Case 6:21-cv-01261-CEM-EJK Document 1 Filed 08/04/21 Page 1 of 33 PageID 1
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`UNITED STATES DISTRICT COURT
`MIDDLE DISTRICT OF FLORIDA
`ORLANDO DIVISION
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`CASE NO.:
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`SURGERY CENTER OF VIERA, LLC,
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`Plaintiff,
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`v.
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`CIGNA HEALTH AND LIFE INSURANCE COMPANY,
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`Defendant.
`______________________________________________ /
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`COMPLAINT
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`Plaintiff, Surgery Center of Viera, LLC (“SCV”), as medical provider,
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`authorized representative, assignee of patient / insured, and power of attorney of
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`patient / insured D.Y., sues Defendant, Cigna Health and Life Insurance Company
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`(“Cigna”), as follows:1, 2
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`NATURE OF THE ACTION, PARTIES,
`JURISDICTION, AND VENUE
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`1.
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`This action arises (Counts I-II, IV-V) under state law for Defendant’s
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`wrongful, unsubstantiated underpayment of monies owed to SCV for medical
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`1 The insurance policy (well, the only thing SCV has that is somewhat close to a policy, for reasons
`discussed below) is attached hereto as Exhibit A and incorporated fully herein by reference.
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`2 The subject insurance product appears fully-insured and not part of an ERISA-governed group
`plan; i.e., appears to be an individual policy. Accordingly, this Complaint does not sound in
`ERISA. Of course, if discovery someday reveal otherwise, a Complaint amendment may be
`warranted to some extent. Moreover, Cigna did not oblige multiple requests (discussed in greater
`detail below) for germane documentation pre-suit, leaving us somewhat in the evidentiary blind.
`So, SCV reserves the right to amend the Complaint on that ground as well, if need be someday.
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`1
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`services SCV provided to the patient / insured, D.Y., on March 15, 2018.3 This
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`action also arises (Count III) under state law for Defendant’s wrongful refusal to
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`provide germane owed documentation.
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`2.
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`At all material times, SCV was a medical provider and a Florida
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`limited liability company with its citizenship (i.e., principal place of business /
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`“nerve center”) in Viera, Florida, Brevard County. SCV is sui juris in all respects.
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`SCV’s members are as follows: (a) Dr. Ara Deukmedjian, domiciled in Brevard
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`County, Florida, (b) Sun Deukmedjian, domiciled in Brevard County, Florida, and
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`(c) Dr. Bharat Patel, domiciled in Brevard County, Florida. At all material times,
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`SCV was the authorized representative of D.Y. with an assignment of benefits as
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`well,4 having provided subject medical services to D.Y. for which a proper amount
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`of compensation was / is due and owing (and, for that matter, records relating to
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`same were / are due and owing). And, again, Defendant honored such authorized
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`representative and assignee capacities by, for examples, carrying out pre-suit
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`reconsideration / appeal with SCV and tendering partial claim payment directly to
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`SCV.
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`3.
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`At all material times, Cigna was an insurance company with its
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`principal place of business / headquarters (“nerve center”) and incorporation in
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`3 Count I sounds in breach of contract for repricing relating to the eight HCFA codes that Cigna
`covered. Count II sounds in breach of contract for Cigna’s denial of three HCFA codes. Count IV
`sounds in unjust enrichment, alternatively pleaded to Counts I and II. Count V sounds in quantum
`meruit, alternatively pleaded to Counts I and II.
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`4 All germane authorization and / or assignment paperwork in SCV’s possession is attached hereto
`as Exhibit B (in redacted form) and incorporated fully herein by reference.
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`2
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`the State of Connecticut and engaged in the business of selling insurance,
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`administering insurance, and / or deciding and paying insurance claims
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`throughout the country, including in the State of Florida.
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`4.
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`This Court has jurisdiction over the entire dispute pursuant to Title
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`28, United States Code, Section 1332, as complete diversity exists between the
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`parties and the amount in controversy exceeds $75,000.00 exclusive of interest,
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`costs and attorney’s fees.
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`5.
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`Venue is proper in the Middle District Court of Florida pursuant to
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`Title 28, United States Code, Section 1391(b), since, for examples, (a) a
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`substantial part of the events or omissions giving rise to the subject action
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`occurred in this jurisdiction, namely the subject medical procedure, Defendant’s
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`underpayment and denial of the subject insurance claim both at the initial claim
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`and subsequent pre-suit appeal stages (Counts I-II, IV-V), and Defendant’s refusal
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`to supply germane documentation / information (Count III) required by the
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`insurance contract and / or Cigna’s written representations, and (b) the Orlando
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`Division of this Court has personal jurisdiction due to Defendant’s minimum
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`contacts in this forum.
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`6.
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`All conditions precedent to the institution of this action (e.g., pre-suit
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`appeals) have occurred, been performed, been waived, or were futile.
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` 7.
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`Upon information and belief, the insurance policy (Ex. A, see n. 1,
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`COMMON ALLEGATIONS
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`supra) was a Cigna LocalPlusIn 5000 product. The patient’s Member / Subscriber
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`3
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`I.D. number was / is 104136384. The reference number assigned to the subject
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`claim was / is 180643907200, the assigned account number was / is 0088120, and
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`the assigned SR number was / is 1076741626. Again, a copy of the insuring
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`agreement (again, the bit that we have) is attached as Exhibit A and incorporated
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`fully herein by reference.
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` 8.
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`At all material times, D.Y. was covered by the Plan as evidenced by
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`several things, with examples now discussed.
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`a. If D.Y. was not an eligible / covered insured, the subject claim would
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`not have been paid by Defendant in any amount, and this eligibility
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`and claim payment correlation reality is stated in the pre-
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`authorization paperwork (provided by Cigna by facsimile dated
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`March 14, 2018, Authorization No. OP0144533331) discussed below
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`and attached as Exhibit C. Exhibit C is incorporated fully herein by
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`reference.
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`b. If the subject surgery (which such surgery was broken down by codes
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`found in the HCFA found in SCV’s initial claim submission packet)
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`had not been covered,5 the subject claim would not have been paid by
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`Defendant in any amount. Regarding coverage of the subject HCFA
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`codes, the EOB furnished by Cigna (further discussed below) is
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`attached as Exhibit E and evidences Defendant’s coverage decision.
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`5 The HFCA form that was part of SCV’s nineteen-page claim submission package to Defendant,
`which such claim submission package is noted below, is attached as Exhibit D. This HCFA
`exhibit is incorporated fully herein by reference.
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`4
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`Exhibit E is incorporated fully herein by reference. And as one can
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`plainly see from Cigna-issued EOB, Defendant unilaterally re-priced
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`the subject claim as to the bulk of codes found on the HCFA, but
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`denied three of the codes found on the HCFA. To this day, we really
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`have no idea how Cigna came up with payments totaling $80,171.26
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`(on a billed amount of $280,259.00) because, at every turn,
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`Defendant has secreted how it came up with $80,171.26; i.e., has
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`never substantiated the determination that $80,171.26 was a
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`“reasonable and customary” amount for of payment for the subject
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`procedure. All the Cigna EOB (Ex. E) says, in glossy fashion and in
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`pertinent part, is “member’s benefit plan limits payment to maximum
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`reimbursable charge.” “Unilaterally repriced” because applicable re-
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`pricing contracts (that SCV had actually agreed to) were already in
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`place (see Exhibit F, attached hereto and fully incorporated herein
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`by reference). Again, Plaintiff presently does not possess the
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`paperwork associated with
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`the mystery Cigna
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`“Maximum
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`Reimbursable Charge” re-pricing formula / program because
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`Defendant has wrongly secreted this paperwork (the very paperwork
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`that would evidence how Defendant came up with its unreasonably
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`low rate of payment) from SCV in the carrier’s perpetual refusal to
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`substantiate the unjustifiably low rate of payment force-fed to SCV
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`here. To be clear, it is SCV’s position that the re-pricing contracts
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`5
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`(either one of the two contracts, PMCS or MultiPlan, attached hereto
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`as Exhibit F, as discussed more fully below) agreed to with Cigna
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`would supplant Cigna’s mystery “Maximum Reimbursable Charge”
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`formula / program unilaterally implemented by Defendant in arriving
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`at the disputed unreasonably low claim payment amount.
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` 9.
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` The pre-surgery authorization paperwork (Ex. C) and process is
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`designed to put coverage (but not the eventual amount of claim payment) to rest,
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`which, as discussed above (and as evidenced by Ex. C) is what happened –
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`Defendant approved eight of the eleven of the subject HCFA codes. Again, Exhibit
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`C is incorporated fully herein by reference.
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` 10.
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`Then, of course, there is Cigna’s incorrect decision to deny three
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`HCFA codes (95955 totaling $1,975.00 for EEG monitoring during surgery; 95937
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`totaling $1,750.00 for neuromuscular junction testing during surgery; 22852
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`totaling $14,230.00 for removal of an old spine fixation device). Cigna sent a July
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`31, 2018 (received on August 6, 2018), letter purporting to deny these codes because
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`“a procedure that is part of another procedure … can’t be paid separately. Also
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`services that are broken out into parts of procedures can’t be separately.” In other
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`words, Cigna was wrongly encouraging bundling. Presumably, had Cigna properly
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`covered these three surgery line-items, such would have also been subjected to
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`Cigna’s mystery “Maximum Reimbursable Charge” formula / program. But, in any
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`event, this coverage determination as to three surgery line-items was amiss and
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`discussed in greater detail below.
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`6
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` 11.
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`To be clear as to the applicable re-pricing contracts attached hereto
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`as Exhibit F, Cigna had a choice to apply the re-pricing structure set forth in any of
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`them. Reason being, Cigna prescribes to both re-pricing agreements / contracts
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`programs as evidenced by Cigna being listed as a participating “payer” / “client” in
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`the lists accompanying both re-pricing contracts (the contracts and the lists are
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`attached hereto as Exhibit F, with the lists being right behind the contracts). So, to
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`be clear, Count I (breach of contract predicated on re-pricing of the eight HCFA
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`codes Cigna covered) sounds in both contracts attached as Exhibit F. By Cigna’s not
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`utilizing either of the two re-pricing contracts entered into with SCV via Preferred
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`Medical Claim Solutions (“PMCS”) (as Cigna’s affiliate and / or subcontractor and
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`/ or vendor and / or agent and / or the like) and MultiPlan (as Cigna’s affiliate and
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`/ or subcontractor and / or vendor and / or agent and / or the like), Cigna breached
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`both of the re-pricing contracts attached hereto as Exhibit F. To be clear, it is SCV’s
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`contention that Cigna was contractually obliged to follow at least one of the two re-
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`pricing contracts attached hereto as Exhibit F. To be clear, had Cigna re-priced the
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`subject claim under any one of the two re-pricing contracts attached hereto as
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`Exhibit F, this legal action (at least Count I) would have never come about. Instead,
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`again, Cigna deviated entirely from its re-pricing contractual obligations (under
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`both of the contracts attached hereto as Exhibit F) by implementing some mystery
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`“Maximum Reimbursable Charge” re-pricing structure.
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` 12.
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`At all material times leading up to the subject medical services
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`received from SCV, D.Y. suffered from chronic lumbar pain and radiculopathy. D.Y.
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`7
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`tried alternative, conservative management treatments, which failed and surgical
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`treatment was deemed medically necessary by both SCV (as evidenced by, for
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`examples, the “operative note,” “history and physical,” and “letter of medical
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`necessity for surgery” found in SCV’s claim submission package but not placed into
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`the public domain at this juncture by way of Complaint exhibit due to SCV’s concern
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`with preserving D.Y.’s privacy rights and not turning an initial pleading into a
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`complete evidence dump) and Cigna (as evidenced by, for example, the pre-
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`authorization paperwork attached as Exhibit C). So, on March 15, 2018, SCV
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`operated on D.Y. to remedy the medical conditions.
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` 13.
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`By facsimile dated March 14, 2018, and prior to the subject procedure,
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`Cigna issued information to SCV approving surgical codes. As mentioned above,
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`this paperwork is attached as Exhibit C.
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` 14.
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`As mentioned above, SCV’s billed charges for the subject medical
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`services rendered to D.Y. totaled $280,259.00, and a claim package was submitted
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`to Cigna relating to same shortly after the subject surgery (via certified mail,
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`certificate number 7001 2510 0003 9686 2408). The SCV cover letter to its claim
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`submission packet is attached hereto as Exhibit G and makes specific reference to
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`SCV’s appropriate expectation that claim payment would unfold pursuant to one of
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`the germane re-pricing contracts (see Ex. F) that existed (not some mystery Cigna
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`“Maximum Reimbursable Charge” formula / program that Defendant would
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`eventually unilaterally employ as to eight of the eleven HCFA codes the carrier
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`actually paid out on).
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`8
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` 15.
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` At all material times, Cigna was in agreement with PMCS (as Cigna’s
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`affiliate and / or subcontractor and / or vendor and / or agent and / or the like),
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`and MultiPlan (as Cigna’s affiliate and / or subcontractor and / or vendor and / or
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`agent and / or the like) to secure discounted rates from providers (like SCV), which
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`were secured here in relation to SCV.6
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` 16.
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`The PMCS allowed amount re-pricing contract (see Ex. F) was in full
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`force and effect and was a legally valid and binding contract that established /
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`developed (a) an allowed amount re-pricing rate of 80% of SCV’s billed charges
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`less patient responsibilities (e.g., co-pay, deductible, co-insurance) subject to the
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`patient’s annual out-of-pocket maximum, and (b) a 100% reimbursement rate for
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`hard costs (e.g., prosthetics / implants). The MultiPlan allowed amount re-pricing
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`contract (see Ex. F) was in full force and effect and was a legally valid and binding
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`contract that that established / developed (a) an allowed amount re-pricing rate of
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`60% of SCV’s billed charges less patient responsibilities (e.g., co-pay, deductible,
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`co-insurance) subject to the patient’s annual out-of-pocket maximum, and (b) a
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`120% reimbursement rate for hard costs (e.g., prosthetics / implants). Cigna’s re-
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`pricing of the subject claim not following either of these re-pricing contracts with
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`6 Again, a copy of the pertinent pages of the PMCS and MultiPlan re-pricing contracts that were
`procured on Cigna’s behalf (along with the PMCS and MultiPlan “payer” / “client” lists listing
`Cigna) are attached hereto as Exhibit F. Again, Exhibit F is incorporated fully herein by reference.
`Of note, the PMCS and MultiPlan contracts (or at least germane pages thereof) were supplied to
`Defendant in SCV’s claim submission package (as is SCV’s routine with claim submissions, scores
`of which have involved Cigna over the years), and SCV made clear its expectation that the claim
`would be priced pursuant to the PMCS or MultiPlan contracts / agreements that were brokered
`by Cigna with PMCS and MultiPlan being Cigna’s vendors, agents, or the like tasked with
`achieving discounted rates from medical providers like SCV.
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`9
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`SCV constitutes a breach of both contracts (Count I). Again, Cigna should have re-
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`priced the subject claim under either of these re-pricing contracts (Ex. F) with SCV.
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`Again, had Cigna done so, this legal action would have never come about (at least
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`not Count I).
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` 17.
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`Notwithstanding the existing PMCS and MultiPlan contracts /
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`agreements in place (which, again, were arranged by Cigna with PMCS and
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`MultiPlan as its vendors / agents), by way of EOB that issued in late May 2018 and
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`was received by SCV on June 4, 2018, on Cigna letterhead, Defendant underpaid
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`the subject claim, tendering $80,171.26 predicated on a mystery “Maximum
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`Reimbursable Charge” formula / program. More specifically, Defendant failed to
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`properly pay (proper amount, that is, for eight of the eleven subject HCFA codes)
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`the codes billed by SCV in connection with the medical procedure. Again, Cigna
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`never substantiated its EOB (Ex. E) notwithstanding pre-suit requests to do so.
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`18. Count I does not present a coverage dispute because Defendant
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`properly conceded coverage via the $80,171.26 partial claim payment and did not
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`list any medical judgment related basis (e.g., medical necessity or experimental /
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`investigational) for partial payment amongst the claim decision EOB codes (see Ex.
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`E) relating to the eight HCFA codes that Cigna covered. Rather, Count I is a pure
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`damages dispute pertaining solely to the underpayment (of eight out of eleven
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`HCFA codes) that was predicated on Cigna’s aberrant claim decision-making
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`seemingly predicated on the unsubstantiated mystery “Maximum Reimbursable
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`Charge” formula / program, notwithstanding that Cigna had contracted outside of
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`10
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`that formula / program with SCV via PMCs and MultiPlan re-pricing contracts.
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`19.
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`Following the adverse Defendant claim underpayment via EOB
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`received on June 4, 2018, appeals and / or reconsideration processes were carried
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`out (i.e., exhausted). For example, from the internal records we possess (certainly
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`not from non-existent Cigna production), reconsideration / reopening / appeal
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`letters were sent to Cigna on June 4, 2018, June 29, 2018, July 23, 2018 (pertaining
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`specifically to HCFA code 22852, and stating, in pertinent part, as follows: “We
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`referred to McKensson Clear Claim Connection found on the Cigna website and this
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`procedure is allowed. All the procedure codes and diagnosis were entered for review
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`on coding accuracy, this CPT 22852 was allowed”), and October 16, 2018 (an appeal
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`lodged on SCV’s behalf by a prior law firm named Childress Loucks & Plunkett).
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`20.
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`It does not appear Cigna replied to the aforementioned October 16,
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`2018, appeal package.
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`21. Ultimately, as to the pricing of eight out of eleven HCFA codes, Cigna
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`ratified its claim payment amount decision by letter dated July 27, 2018, and
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`received on August 3, 2018. Per page 24 of Exhibit A, “a final notice of adverse
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`determination will include a discussion of the decision.” The July 27, 2018, final
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`adverse determination letter glossily (and unhelpfully) stated, in pertinent part, as
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`follows: “After reviewing the appeal submitted … , the original decision … is
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`upheld.” The letter goes on to lay out a variety of ways Cigna could have re-priced
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`the claim, but settles in on its own methodology “similar to a methodology utilized
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`by Medicare to determine the allowable amount… .” A glaringly problem with that
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`11
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`(among several problems), however, is that the HCFA codes at issue (for the
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`Ambulatory Surgical Center at issue) do not have corresponding Medicare
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`allowable amounts from which Cigna could have possibly predicated its “Maximum
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`Reimbursable Charge” re-pricing formula / program. What Cigna should have
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`employed were the re-pricing contracts it already had in place with SCV by way of
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`PMCS or MultiPlan because such (to use Cigna’s words from its July 27, 2018,
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`letter) are “nationally-recognized database[s] that use[ ] generally accepted
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`industry standards and practices for determining customary and reasonable billed
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`charge[s] for a service, and that fairly and accurately reflect[ ] the market rate.”
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`And, to also borrow words from Cigna’s July 27, 2018, letter, PMCS and MultiPlan
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`also are predicated on a review of SCV’s “normal charge for a similar service or
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`supply.”
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`22. Ultimately, as to Cigna’s denial of three of the eleven HCFA codes at
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`issue, Cigna sent a letter dated July 31, 2018, and received on August 6, 2018. We
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`already cited to this letter above, this is the letter that encouraged SCV to bundle
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`charges. Nowhere in this July 31, 2018, letter (or in any other Cigna paperwork we
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`presently possess) did Cigna explain why bundling as to these three codes was
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`appropriate or required. For example, SCV’s removable of an old device from D.Y.
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`from a prior surgery was medically necessary for SCV properly fixing D.Y. during
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`SCV’s surgery and was certainly separate from SCV’s affirmative surgical efforts. As
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`another example, EEG and neuromonitoring are definitely side procedures (so to
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`speak) from the primary surgical efforts, designed to protect a patient during
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`12
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`surgery
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`involving something as serious as a spine; e.g., ensuring that
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`neuromuscular function is not compromised by the primary surgical effort and / or
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`things like paralysis do not result. Nowhere does the Cigna letter received on August
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`6, 2018, letter say that the three denied HCFA codes were not medically necessary
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`or experimental / investigational, for examples. Rather, the letter received on
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`August 6, 2018, says, distilled, that Cigna just thinks that such additional
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`procedures should be bundled / lumped into the primary procedure. Why? What is
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`the rationale? What is the support in the medical community for that? Why do
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`surgeons have to eat the cost of removing old defunct devices from a prior surgeon
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`or the cost of employing modern technology designed to make sure a spine surgery
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`is performed safely without creating (or certainly highly limiting the risk of
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`creating) future neuromuscular problems for the patient?
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`23. By letter dated January 30, 2020 (attached hereto as Exhibit H,
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`incorporated fully herein by reference), undersigned counsel (on SCV’s behalf)
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`asked for several pieces of information that would have been enlightening as to
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`Cigna’s reasoning for doing what it did here, both with respect to the underpayment
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`of eight HCFA codes and with respect to the denial of three HCFA codes. No
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`response from Cigna as to the January 30, 2020, letter, despite Cigna (by letter
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`dated March 6, 2020) having recognized Callagy Law’s authorization. Moreover,
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`when it comes to requests for germane documentation, Cigna did not even oblige
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`prior requests from the patient or SCV for perhaps the most germane document of
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`them all – the insurance policy. Like a June 25, 2018, SPD request letter from SCV,
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`for example. To be clear, the fragment of an insurance policy attached hereto as
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`Exhibit A is something SCV happened to possess through the patient, so that is what
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`we are going off of for now because we have no other choice.
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`24. Defendant was obligated to provide the aforementioned requested
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`documentation / information (see Ex. H). We do not have the full insurance policy
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`because of Cigna’s production failures (we just have Exhibit A), but we do have
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`Cigna letters that say this: “You have the right to receive free copies of all
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`documents, records and other information related to this claim for benefits. This
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`includes copies of the policy or guideline we used to make our decision.” And this:
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`“You are entitled to receive free of charge, copies of all documents, records and
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`other information relevant to our appeal for benefits. This includes the benefit
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`provision, guideline or protocol upon which the decision was made.”
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`25.
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` So, regrettably, SCV’s (and D.Y.’s) entire valuable pre-suit remedies
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`process (which such pre-suit mechanisms are designed to try to avoid lawsuits like
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`this) was squandered by Defendant by keeping SCV in the “evidentiary” blind due
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`to Defendant’s documentation / information production failures and naked
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`paperwork (e.g., EOB, July 2018 letters, one of which trickled into August 2018 as
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`to when such was actually received). Defendant’s failures, of course, also
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`compromised SCV’s ability to make heads-or-tails of Defendant’s unreasonably
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`low rate of payment as to eight HCFA codes and denial as to three HCFA codes.
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`14
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`Case 6:21-cv-01261-CEM-EJK Document 1 Filed 08/04/21 Page 15 of 33 PageID 15
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`26. As to re-pricing, we can only assume the true insurance policy (again,
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`all we have is Exhibit A) reflects that which was discussed in Cigna letters, as set
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`forth in Paragraph 21 above.
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` 27.
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`Again, where (as here) separate and distinct re-pricing contracts /
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`agreements have been established (Ex. F), such contracts / agreements (Ex. F)
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`control. The re-pricing program that Defendant tried to pull off (whatever that
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`formula / program was within “Maximum Reimbursable Charge”) is inapplicable
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`because of Cigna’s having contracted with SCV via PMCS and MultiPlan. But, again,
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`even insurance policy language (well, policy language suggested by Cigna’s letter
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`because we do not have the actual policy from Cigna, see Paragraph 21, supra)
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`suggests that databases such as PMCS and MultiPlan were fair game. What is
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`certainly not fair game is some Cigna re-pricing formula seemingly predicated on
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`and / or modeled after Medicare when SCV’s HCFA codes (for the Ambulatory
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`Surgery Center that SCV is) do not have comparable Medicare allowables.
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` 28. Defendant’s implementation of its mystery re-pricing formula is
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`untenable because SCV did not agree to anything with Cigna to that effect. SCV did,
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`however, contract (agree on discounted re-pricing) with Cigna via two of Cigna’s
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`vendors (PMCS and MultiPlan, see Ex. F). And, thus, the re-pricing structures of
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`the PMCS and MultiPlan contracts (again, Cigna’s implementation / honoring of
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`any one of these re-pricing structures would have been acceptable) are precisely the
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`kind of nationally recognized databases that Paragraph 21 above speaks to; i.e.,
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`precisely the contracts upon which the subject claim should have been re-priced.
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`
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`15
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`Case 6:21-cv-01261-CEM-EJK Document 1 Filed 08/04/21 Page 16 of 33 PageID 16
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` 29.
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`And, again, Defendant erred in refusing SCV’s pre-suit requests for
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`germane documentation / information, including documentation / information
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`(see Ex. H) concerning, among other things, what re-pricing / allowed amount
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`formula Defendant employed in arriving at the unreasonably low rate of payment
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`and what exactly were the bases for Cigna’s denial of three HCFA codes.
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` 30.
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` Defendant wronged SCV in many ways, most notably by way of the
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`significant underpayment as to eight of eleven HCFA codes at issue. But, also, of
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`course, as to Cigna’s denial of three of the eleven HCFA codes at issue. Once more,
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`a contract is a contract, Defendant should have employed PMCS or MultiPlan re-
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`pricing contracts (Exhibit F) already in place (i.e., already agreed to between the
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`parties) to assess a proper re-priced amount; but, instead, Defendant implemented
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`a mystery re-pricing system (not agreed to by SCV) to arrive at the unreasonably
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`low rate of payment at issue. Defendant’s unilateral, unsubstantiated re-pricing
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`process deviated entirely from the re-pricing contracts (Ex. F) already in place with
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`SCV, thereby breaching all such re-pricing contracts.
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` 31.
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`Under the PMCS re-pricing analysis (which, again, was a re-pricing
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`contract / agreement established by Cigna that SCV actually agreed to, and unlike
`
`the mystery re-pricing formula / program that Defendant unilaterally employed
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`here without SCV’s agreement), the basic structure of which such re-pricing
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`contracts is laid out in Paragraph 16 above, Defendant should have used an 80%
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`rate to calculate the allowed amount equaling $243,187.00 (which such amount is
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`80% of all non-implant HCFA line-items and 100% of all implant HCFA line-
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`
`
`16
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`

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`Case 6:21-cv-01261-CEM-EJK Document 1 Filed 08/04/21 Page 17 of 33 PageID 17
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`items). This is the amount that the assumed patient responsibilities (capped at an
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`annual out-of-pocket maximum) should have been deducted from. The
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`$243,187.00 less Defendant’s prior payment (which such prior payment
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`presumably already took patient responsibilities subject to the annual out-of-
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`pocket maximum into consideration) leaves an outstanding balance of $163,015.74
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`due and owing to SCV. This amount is exclusive of attorneys’ fees, costs, interest,
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`and / or extra-contractual exposure. Or Defendant could have gone with the 60%
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`/ 120% re-pricing structure set forth in Cigna’s MultiPlan contract with SCV
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`(rather than the 80% / 100% structure of the PMCS contract) and not have given
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`way to this legal action (at least not Count I); i.e., not have been in breach of any of
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`the contracts attached hereto as Exhibit F or inequitably enriched. A MultiPlan re-
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`price would have yielded $144,923.54 due and owing from Cigna after the
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`MultiPlan 60% / 120% re-pricing structure is applied and Cigna’s past partial
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`payment is taken into consideration.
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`32.
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`SCV has suffered significant financial harm no matter how one slices
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`this situation. The financial harm by way of owed medical services monies is in
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`excess of $75,000.00, not including interest of attorneys’ fees, costs, or interest, if
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`the negotiated, agreed to rate structure prescribed by any one of Cigna’s two third-
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`party re-pricing vendors at issue here (PMCS or MultiPlan) is honored / enforced
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`as it should be, or even, for that matter, if rates prescribed by publicly available
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`databases assessing the charges of providers of like kind within like geographies,
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`
`
`17
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`Case 6:21-cv-01261-CEM-EJK Document 1 Filed 08/04/21 Page 18 of 33 PageID 18
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`like Agency for Health Care Administration (“AHCA”),7 were utilized in the re-
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`pricing assessment.
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` 33.
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`SCV exhausted the pre-suit appeal process to the best of its ability,
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`hindered by Defendant’s wrongful refusal to provide germane documentation as
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`discussed above, which such materials were requested by SCV in an effort to
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`accomplish Defendant’s doing the right thing (i.e., properly compensating SCV)
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`sans litigation, to no avail. Hence, this lawsuit as SCV’s regrettable last resort.
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`COUNT I – BREACH OF THE TWO SUBJECT RE-PRICING
`CONTRACTS ATTACHED AS EXHIBIT F (CLAIM UNDERPAYMENT)
`AS IT PERTAINS TO EIGHT OUT OF ELEVEN SUBJECT HCFA CODES
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`SCV re-alleges Paragraphs 1 through 33 as if fully set forth herein, and
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`further alleges as follows.
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`34.
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`At all material times to this action and in exchange for a valuable
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`premium, Defendant provided health insurance to D.Y. under the insurance policy
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`(Exhibit A, which represents a fragment of the insuring agreement in our
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`possession due to Cigna’s production failures).
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`35.
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`The subject medical services (at least eight out of eleven subject
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`HCFA codes) were covered by Cigna, as evidenced by, for examples, (a)
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`Defendant’s partial payment relating to same, (b) the Cigna-issued EOB (Ex. E),
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`(c) pre-authorization paperwork (Ex. C) approving eight of the subject HCFA (Ex.
`
`D) codes, and (d) et cetera. A fuller discussion as to why coverage is not at issue in
`
`
`http://www.floridahealthfinder.gov/LandingPages/HospitalASC.aspx
`e.g.,
`See,
`7
`http://www.floridahealthfinder.gov/CompareCare/SelectChoice.aspx.
`
`and
`
`
`
`18
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`Case 6:21-cv-01261-CEM-EJK Document 1 Filed 08/04/21 Page 19 of 33 PageID 19
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`this pure pricing dispute can be found in the above common allegations, namely
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`Paragraphs 8-9.
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`36.
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`Defendant erred in deciding to not fully c