr. Murphy assert federal claims against Cigna under
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`the Families First Coronavirus Response Act, the CARES Act, and ERISA.
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`5.
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`This Court also has supplemental jurisdiction over the Murphy Practice’s
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`and Dr. Murphy’s state law claims against Cigna because these claims are so related to
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`the Murphy Practice’s and Dr. Murphy’s federal claims that the state law claims form a
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`part of the same case or controversy. This Court accordingly has supplemental
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`jurisdiction over these claims pursuant to 28 U.S.C. § 1367(a).
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`6.
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`This Court has personal jurisdiction over Cigna because Cigna carries on
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`one or more businesses or business ventures in this judicial district; there is the requisite
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`Case 3:20-cv-01675-JBA Document 29 Filed 03/24/21 Page 3 of 38
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`nexus between the businesses and this action; and Cigna engages in substantial, and
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`not isolated, activity within this judicial district.
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`7.
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`Venue is proper in this District under 28 U.S.C. § 1391(b)(2), because a
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`substantial portion of the events giving rise to this action arose in this District.
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`PARTIES
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`8.
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`At all times relevant to this matter, Plaintiff Murphy Medical Associates LLC
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`is a limited liability company organized under Connecticut law. Its principal place of
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`business is located at One East Putnam Avenue, Greenwich, Connecticut 06830.
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`9.
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`At all times relevant to this matter, Plaintiff Diagnostic and Medical
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`Specialists of Greenwich, LLC is a limited liability company organized under Connecticut
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`law. Its principal place of business is located at One East Putnam Avenue, Greenwich,
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`Connecticut 06830.
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`10. At all times relevant to this matter, Plaintiff North Stamford Medical
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`Associates, LLC is a limited liability company organized under Connecticut law. Its
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`principal place of business is located at 30 Buxton Farms Road, Suite 220, Stamford,
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`Connecticut 06605.
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`11. At all times relevant to this matter, Plaintiff Steven A.R. Murphy, M.D. is a
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`physician licensed to practice medicine in Connecticut and New York. His principal place
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`of practice is located at One East Putnam Avenue, Greenwich, Connecticut 06830
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`12. Upon information and belief, at all times relevant to this matter, Defendant
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`Cigna Health and Life Insurance Company is a corporation organized under Connecticut
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`law. Its principal place of business is located at 900 Cottage Grove Road, Bloomfield,
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`Connecticut 06152.
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`13. Upon information and belief, at all times relevant to this matter, Defendant
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`Connecticut General Life Insurance Company is a corporation organized under
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`Connecticut Law. Its principal place of business is located at 900 Cottage Grove Road,
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`Bloomfield, Connecticut 06152.
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`RELEVANT FACTS
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`14. At the start of the COVID-19 pandemic, the Murphy Practice – a cutting
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`edge internal and preventative medical practice based in southwestern Connecticut – was
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`one of the first (if not the first) to answer the call of towns and institutions throughout
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`Fairfield and New Haven Counties, Connecticut, and Westchester County, New York
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`about the desperate need for timely COVID-19 testing.
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`15.
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`Formed by Dr. Murphy over a decade ago, the mission of the Murphy
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`Practice is to provide high-quality preventive and general health services, as well as acute
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`primary care, to men, women, and adolescents. Dr. Murphy, a board-certified internist, is
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`the principal of the Murphy Practice.
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`16.
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`The Murphy Practice accomplishes its mission by offering an array of
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`preventive medical services, including diagnostic laboratory testing and imaging such as
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`ultrasounds and echocardiograms.
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`17. Patients of the Murphy Practice can also receive care and consultations
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`concerning a myriad of other services, including allergy testing, testosterone therapy,
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`chronic disease management, gynecology, immigration physicals, medical marijuana,
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`vitamin therapy, vein evaluation, urgent care and weight loss.
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`18. Dr. Murphy completed his internship in medical genetics and pediatrics at
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`Mount Sinai Hospital in New York. He subsequently served as the chief resident in internal
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`medicine at Greenwich Hospital-Yale New Haven Health in Greenwich, Connecticut. Prior
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`to entering private practice, Dr. Murphy also served as a clinical fellow in medical genetics
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`at Yale Medical School in New Haven, Connecticut.
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`19. As a physician, Dr. Murphy specializes in general medical care,
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`personalized medicine and genetics, weight loss medicine, adolescent care, and
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`hereditary cancers. In addition, Dr. Murphy is an FAA Senior Aviation Medical Examiner,
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`a United States Civil Surgeon, and an obesity medicine specialist.
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`20. Dr. Murphy serves as an assistant professor of medicine, cell biology, and
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`anatomy at New York Medical College in Valhalla, New York.
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`21. Among its other services, the Murphy Practice operates a state-licensed
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`physician office laboratory located at 30 Buxton Farms Road in Stamford, Connecticut.
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`Dr. Murphy is the certified laboratory director for this laboratory under the federal Clinical
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`Laboratory Improvement Amendments (“CLIA”) and Connecticut law.
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`The Murphy Practice’s COVID-19 Response
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`22.
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`The Murphy Practice invested hundreds of thousands of dollars to transform
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`its traditional medical practice to set up COVID-19 testing sites throughout southwestern
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`Connecticut and the Hudson Valley. These sites – which were erected virtually overnight
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`– were designed to provide efficient drive and/or walk-through COVID-19 testing to
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`patients with symptoms or suspected exposure. These testing sites were unquestionably
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`the first line of defense against the pandemic.
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`23. Ultimately, the Murphy Practice operated drive and/or walk-through COVID-
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`19 testing sites in Greenwich, Stamford, New Canaan, Darien, Fairfield, Bridgeport, New
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`Haven, West Haven, Stratford, and Ridgefield, Connecticut, and Bedford, Brooklyn, and
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`Pound Ridge, New York.
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`24.
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`In addition to creating the physical infrastructure for the sites, the Murphy
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`Practice had to assemble the clinical and administrative staff needed to operate the sites
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`and to perform the testing, including physicians, medical students, physician assistants,
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`nurse practitioners, registered nurses, medical assistants, registrars, coordinators, and IT
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`staff. It had to develop extensive protocols and procedures to ensure the sites were
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`effectively and efficiently operating, and all safety, infection control, OSHA, and CDC
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`guidance were observed.
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`25.
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`The Murphy Practice also invested significant hours and resources
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`researching peer-reviewed and other expert literature to determine the most effective and
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`informative way to fulfill its COVID-19 testing mission.
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`26.
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`Through this research, and based on personal experience, the Murphy
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`Practice concluded that performing a COVID-19 test in a vacuum, without performing any
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`other diagnostic testing, would fail to adhere to the requisite standard of care. Thus,
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`patients who present with symptoms of COVID-19, or patients who have or potentially
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`have exposure to COVID-19, need to be tested for COVID-19 as well as other respiratory
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`viruses and infections that could possibly cause the same or similar symptoms as COVID-
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`19, or could possibly co-exist with COVID-19. Information about other potential respiratory
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`viruses or infections is vitally important to ensure that patients who present with symptoms
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`or were possibly exposed to COVID-19 receive the most appropriate and effective
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`treatment for a life-threatening condition.1
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`1 See, e.g., Bangshun He et al., Tumor Biomarkers Predict Clinical Outcome of COVID-
`19 Patients, 81 J. OF INFECTION 452 (2020).
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`27. Medical Studies have also concluded that a statically significant percentage
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`of patients (20% in one study) who tested positive for COVID-19 also tested positive for
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`one or more respiratory pathogens.2
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`28.
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`In particular, FAQs regarding the federal COVID-19 testing law that have
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`been prepared jointly by the Departments of Labor, Health and Human Services (HHS),
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`and the Treasury (collectively, “FAQs”), state that “the CDC strongly encourages
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`clinicians to test for other causes of respiratory illnesses.”3
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`29. As a result, when testing for COVID-19 among symptomatic patients the
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`Murphy Practice also tested for other respiratory pathogens.
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`30.
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`Initially, this was accomplished by splitting the samples taken from patients
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`and sending one sample to a lab with the capability to test for COVID-19, and one sample
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`to the Murphy Practice lab, which was able to test for non-COVID respiratory viruses, but
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`did not yet have the capacity to test for COVID-19. The Murphy Practice utilized a BioFire
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`Film Array Panel test for its COVID-related respiratory virus testing.
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`31.
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`These Panels are front-line tests to help clinicians quickly and accurately
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`diagnose numerous respiratory infections, which present with nearly indistinguishable
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`2 Of the 116 specimens positive for SARS-CoV-2, 24 (20.7%) were positive for 1 or
`more additional pathogens, compared with 294 of the 1101 specimens (26.7%) negative
`for SARS-CoV-2 (Table 1) (difference, 6.0% [95% CI, –2.3% to 14.3%]). “Rates of Co-
`infection Between SARS-CoV-2 and Other Respiratory Pathogens,” JAMA.
`2020;323(20):2085-2086. doi:10.1001/jama.2020.6266, Available at
`https://jamanetwork.com/journals/jama/fullarticle/2764787
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`3 “FAQS ABOUT FAMILIES FIRST CORONAVIRUS RESPONSE ACT AND
`CORONAVIRUS AID, RELIEF, AND ECONOMIC SECURITY ACT IMPLEMENTATION
`PART 42,” dated April 11, 2020, available at
`https://www.cms.gov/files/document/FFCRA-Part-42-FAQs.pdf
`at Q.5.
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`symptoms and contribute to a significant healthcare burden. These multiplex PCR
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`respiratory panels utilize a syndromic approach to target a broad grouping of probable
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`respiratory pathogens.
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`32. After months of working unsuccessfully to obtain the equipment necessary
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`to directly provide COVID-19 testing, in May of 2020 an advanced BioFire Film Array
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`System, with COVID-19 testing capability, was approved by the FDA for COVID-19
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`testing.4 The Murphy Practice was able to purchase the new BioFire machine.
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`33. According to the makers of BioFire, “[t]he inclusion of SARS-CoV-2 in the
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`BIOFIRE® RP2.1 panel allows healthcare providers to quickly identify patients with
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`common respiratory pathogens, as well as those with COVID-19, using one simple test.
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`The BIOFIRE® RP2.1 panel takes approximately 45 minutes and tests nasopharyngeal
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`swab samples in transport media.”5
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`34.
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`The new BioFire machines are not capable of running a test limited to the
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`detection of COVID-19. They are only capable of running an enhanced 21 channel PCR
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`BioFire test that detects COVID-19, as well as other common respiratory virus and
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`bacterial infections.
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`35.
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`The BioFire machine was an extraordinary advance, and it enabled the
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`Murphy Practice to test far more efficiently. BioFire is capable of producing COVID-19
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`test results on the same day a sample was taken, as opposed to commercial labs in
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`4 https://docs.biofiredx.com/wp-content/uploads/PRESS-RELEASE-BIOFIRE%C2%AE-
`Respiratory-Panel-2.1-RP2.1-with-SARS-CoV-2.pdf
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`5 Id.
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`Connecticut, where results could take a week to 10 days. For symptomatic patients, the
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`time difference was potentially life-saving.
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`36. Once the Murphy Practice had COVID-19 testing capacity through the
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`BioFire machines, patients who were symptomatic or otherwise had a need for expedited
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`results had their samples run through BioFire, which often provided them with results in
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`one day or less. For others, the samples were sent to an outside lab that did the COVID-
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`19 testing.
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`37.
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`The Murphy Practice also provided COVID-19 antibody blood testing in its
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`lab for patients who knew or had reason to believe that they had recovered from COVID-
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`19.
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`38. And, for patients who tested positive for COVID-19 – or who had COVID-19
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`antibodies in their system – additional blood testing was necessary to determine the
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`potentially life-threatening damage that the virus was doing or had done to the body’s
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`organs and systems. As a result, in addition to the antibody testing specifically covered
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`by the FFCRA and the CARES Act, these patients also received medically necessary
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`comprehensive blood testing performed to determine the potentially life-threatening
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`damage that the virus was doing or had done to the body’s organs and systems. This
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`blood testing includes checking for certain protein levels, vitamin levels, hormone levels,
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`and other indicia that will provide key insights into the operation of various vital organs
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`and systems.6
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`6 See, e.g., Thirumalaisamy P. Velavan & Christian G. Meyer, Mild Versus Severe
`COVID-19: Laboratory Markers, 90 INT’L J. OF INFECTIOUS DISEASE 304 (2020); Jean M.
`Connors & Jerrold H. Levy, COVID-19 and Its Implications for Thrombosis and
`Anticoagulation, 135 BLOOD 2033 (2020); David O. Meltzer et al., Association of Vitamin
`D Status and other Clinical Characteristics with COVID-19 Test Results, 3 JAMA
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`39. Along with the testing services described above, the Murphy Practice’s
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`clinical personnel provided telemedicine preventative medicine counseling and education
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`to the patients, including how to observe universal precautions and proper nutrition during
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`the pandemic, and other important issues, as specifically recommended by the Centers
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`for Disease Control.7
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`40. Also, during the time period between the day the sample was taken and the
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`results were available, the Murphy Practice’s clinical personnel conducted telemedicine
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`visits with the patients to check on their conditions and determine whether further medical
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`intervention was needed. The frequency and duration of these visits was dependent on
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`each patient’s unique condition, with an emphasis and priority on following up with
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`symptomatic patients suspected of being infected with the virus.
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`41.
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`Finally, when the results of the tests were available, the results were posted
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`on the patient’s individual registration portal. For positive tests a telemedicine visit was
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`scheduled with the patient to review the results and next steps with a clinician. The patient
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`was advised to schedule an appointment to receive a comprehensive blood panel test.
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`The purpose of this blood test, as discussed above, is to determine the potentially life-
`
`NETWORK OPEN E2019722 (2020); Brody H. Foy, Jonathan C.T. Carlson & Erik
`Reinersten, Association of Red Blood Cell Distribution Width with Mortality Risk in
`Hospitalized Adults with SARS-CoV-2 Infection, 3 JAMA NETWORK OPEN E2022058
`(2020).
`
`7 “All persons being tested, regardless of results, should receive counseling on the
`continuation of risk reduction behaviors that help prevent the transmission of SARS-
`CoV-2 (e.g., wearing masks, physical distancing, avoiding crowds and poorly ventilated
`spaces).” Overview of Testing for SARS-CoV-2 (COVID-19), available at
`https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html
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`threatening damage that the virus was doing or had done to the body’s organs and
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`systems.
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`42.
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`The Murphy Practice unquestionably fulfilled its mission to provide ready
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`access to COVID testing and related services to residents of southeastern Connecticut.
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`From March 1, 2020 through December 31, 2020, the Murphy Practice engaged in over
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`75,000 encounters with patients, and collectively tested and provided medical treatment
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`and care to over 35,000 of those patients. To date, the Murphy Practice has provided
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`COVID-19 testing to approximately 3,000 uninsured patients, without cost to the patients.
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`43.
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`The Murphy Practice has received accolades for its public health efforts
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`from federal and state elected representatives, local government officials, and the media.
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`Indeed, the Murphy Practice’s efforts in creating the first walk up and/or drive through
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`testing sites in Connecticut played a significant part in the relative success that
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`Connecticut enjoyed in combating the COVID-19 crisis.
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`The Requirement That Health Plans Cover COVID-19 Testing and Related
`Services
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`44.
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`In March of 2020 Congress, in recognition of the public health emergency
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`and the desperate need to address it by making COVID-19 testing readily available to
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`anyone who needed it, enacted two statues that addressed the issue of payment for
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`testing: the Families First Coronavirus Response Act (“FFCRA”) and the CARES Act.
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`45. Specifically, through the FFCRA Congress mandated that health plans and
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`managed care companies, such as Cigna, must cover and reimburse providers for
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`conducting COVID-19 testing, COVID antibody testing, and related testing and services.
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`46. Moreover, in recognition of the emergency conditions, Congress went much
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`further than merely requiring insurers to cover testing. To make sure that no patient would
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`be deterred from getting a COVID-19 test due to a concern for the cost, Congress required
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`coverage for COVID-19 testing and related services to be provided without cost sharing,
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`deductibles, copayments or coinsurance, or other medical management requirements.
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`47.
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`In essence, Congress sought to ensure that any patient with health
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`insurance could get a COVID-19 test without any out-of-pocket costs, and without having
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`to get permission from their insurer.
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`48.
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`Further, Congress addressed the possibility that a patient would have
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`access to a COVID-19 test that was provided by practice that was not in the patient’s
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`insurance network.
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`49. All healthcare providers are either “in-network” or “out-of-network” with
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`respect to a particular insurance carrier. “In-network” or “participating” providers describes
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`those who contract with a health insurer to accept discounted negotiated rates as
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`payment in full for covered services. The members typically can obtain services from an
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`“in-network” provider at little or no cost to the member.
`
`50.
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`“Out-of-network” or “non-participating” providers are those that do not have
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`contracts with an insurance carrier to accept discounted rates and instead set their own
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`fees for services.
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`51. Guidance from the Departments of Labor, Health and Human Services and
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`the Treasury has clarified that the FFCRA and the CARES Act apply to COVID-19 testing,
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`antibody testing, and related services rendered by both “in-network” and “out-of-network
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`providers.” 8
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`8 FAQs dated April 11, 2020, at Q.7 and Q.4, available at https://www.cms.gov/files/document/FFCRA-Part-42-
`FAQs.pdf
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`52. However, insurers typically seek to dissuade their members from using “out
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`of network” providers, as a cost saving measure. Some healthcare plans provide no “out
`
`of network” benefits at all, meaning that any services obtained from an “out of network
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`provider” must be paid for by the patient. Alternatively, many plans will pay only a
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`percentage of “out of network” charges, leaving the patient responsible for the remainder.
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`53.
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`The FFCRA and the CARES Act addressed how insurers were required to
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`reimburse both “in network” and out of “network providers.” In a section titled “ACCESS
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`TO HEALTH CARE FOR COVID-19 PATIENTS,” the CARES Act added a requirement
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`that health plans covered by the FFCRA “shall reimburse the provider of the
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`diagnostic testing as follows . . .” for covered tests and services. The Act then set forth
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`alternative methods to calculate the actual payment amounts health plans were required
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`to pay providers for testing and related services. Importantly, the Act addressed payment
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`for services provided by “out of network” providers as well as “in network” providers.
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`54.
`
`If the patient’s plan already had a negotiated rate with the provider, i.e., the
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`provider was “in-network,” the plan had to pay that negotiated rate.
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`55. Congress also addressed the potential problem of a patient who obtains a
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`COVID test from an “out-of-network” provider. Such a patient would ordinarily face the
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`prospect of having to pay the full price to the provider, seek reimbursement from their
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`insurer, and risk receiving no reimbursement, or at best partial reimbursement.
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`56. However, the Act also addressed the payment requirements for providers
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`who did not have a negotiated rate, i.e., “out-of-network providers.” Insurers are required
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`to pay “out of network” providers their full cash price for the test, unless the insurer is able
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`to negotiate a lower rate with the provider.
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`57. Guidance has also confirmed that, in addition to reimbursing providers for
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`the COVID tests, insurers must reimburse providers for other related items and services
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`furnished during a visit that results in an order for a COVID-19 or COVID-19 antibody test.
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`58. More recently, the CDC has specifically expressed its approval of tests that,
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`like the BioFire Array, screen patients for influenza variants, along with COVID-19.9
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`CIGNA’s FAILURE TO FOLLOW THE LAW
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`59. Sadly, however, Cigna has not honored its obligation to reimburse the
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`Murphy Practice for this vitally needed public health service. This is tragic, because, while
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`it is virtually impossible in this polarized political environment for our federal elected
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`officials to agree on anything, they did agree on payment for COVID-19 testing and related
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`services.
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`60.
`
` Cigna has instead engaged the Murphy Practice in a paperwork war of
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`attrition. Specifically, Cigna has made and continues to make voluminous frivolous and
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`bad faith medical records and audit requests in response to every claim submitted by the
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`Murphy Practice, in a clear effort to overwhelm the practice and to delay or avoid its
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`payment obligations indefinitely.
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`61.
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`Indeed, Cigna’s requests would require the Murphy Practice to provide
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`hundreds of thousands of pages of documents, and cause the entire practice, and the
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`COVID-19 testing operation that is so vital to the ongoing public health emergency, to
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`grind to a halt.
`
`9 “Why the CDC Flu SC2 Multiplex Assay Is Important: Serves as a single test to diagnose infection caused by one
`of three viruses: SARS-CoV-2, influenza A, and influenza B,” available at https://www.cdc.gov/coronavirus/2019-
`ncov/lab/multiplex.html .
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`Case 3:20-cv-01675-JBA Document 29 Filed 03/24/21 Page 15 of 38
`
`62. More importantly, Cigna’s practices are specifically prohibited. According
`
`to FAQs released on February 26, 2021, “The FFCRA prohibits plans and issuers from
`
`imposing medical management, including specific medical screening criteria, on
`
`coverage of COVID-19 diagnostic testing.”10
`
`63. Rather,
`
`“When an individual seeks and receives a COVID-19
`diagnostic test from a licensed or authorized health care
`provider, or when a licensed or authorized health care
`provider refers an individual for a COVID-19 diagnostic test,
`plans and issuers generally must assume that the receipt of
`the test reflects an ‘individualized clinical assessment’ and the
`test should be covered without cost sharing, prior
`authorization, or other medical management requirements.”11
`
`64. Cigna has simply ignored this direction. Although a few payments have
`
`been made, as of now, the amount owed to the Murphy Practice for this testing totals
`
`more than $6 million dollars.12 Cigna has denied reimbursement for COVID-19 testing
`
`and testing-related services for over 4,000 Cigna members or beneficiaries.
`
`65. Notably, the Murphy Practice often initially submitted a claim for
`
`reimbursement only for the BioFire Covid-19 test array, even if many of the medically
`
`necessary ancillary services described above were also provided. Those tests and
`
`services were billed separately.
`
`66.
`
`In these situations, despite the CARES Act guidance discussed above
`
`advising that “plans and issuers generally must assume that the receipt of the test reflects
`
`10 https://www.cms.gov/files/document/faqs-part-44.pdf at page 2.
`
`11 Id.
`
`12 Cigna recently issued a “retrospective review letter,” demanding repayment of the
`amounts previously paid.
`
`6007563v.4
`
`15
`
`

`

`Case 3:20-cv-01675-JBA Document 29 Filed 03/24/21 Page 16 of 38
`
`an ‘individualized clinical assessment’ and the test should be covered without cost
`
`sharing, prior authorization, or other medical management requirements,” CIGNA either
`
`requested medical records or denied the claim.
`
`67. Despite the impropriety of the record requests, the Murphy Practice
`
`responded, providing Cigna with the test order form, signed by a physician, and the test
`
`results. These documents demonstrated conclusively that “an individual [sought] and
`
`receive[d] a COVID-19 diagnostic test from a licensed or authorized health care provider.”
`
`As the above guidance makes clear, Cigna “generally must assume that the receipt of the
`
`test reflects an ‘individualized clinical assessment’ and the test should be covered without
`
`cost sharing, prior authorization, or other medical management requirements.”
`
`68. But even after receiving the records Cigna did not reimburse the practice.
`
`Rather, Cigna simply sent another request for medical records of denied the claim. Cigna
`
`has even engaged in the practice of denying testing claims before the Murphy Practice
`
`has responded with requested records or reasonably could respond to those claim
`
`appeals.
`
`69. Cigna has also routinely, and without justification, refused to pay for the
`
`other, related testing and services the FFCRA and the CARES act require them to cover,
`
`including, for example, the patient’s visit to a Murphy Practice location, the consultation
`
`regarding testing, the taking of samples, the related testing ordered during that visit, and
`
`the telemedicine follow-ups.
`
`ERISA
`70. Moreover, even if the Families First Coronavirus Response Act and CARES
`
`Act did not, on their own, obligate Cigna to reimburse the Murphy Practice for the
`
`6007563v.4
`
`16
`
`

`

`Case 3:20-cv-01675-JBA Document 29 Filed 03/24/21 Page 17 of 38
`
`medically necessary COVID-19-related testing that it performed – which they most
`
`certainly do – Cigna would still be obligated to reimburse the Murphy Practice for the
`
`COVID-19-related testing. This is because the FFCRA and CARES Acts are to be treated,
`
`for enforcement purposes, as if they were included in ERISA.
`
`71. Even were this not the case, the FFCRA and the CARES Act broadly apply
`
`to all health care plans, including ERISA plans, meaning that ERISA plans are required
`
`to cover COVID-19 testing and related services as provided in the FFCRA and the
`
`CARES Act.
`
`72. On information and belief, a significant number of claims the Murphy
`
`Practice has submitted to CIGNA relate to patients enrolled in ERISA plans. ERISA and
`
`the FFCRA and the CARES Act require all CIGNA ERISA plans to cover COVID 19-
`
`related testing and services regardless of the terms of their plan.
`
`73.
`
`The Murphy Practice is “out-of-network” or non-participating with Cigna.
`
`74. On information and belief, many of the ERISA plans that Cigna administers
`
`provide benefits for medically necessary healthcare services plan beneficiaries obtain
`
`from “out of network” providers.
`
`75. On information and belief, Cigna’s blanket denials of the Murphy Practice’s
`
`claims for COVID-19 testing, and unjustifiable records requests, violate the provisions of
`
`these ERISA plans and wrongfully deny benefits due under ERISA.
`
`76.
`
`To the extent that any of CIGNA’s ERISA plans have not followed the
`
`requirements of the FFCRA and CARES Act, and do not provide full coverage of COVID-
`
`19 testing services, they are in violation of the FFCRA, the CARES Act and ERISA.
`
`6007563v.4
`
`17
`
`

`

`Case 3:20-cv-01675-JBA Document 29 Filed 03/24/21 Page 18 of 38
`
`77.
`
`To the extent that any of CIGNA’s ERISA plans do provide COVID-19
`
`testing benefits as required by the FFCRA and the CARES Act, CIGNA has wrongfully
`
`failed to pay the Murphy Practice as required by the plans, in violation of ERISA.
`
`78. Many of the Cigna members who received testing services at the Murphy
`
`Practice locations executed assignments of benefits forms. The assignment documents
`
`stated that each patient “assign to DMSOG/NSMA13, for application onto your bill for
`
`services, all of your rights and claims for the medical benefits to which you or your
`
`dependents are entitled, under any federal or state healthcare plan (including, but not
`
`limited to, Medicare or Medicaid), insurance policy, any managed care arrangement or
`
`other similar third-party payor arrangement . . .”
`
`79. Other patients registered electronically, and in the electronic forms that they
`
`completed they were advised and agreed that federal law requires their insurer to cover
`
`the entire cost of testing and related services, that the Murphy Practice would bill their
`
`insurer, and that the Murphy Practice woul

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