Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 1 of 30
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`UNITED STATES DISTRICT COURT
`DISTRICT OF CONNECTICUT
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`MURPHY MEDICAL ASSOCIATES, LLC;
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`COMPLAINT
`DIAGNOSTIC AND MEDICAL SPECIALISTS
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`OF GREENWICH, LLC; and STEVEN A.R.
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`JURY TRIAL DEMANDED
`MURPHY, M.D.,
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`CENTENE CORPORATION, FIDELIS CARE and
`WELLCARE HEALTH PLANS, INC.
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`Defendant.
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`Plaintiffs,
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`vs.
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`Plaintiffs Murphy Medical Associates LLC, Diagnostic and Medical Specialists of
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`Greenwich, LLC (collectively, “Murphy Practice”) and Steven A.R. Murphy, M.D. (“Dr.
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`Murphy”), by their attorneys, Harris Beach, PLLC, for their Complaint against the Defendant,
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`Centene Corporation ( “Centene”), Fidelis Care (“Fidelis”) and WellCare Health Plans, Inc.
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`(“WellCare”)(collectively, “Defendants”), allege as follows.
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`INTRODUCTION
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`1.
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`Plaintiffs bring this case because Centene, one of the largest publicly traded health
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`plan issuers in the United States and two of its wholly owned managed care health insurance
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`subsidiaries, Fidelis and WellCare, are blatantly defying federal and state law, as well as principles
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`of equity, by refusing to reimburse Plaintiffs for COVID-19 testing that Plaintiffs provided to
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`members and/or beneficiaries of Defendants’ health plans in the midst of a public health crisis.
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`2.
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`In 2020, and in response to the COVID-19 pandemic and public health emergency,
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`Congress twice passed statutes – the Families First Coronavirus Response Act (FFCRA) and the
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`Coronavirus Aid, Relief, and Economic Security Act (CARES Act) – requiring all fully-insured,
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`3:22-cv-504
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 2 of 30
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`level-funded, and self-insured health plans, including those plans that Fidelis and WellCare
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`administer, to cover such COVID-19 tests and related services, regardless of whether they are
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`provided by in-network or out-of-network providers. Such coverage must be complete:
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`copayments, deductibles, coinsurance and limits on coverage are not permitted.
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`3.
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`The recent emergence of the highly transmissible BA.2 Omicron variant ensures
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`that the need for continued, efficient COVID-19 testing persists. The Murphy Practice will
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`continue to provide critical COVID-19 testing to uphold its Hippocratic Oath during this public
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`health crisis.
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`4.
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`Defendants, however, have refused to honor federal law and, instead, have issued
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`outright denials or infinitesimal “reimbursement” of claims submitted by the Murphy Practice. The
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`Murphy Practice has appealed every claim submitted to Fidelis and WellCare, which were
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`summarily denied and later advised to the Murphy Practice that it has exhausted all appeal rights.
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`5.
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`Plaintiffs, therefore, are left with no recourse against Defendants other than through
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`this Court to hold Defendants accountable for their wrongful conduct during the current public
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`health crisis.
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`PARTIES
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`6.
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`At all times relevant to this matter, Plaintiff Murphy Medical Associates LLC is a
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`limited liability company organized under Connecticut law. Its principal place of business is
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`located at 30 Buxton Farms Road, Stamford, Connecticut 06905.
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`7.
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`At all times relevant to this matter, Plaintiff Diagnostic and Medical Specialists of
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`Greenwich, LLC is a limited liability company organized under Connecticut law. Its principal
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`place of business is located at 30 Buxton Farms Road, Stamford, Connecticut 06905.
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`8.
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`At all times relevant to this matter, Plaintiff Steven A.R. Murphy, M.D. (“Dr.
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`Murphy”) is a physician licensed to practice medicine in Connecticut and New York. His principal
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`place of practice is located at 30 Buxton Farms Road, Stamford, Connecticut 06905.
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`9.
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`10.
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`Dr. Murphy, a board-certified internist, is the principal of the Murphy Practice.
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`Dr. Murphy completed his internship in medical genetics and pediatrics at Mount
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`Sinai Hospital in New York. He subsequently served as the Chief Resident for Internal Medicine
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`at Greenwich Hospital-Yale New Haven Health in Greenwich, Connecticut from July 2007
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`through May 2008. Prior to entering private practice, Dr. Murphy also served as a clinical fellow
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`in medical genetics at Yale Medical School in New Haven, Connecticut from June 2008 until
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`November 2008.
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`11.
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`As a physician, Dr. Murphy specializes in general medical care, personalized
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`medicine and genetics, weight loss medicine, adolescent care, and hereditary cancers. In addition,
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`Dr. Murphy is an FAA Senior Aviation Medical Examiner, a United States Civil Surgeon, and an
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`obesity medicine specialist.
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`12.
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`Dr. Murphy also 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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`13.
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`Dr. Murphy is the certified laboratory director for Plaintiff Diagnostic and Medical
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`Specialists of Greenwich, LLC under the federal Clinical Laboratory Improvement Amendments
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`(“CLIA”) and Connecticut law.
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`14.
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`Upon information and belief, Defendant Centene is a publicly traded managed care
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`company that issues and administrates various health plans with its principal place of business
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`located at 7700 Forsyth Boulevard St. Louis, MO 63105.
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 4 of 30
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`15.
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`Defendant Centene is multi-billion-dollar company and one of the largest health
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`insurance providers in the United States with reported 2021 revenues of $126 billion.
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`16.
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`Upon information and belief, Fidelis is a corporation organized under New York
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`law with its principal place of business located at 100 Willowbrook Office Park #100, Fairport,
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`NY 14450. Fidelis is a wholly owned subsidiary of Defendant Centene.
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`17.
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`Upon information and belief, WellCare is corporation organized under Florida law
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`with its principal place of business located at 7700 Forsyth Boulevard St. Louis, MO 63105.
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`WellCare is a wholly owned subsidiary of Defendant Centene.
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`JURISDICTION AND VENUE
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`18. This Court has jurisdiction over this dispute under 28 U.S.C. § 1331 because the
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`Murphy Practice asserts federal claims against Defendants under the Families First Coronavirus
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`Relief Act, the CARES Act, the Affordable Care Act, and ERISA.
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`19. This Court also has supplemental jurisdiction over the Murphy Practice state law
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`claims against Defendants because these claims are so related to the Murphy Practice’s federal
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`claims that the state law claims form a part of the same case or controversy. This Court accordingly
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`has supplemental jurisdiction over these claims pursuant to 28 U.S.C. § 1367(a).
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`20. This Court also has personal jurisdiction over Defendant Centene because Centene
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`carries on one or more businesses or business ventures in this judicial district; there is the requisite
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`nexus between the businesses and this action; and Centene engages in substantial, and not isolated,
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`activity within this judicial district.
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`21. This Court also has personal jurisdiction over Defendant Fidelis because Fidelis
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`carried on one or more businesses or business ventures in this judicial district; there is the requisite
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`nexus between the businesses and this action; and Fidelis engaged in substantial, and not isolated,
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 5 of 30
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`activity within this judicial district.
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`22. This Court also has personal jurisdiction over Defendant WellCare because
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`WellCare carries on one or more businesses or business ventures in this judicial district; there is
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`the requisite nexus between the businesses and this action; and WellCare engages in substantial,
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`and not isolated, activity within this judicial district.
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`23. Venue is proper in this District under 28 U.S.C. § 1391(b)(2), because a substantial
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`portion of the events giving rise to this action arose in this District.
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`FEDERAL LAW REQUIRES DEFENDANTS TO REIMBURSE PLAINTIFFS
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`In March 2020, Congress, in recognition of the COVID-19 public health emergency
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`24.
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`and the desperate need to address it by making COVID-19 testing readily available to anyone who
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`needed or wanted it, enacted two statutes that addressed the issue of payment for testing: the
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`Families First Coronavirus Response Act (“FFCRA”) and the Coronavirus Aid, Relief, and
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`Economic Security Act (“CARES Act”).
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`25.
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`Specifically, through the FFCRA, Congress mandated that health plans, including
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`large and small group plans, self-funded plans, managed care plans and individual market plans,
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`such as Defendants’, must cover and reimburse providers for conducting COVID-19 testing,
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`COVID antibody testing, and related testing and services.
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`26.
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`In recognition of the public health crisis, Congress went much further than merely
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`requiring health plans to cover testing. To ensure that no patient would be deterred from getting a
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`COVID-19 test due to a concern for the cost, Congress required coverage for COVID-19 testing
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`and related services to be provided without cost sharing, deductibles, copayments or coinsurance,
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`or other medical management requirements, regardless of whether the COVID-19 testing and
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`related services were provided by “in-network” or “out of network” providers.
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`27.
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`Indeed, guidance from the Departments of Labor (“DOL”), Health and Human
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`Services (“HHS”) and the Treasury has clarified that the FFCRA and the CARES Act apply to
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`COVID-19 testing, antibody testing, and related services rendered by both “in-network” and “out-
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`of-network providers.” 1
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`28.
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`In essence, Congress sought to ensure that any patient with health coverage could
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`get a COVID-19 test without any out-of-pocket costs, and without having to get permission from
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`their health plan, heath plan administrator or employer under a self-funded plan.
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`29.
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`After FFCRA and the CARES Act’s enactment, subsequent letters from Congress to
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`the HHS, DOL and the Secretary of Treasury emphasized the obligations of group health plans and
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`insurers to provide robust and comprehensive coverage of COVID-19 testing.2
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`PLAINTIFFS’ RESPONSE TO THE COVID-19 CRISIS
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`Formed by Dr. Murphy over a decade ago, the mission of the Murphy Practice is to
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`30.
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`provide high-quality preventive and general health services, as well as acute primary care, to men,
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`women, and adolescents. Dr. Murphy, a board-certified internist, is the principal of the Murphy
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`Practice.
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`31. Among its other services, the Murphy Practice operates a state-licensed physician
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`office laboratory located at 30 Buxton Farms Road in Stamford, Connecticut. Dr. Murphy is the
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`certified laboratory director for this laboratory under the federal Clinical Laboratory Improvement
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`Amendments (“CLIA”) and Connecticut law.
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`1 FAQs dated April 11, 2020, at Q.7 and Q.4, available at https://www.cms.gov/files/document/FFCRA-Part-42-
`FAQs.pdf
`2 See Letter to HHS, DOL, and Secretary of Treasury dated July 8, 2022, available at
`https://edlabor.house.gov/imo/media/doc/Democratic%20Health%20Leaders%20Demand%20Trump%20Administr
`ation%20Immediately%20Revisit%20Guidance%20Limiting%20COVID-19%20Testing%20Coverage.pdf
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 7 of 30
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`32. On or about March 9, 2020 and in response to the COVID-19 pandemic, the Murphy
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`Practice, an internal medicine practice with offices throughout Connecticut, invested hundreds of
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`thousands of dollars to transform its traditional medical practice to set up COVID-19 testing sites
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`throughout Connecticut and New York.
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`33.
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`These sites were erected virtually overnight and were designed to provide efficient
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`drive and/or walk-through COVID-19 testing to patients with symptoms or suspected exposure to
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`the novel coronavirus. These sites helped to fill the void for COVID-19 testing and were
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`unquestionably one of the first lines of defense against the pandemic.
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`34.
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`In addition to creating the physical infrastructure for the sites, the Murphy Practice
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`had to assemble the clinical and administrative staff needed to operate the sites and to perform the
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`testing, including physicians, medical students, physician assistants, nurse practitioners, registered
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`nurses, medical assistants, registrars, coordinators, and IT staff. It also had to develop extensive
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`protocols and procedures to ensure the sites were effectively and efficiently operating, and all safety,
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`infection control, OSHA, and CDC guidance were observed.
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`35. Ultimately, the Murphy Practice operated drive and/or walk-through COVID-19
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`testing sites in, among other places, Greenwich, Stamford, New Canaan, Darien, Fairfield,
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`Bridgeport, New Haven, West Haven, Stratford, and Ridgefield, Connecticut, and Bedford,
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`Brooklyn, and Pound Ridge, New York.
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`36.
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`Since March 9, 2020, the Murphy Practice has provided COVID-19 testing and/or
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`related services to over 35,000 patients and engaged in over 85,000 unique encounters with those
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`patients.
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 8 of 30
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`37. Generally, the Murphy Practice has utilized nasopharyngeal swabs to collect patient
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`samples to test for SARS-CoV-2, which was either sent to the Murphy Practice’s lab or to a third-
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`party laboratory for processing.
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`38.
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`Through its fully licensed physician office laboratory located at 30 Buxton Farms
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`Road in Stamford, Connecticut, the Murphy Practice has been able to process internally many of
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`the patient samples that the Murphy Practice collects.
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`39.
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` Each swab taken by the Murphy Practice was either sent to the Murphy Practice’s
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`lab or to a third-party laboratory for processing.
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`40.
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`In May 2020 an advanced BioFire Film Array System, with COVID-19 testing
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`capability, was approved by the FDA for COVID-19 testing.3 The Murphy Practice was able to
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`purchase the new BioFire machine.
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`41. 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 common
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`respiratory pathogens, as well as those with COVID-19, using one simple test. The BIOFIRE®
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`RP2.1 panel takes approximately 45 minutes and tests nasopharyngeal swab samples in transport
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`media.”4
`42.
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`Beginning in or about June 1, 2020, and for the vast majority of swabs that the
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`Murphy Practice processed internally in its laboratory, the Murphy Practice utilized the BioFire
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`2.1 Respiratory Panel, a respiratory panel that tests for 22 respiratory pathogens, including SARS-
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`CoV-2.5
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`https://docs.biofiredx.com/wp-content/uploads/PRESS-RELEASE-BIOFIRE%C2%AE-Respiratory-Panel-2.1-
`3
`RP2.1-with-SARS-CoV-2.pdf
`4 Id.
`5 On March 17, 2021, the BioFire 2.1 became the first Covid-19 test to upgrade from an emergency use authorization
`to fully approved FDA status. See https://www.biomerieux.com/en/biofirer-respiratory-21-rp21-panel-sars-cov-2-
`obtains-de-novo-fda-authorization;
`https://www.news-medical.net/news/20210317/FDA-authorizes-marketing-of-
`first-SARS-CoV-2-diagnostic-test-using-De-Novo-premarket-review-pathway.aspx. The myriad benefits of testing
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 9 of 30
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`43. The BioFire 2.1 Respiratory Panel allows the Murphy Practice to test for COVID-19
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`as well as other respiratory viruses and infections that could possibly cause the same or similar
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`symptoms as COVID-19, or could possibly co-exist with COVID-19. Information about other
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`potential respiratory viruses or infections is vitally important to ensure that patients who present with
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`symptoms or were possibly exposed to COVID-19 receive the most appropriate and effective course
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`of treatment.
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`44.
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`In fact, medical studies have concluded that a significant percentage of patients
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`(20% in one study) who tested positive for COVID-19 also tested positive for one or more
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`respiratory pathogens.6
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`45.
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`FAQs regarding the federal COVID-19 testing law that have been prepared jointly
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`by the Departments of Labor, Health and Human Services (HHS), and the Treasury (collectively,
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`“FAQs”), state that “the CDC strongly encourages clinicians to test for other causes of respiratory
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`illnesses.”7
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`46.
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`The Murphy Practice’s use of its BioFire machines at its internal laboratory allowed
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`the Murphy Practice, generally, to analyze the samples being tested and produce results at a much
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`faster rate than commercial third-party labs.
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`47.
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`In addition to the testing, the Murphy Practice, when medically appropriate, also
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`conducted a thorough medical history and basic examination on patients who seek COVID-19
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`testing. A baseline assessment of the patient’s current medical status is absolutely required to ensure
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`for other pathogens simultaneously with testing for SARS-CoV-2 are well stated in the literature and federal guidance.
`6 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
`7 See FAQs About Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act
`Implementation
`(hereinafter
`“FAQs”),
`Part
`42
`(April
`11,
`2020),
`available
`at
`https://www.cms.gov/files/document/FFCRA-Part-42-FAQs.pdf at Q.5.
`9
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 10 of 30
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`that the patient receives the most appropriate and effective treatment. Patients also need preventative
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`medicine counseling regarding the taking of universal precautions and other vitally necessary actions
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`or things to avoid. All of this was particularly important during the early days of the pandemic when
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`patients had little personal direct access to primary care physicians because of pandemic closures.
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`48.
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`Further, during the time period between the day the sample was taken and the results
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`were available, the Murphy Practice’s clinical personnel conducted telemedicine visits with the
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`patients to check on their conditions and determine whether further medical intervention was needed.
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`The frequency and duration of these visits was dependent on each patient’s unique condition, with
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`an emphasis and priority on following up with patients suspected of being infected with the virus.
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`49.
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`Beginning in or about May 2020, the Murphy Practice began providing COVID-19
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`testing and related services to members or beneficiaries of Centene, through the health plans it issues
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`and/or administers through its wholly owned subsidiaries, Fidelis and WellCare.
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`50.
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`The Murphy Practice generally receives assignment of benefit forms from patients
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`who receive testing services at the Murphy Practice testing sites. Other patients that registered
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`electronically assigned their benefits to the Murphy Practice.
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`51.
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`Exhibit 1 to this Complaint is a complete list of the claims against Defendant Fidelis
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`that are the subject of this Complaint. 8
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`52.
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`Exhibit 2 to this Complaint is a complete list of the claims against Defendant
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`WellCare that are the subject of this Complaint. 9
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`8 In order to protect the patients’ identity, the Murphy Practice will only reference each patient’s identity by their
`initials throughout the spreadsheet.
`9 In order to protect the patients’ identity, the Murphy Practice will only reference each patient’s identity by their
`initials throughout the spreadsheet.
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`53. As the operator of state- or locality-administered sites, drive-through sites, and/or
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`sites that do not require appointments, plans and issuers generally must assume that the receipt of
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`the test reflects an “individualized clinical assessment.”
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`54. As a result, the Murphy Practice was entitled to assume the diagnostic impetus
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`behind each test, consistent with the goals of both pieces of legislation: anyone who wanted a test
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`could get a test.
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`55. Upon information and belief, all swabs of Defendants members and/or beneficiaries
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`were processed in the Murphy Practice’s laboratory.
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`56. Based on the provisions of the FFCRA, the CARES Act, and the Affordable Care Act
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`discussed above, the Murphy Practice had every expectation that Defendants would honor their
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`obligations and reimburse the practice for COVID-19 testing and related services provided to their
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`members or beneficiaries. Indeed, large health plans and managed care companies similarly situated
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`to Centene, Fidelis and WellCare honored their obligations to the Murphy Practice.
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`57. To date, the Murphy Practice has billed Fidelis approximately $2,212,761.00 for over
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`1800 claims relating to COVID-19 testing and related services provided to the aforementioned
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`Fidelis members and/or beneficiaries, yet has only been reimbursed approximately $147,938.02.
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`58. As a result, Fidelis owes the Murphy Practice approximately $2,064,822.98 for
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`COVID-19 testing and related services provided to the aforementioned members and/or beneficiaries
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`of Fidelis’ health plans.
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`59. To date, the Murphy Practice has billed WellCare approximately $376,965.00 for
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`over 440 claims relating to COVID-19 testing and related services provided to the aforementioned
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`WellCare members and/or beneficiaries, yet has only been reimbursed approximately $39,091.79.
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 12 of 30
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`60. As a result, WellCare owes the Murphy Practice approximately $337,873.21 for
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`COVID-19 testing and related services provided to the aforementioned members and/or beneficiaries
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`of WellCare’s health plans.
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`61.
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`In response to Defendants’ denials and infinitesimal “reimbursements”, the Murphy
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`Practice, and through counsel, sent numerous correspondence to Fidelis and WellCare requesting an
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`explanation for their behavior.
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`62. Defendants either ignored or failed to engage in a meaningful dialogue regarding the
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`claims and, instead, continued to send denials or send fractional reimbursement checks to the
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`Murphy Practice.
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`63. The Murphy Practice has attempted to appeal every claim which Defendants have
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`denied and, through that appeal process, sent Defendants hundreds of pages of responsive medical
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`and laboratory records.
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`64. The Murphy Practice’s efforts have largely fallen on deaf ears.
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`65. Defendants, notwithstanding the aforementioned FFCRA and CARES Act, have
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`summarily denied each attempted appeal without any investigation into the claims.
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`66. Each denial was made without sufficient investigation, lacked any reasonably
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`arguable basis and was in violation of federal and state law.
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`67. Defendants have since advised the Murphy Practice that the Murphy Practice has
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`exhausted its right of appeal on any of the denied claims.
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`68. Defendants have unlawfully denied or issued fractional reimbursements for each
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`claim submitted by the Murphy Practice in order to strangle and ultimately force the Murphy Practice
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`to accept dramatically reduced reimbursement rates for COVID-19 testing and related services.
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`69. Defendants are well aware that the Murphy Practice’s ability to continue to operate
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`these necessary COVID-19 testing sites is severely hampered by withholding payment for COVID-
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`19 testing and related services provided by the Murphy Practice to Defendants members and/or
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`beneficiaries.
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`70.
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`This is precisely Defendants’ intent.
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`71. Despite not receiving reimbursement from Defendants, the Murphy Practice has not
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`and will not bill Defendants’ members or beneficiaries (or any patient for that matter) for any of
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`the testing services during this public health crisis.
`72. Despite not receiving reimbursement from Defendants, the Murphy Practice will
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`continue running all of its existing testing sites and will establish new testing sites to care for all
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`patients, including Fidelis and WellCare members and/or beneficiaries, to help curb the spread of
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`the new Omicron BA.2 variant during this everlasting public health crisis.
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`FIRST CAUSE OF ACTION
`(FFCRA and CARES Act)
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`73.
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`Plaintiffs repeat, reiterate and re-allege each and every allegation contained above as
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`if more fully set forth at length herein.
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`74.
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`Centene, through its wholly owned subsidiaries, Fidelis and WellCare, offer group
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`health plans and are health insurance issuers offering group or individual health insurance coverage
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`as those terms are defined in section 6001 of the Families First Coronavirus Response Act.
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`75.
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`The COVID-19 testing and related services that the Murphy Practice provided to
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`Fidelis and WellCare members and beneficiaries constitute in vitro diagnostic products for the
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`detection of COVID-19 or the diagnosis of the virus that causes COVID–19 that are approved,
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`cleared, or authorized under Federal Food, Drug, and Cosmetic Act, and the administration of such
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`in vitro diagnostic products pursuant to 21 C.F.R. § 809.3(a), as provided by section 6001 of the
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 14 of 30
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`FFCRA.
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`76.
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`To the extent that any Defendants members and/or beneficiaries submitted to the
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`Murphy Practice for COVID-19 testing for non-diagnostic purposes (i.e. employer return to work
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`testing mandates or student return to school testing mandates), Defendants were still financially
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`responsible to reimburse the Murphy Practice for the costs of each test, since the Murphy Practice
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`was entitled to assume the diagnostic impetus behind each encounter. 10
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`77.
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`Regardless, subsequent letters from Congress to HHS, DOL and the Secretary of
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`Treasury made clear that “widespread testing must be in place to detect and stop the spread of
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`COVID-19 and ensuring safety in the workplace is critical.”11 As a result, Defendants were
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`financially responsible to reimburse the Murphy Practice of the costs of each test, regardless of the
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`impetus behind each test.
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`78.
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`The Murphy Practice did not have a negotiated rate with Defendants for the provision
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`of these services.
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`79. Under section 3202(a) of the CARES Act, if a health plan does not have a negotiated
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`rate with a provider such as the Murphy Practice for providing COVID-19 testing and/or related
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`services, the health plan is obligated to pay the provider its cash price for providing those services.
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`80. Defendants, despite numerous and persistent demands and requests, has failed and
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`refused to provide anything remotely close to the Murphy Practice’s cash price for providing the
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`COVID-19 testing related services.
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`10 FAQs Part 44 (February 26, 2021).
`11 See Letter to HHS, DOL, and Secretary of Treasury dated July 8, 2022, available at
`https://edlabor.house.gov/imo/media/doc/Democratic%20Health%20Leaders%20Demand%20Trump%20Administr
`ation%20Immediately%20Revisit%20Guidance%20Limiting%20COVID-19%20Testing%20Coverage.pdf
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`14
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 15 of 30
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`81. By reason of the foregoing, Plaintiffs have been damaged and are entitled to a
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`judgment against Centene and/or Fidelis in the amount of at least $2,064,822.98, plus interest,
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`together with the costs and disbursements of this action, including reasonable attorneys’ fees.
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`82. By reason of the foregoing, Plaintiffs have been damaged and are entitled to a
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`judgment against Centene and/or WellCare in the amount of at least $337,873.21, plus interest,
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`together with the costs and disbursements of this action, including reasonable attorneys’ fees.
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`SECOND CAUSE OF ACTION
`(ACA)
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`83.
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`Plaintiffs repeat, reiterate and reallege each and every allegation contained above as
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`if more fully set forth at length herein.
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`84.
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`The Patient Protection and Affordable Care Act added section 2719A to the Public
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`Health Services Act, 42 U.S.C. § 300gg-19a.
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`85.
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`Section 2719A requires any group health plan, or health insurer that provides or
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`covers benefits with respect to services in an emergency department of a hospital, to cover any
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`emergency services, including, emergency services outside of the emergency department, without
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`the need for prior authorization, without regard to the provider’s status as an out-of-network provider,
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`and in a manner that ensures that the patient’s cost-sharing requirement is the same requirement that
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`would apply if such services were provided in-network. 42 U.S.C. § 300gg-19a. These requirements
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`are expressly incorporated into group health plans covered by ERISA. 29 U.S.C. § 1185d(a).
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`86. Defendants’ health plans at issue in this lawsuit are health plans that are subject to
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`the provisions of 42 U.S.C. § 300gg-19a or 29 U.S.C. § 1185d(a).
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`87.
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`The COVID-19-related testing services provided by the Murphy Practice that are at
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`issue in this lawsuit meet the definition of emergency services under 42 U.S.C. § 300gg-19a.
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`15
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 16 of 30
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`88. Accordingly, Defendants were obligated to cover these COVID-19-related testing
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`services under 42 U.S.C. § 300gg-19a and 29 U.S.C. § 1185d(a).
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`89.
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`Regulations provided pursuant to these sections require that, to satisfy their coverage
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`obligations for emergency services, health plans must reimburse out-of-network providers at the
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`greater of (a) the amount negotiated with in-network providers for the emergency service, accounting
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`for in-network co-payment and co-insurance obligations; (b) the amount for the emergency service
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`calculated suing the same method the plan generally uses to determine payments for out-of-network
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`services (such as usual, customary, or reasonable charges), but substituting in-network cost-sharing
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`provisions for out-of-network cost-sharing provisions; or (c) the amount that would be paid under
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`Medicare for the emergency service, accounting for in-network co-payment and co-insurance
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`obligations. 29 C.F.R. § 590.715-719A(b)(3)(i)(A)-(C).
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`90. Defendants, despite numerous and persistent demands and requests, have failed and
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`refused to provide to the Murphy Practice anything remotely close to the reimbursement required by
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`29 C.F.R. § 590.715-719A(b)(3)(i)(A)-(C).
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`91. By reason of the foregoing, Plaintiffs have been damaged and are entitled to a
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`judgment against Centene and/or Fidelis in the amount of at least $2,064,822.98, plus interest,
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`together with the costs and disbursements of this action, including reasonable attorneys’ fees.
`
`92. By reason of the foregoing, Plaintiffs have been damaged and are entitled to a
`
`judgment against Centene and/or WellCare in the amount of at least $337,873.21, plus interest,
`
`together with the costs and disbursements of this action, including reasonable attorneys’ fees.
`
`THIRD CAUSE OF ACTION
`(ERISA)
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`93.
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`Plaintiffs repeat, reiterate and reallege each and every allegation contained above as
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`if more fully set forth at length herein.
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`
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`16
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`Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 17 of 30
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`94. Even if the FFCRA and CARES Act did not, on their own, obligate Defendants to
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`reimburse the Murphy Practice for the medically necessary COVID-19-related testing and related
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`services that it performed – which they most certainly do – Defendants would still be obligated to
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`reimburse the Murphy Practice for these services. This is because the FFCRA and CARES Acts are
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`to be treated, for enforcement purposes, as if they were included in ERISA.
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`95. Even were this not the case, the FFCRA and the CARES Act broadly apply to all
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`health care plans governed by ERISA, meaning that ERISA plans are required to cover COVID-19
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`testing and related services as provided in the FFCRA and the CARES Act.
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`96. On information and belief, a significant number of claims the Murphy Practice has
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`submitted to Defendants relate to patients enrolled in Defendants’ health plans or health plans
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`Defendants’ administer subject