Case 6:22-cv-00828 Document 1 Filed 05/02/22 Page 1 of 27 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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`UNITEDHEALTHCARE INSURANCE
`COMPANY, BROOKDALE SENIOR LIVING,
`INC., and BROOKDALE SENIOR LIVING
`WELFARE PLAN,
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`Defendants.
`__________________________________/
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`COMPLAINT
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`
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`Plaintiff, Surgery Center of Viera, LLC (“SCV”), as medical provider,
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`authorized representative, and assignee of patient / insured, T.T., sues
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`Defendants, UnitedHealthcare Insurance Company (“UHC”), Brookdale Senior
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`Living, Inc. (“Brookdale”), and Brookdale Senior Living Welfare Plan (the “Plan”),1
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`as follows:
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`1 The 2019 Plan document provided to SCV by UHC pre-suit is attached hereto as Exhibit A and
`incorporated fully herein by reference. The date of service at issue was January 25, 2019. This
`Plan appears to be self-funded / self-sponsored. So, if Brookdale had nothing to do with pre-suit
`claim and / or appeal decision-making as to the unreasonably low rate of payment at issue here
`(i.e., the liability component of Counts I-III below), SCV is willing to dismiss without prejudice
`the Brookdale Defendants as to Counts I-III if it were to agree / stipulate as to the following:
`prompt satisfaction of monies deemed owed to SCV by the trier of fact; i.e., prompt satisfaction of
`outstanding benefits when UHC’s claim / appeal decision-making as to the amount of medical
`service monies tendered to SCV is someday determined improper.
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`1
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`Case 6:22-cv-00828 Document 1 Filed 05/02/22 Page 2 of 27 PageID 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, in part (Counts I-III), under state law for
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`Defendants’ wrongful, unsubstantiated underpayment of monies owed to SCV for
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`medical services SCV provided to the patient / insured, T.T., on January 25, 2019,
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`which such causes of action have absolutely nothing to do with “right of payment”
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`/ coverage (i.e., have everything to do with unreasonably low “rate of payment” /
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`benefits) and which such causes of action have to do with third-party re-pricing
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`contracts separate and distinct from the insurance policy / plan document.
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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 T.T. with a power of attorney (in the
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`authorized representative and assignee veins) as well,2 having provided subject
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`medical services to T.T. for which a proper amount of compensation (Counts I-III)
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`was / is due and owing. And, again, Defendants honored such authorized
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`representative / assignee / power of attorney capacities by, for examples, carrying
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`2 All germane authorization / assignment / power of attorney 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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`out pre-suit appeal with SCV (and / or SCV counsel0 and tendering partial claim
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`payment directly to SCV. At the very least, such pre-suit Defendants conduct
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`constitutes a waiver and / or estoppel of any anti-assignment argument
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`Defendants may try to ex post facto make in the courtroom.
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`3.
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`At all material times, UHC was an insurance company with its state
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`of incorporation and principal place of business / headquarters (“nerve center”) in
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`the State of Minnesota 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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`At all material times, Brookdale was a corporation with its
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`citizenship (i.e., state of incorporation) in the State of Delaware and its principal
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`place of business / headquarters (“nerve center”) in Tennessee and engaged (in
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`pertinent part here) in the administration and / or sponsorship of the Plan. The
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`Plan has the same citizenship and nerve center as Brookdale, Delaware and
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`Tennessee, respectively.
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`5.
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`This Court has jurisdiction pursuant to Title 28, United States Code,
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`Section 1332, as complete diversity exists between the parties and the amount in
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`controversy exceeds $75,000.00 exclusive of interest, costs and attorney’s fees.
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`6.
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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, Defendants’
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`3
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`Case 6:22-cv-00828 Document 1 Filed 05/02/22 Page 4 of 27 PageID 4
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`underpayment of the subject insurance claim both at the initial claim and
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`subsequent pre-suit appeal stages (Counts I-III), and (b) the Orlando Division of
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`this Court has personal jurisdiction due to Defendants’ minimum contacts in this
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`forum.
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`7.
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`All conditions precedent to the institution of this action (e.g.,
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`administrative pre-suit appeals) have occurred, been performed, been waived, or
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`were futile.
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`COMMON ALLEGATIONS
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`8. The Plan’s Group number was / is 709155. Again, a copy of the insuring
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`agreement (which is separate and distinct from the re-pricing contract / agreement
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`at issue in this lawsuit, see Exhibit C incorporated fully herein by reference, and
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`whatever mystery re-pricing program UHC employed via Viant pursuant to the
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`carrier’s EOB) is attached as Exhibit A and incorporated fully herein by reference.
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`Moreover, T.T.’s Member ID No. was / is 000613094. Moreover, UHC’s assigned
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`Transaction No. W1140241001.
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` 9.
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`At all material times, T.T. was covered (i.e., coverage is not an issue
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`here) by the Plan as evidenced by several things, with examples now discussed.
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`a. If T.T. was not an eligible / covered insured, the subject claim would
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`not have been paid by Defendants 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 (Authorization No. A061652722) discussed
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`below and attached as Exhibit D. Exhibit D, made up of a UHC
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`4
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`authorization letter / printout with the authorization date being
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`December 28, 2018, according to same, is incorporated fully herein
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`by 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,3 the subject claim would not have been paid by
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`Defendants in any amount. Regarding coverage of the subject HCFA
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`codes, Defendants’ EOB furnished by UHC (further discussed below)
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`is attached as Exhibit F and evidences Defendants’ coverage
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`decision. Exhibit F (made up of an EOB dated February 15, 2019) is
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`incorporated fully herein by reference. As one can plainly see from the
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`UHC-issued EOB, Defendants unilaterally re-priced the subject claim
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`and did not deny any aspects of the claim on coverage grounds (e.g.,
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`medical necessity, experimental / investigational). To this day, we
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`really have no idea how UHC came up with payments totaling
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`$16,125.56 (on a billed amount of $193,438.00) because at every turn
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`(SCV’s requests and undersigned counsel’s requests), Defendants
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`have secreted how they came up with the aforementioned rate of
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`payment; i.e., have never substantiated their determination that
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`$16,125.56 was a “reasonable” or “recognized” amount for of payment
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`3 The HFCA form was part of SCV’s claim submission package to Defendants. SCV’s claim
`submission package is attached hereto as Exhibit E and incorporated fully herein by reference.
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`5
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`for the subject procedure. “Unilaterally” because an applicable re-
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`pricing contract (that SCV had actually agreed to, unlike the unagreed
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`to UHC mystery Viant re-pricing contract / agreement / formula /
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`program) was already in place (see Ex. C). Again, Plaintiff presently
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`does not possess the paperwork associated with the UHV mystery
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`Viant re-pricing formula because Defendants have wrongly secreted
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`this paperwork (the very paperwork that would evidence how
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`Defendants came up with their unreasonably low rate of payment)
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`from SCV in their perpetual refusal to substantiate the unjustifiably
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`low rate of payment force-fed to SCV here. But, as with the re-pricing
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`contract (Ex. C) that SCV maintains should apply here in determining
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`the proper rate of payment not the UHC mystery Viant re-pricing
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`contract / agreement / formula / program unilaterally implemented
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`by Defendants in arriving at the disputed unreasonably low claim
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`payment amount is also separate and distinct from the insurance
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`policy / plan document (Ex. A). Meaning, there is absolutely no
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`“relation to” defensive ERISA preemption at play with a pricing
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`dispute of this nature predicated on re-pricing contracts standing
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`alone from Exhibit A.
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` In sum, as evidenced by the variety of things noted in this averment, this
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`action has nothing to do with coverage (i.e., “right of payment”), it has everything
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`to do with the amount Defendants paid out (i.e., “rate of payment”) on covered
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`6
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`HCFA codes based on a mystery UHC re-pricing contract / formula / program
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`separate and distinct from the plan insurance document (Exhibit A). In other
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`words, the UHC mystery Viant re-pricing contract / formula / program that
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`Defendants used in re-pricing the subject claim and the re-pricing contract /
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`agreement (Ex. C) that SCV contends should have been used do not “relate to” the
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`Plan document (Ex. A); i.e., resolution of Counts I-III will not relate to (at least not
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`beyond a fleeting reference to, at most) the Plan document (Ex. A).4 Once more,
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`“relation to” defensive ERISA preemption simply does not apply here in relation to
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`Counts I-III. And as many Courts (several in this jurisdiction, to boot) have found,
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`complete preemption most definitely does not apply to cases of this ilk.
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` 10.
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`The fact that this dispute has nothing to do with coverage (i.e., has
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`everything to do with pricing / rate of payment) is further evidenced by Defendants’
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`pre-surgery authorization paperwork (see Ex. D). The pre-surgery authorization
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`paperwork (Ex. D) and process is designed to put coverage (but not the eventual
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`amount of claim payment) to rest, which, as discussed above (and as evidenced by
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`Ex. D) is what happened – Defendants deemed the subject procedure medically
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`necessary (which such medical necessity would relate to coverage). Exhibit D is
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`incorporated fully herein by reference.
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` 11.
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`At all material times leading up to the subject medical services
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`4 This averment refers to Defendants’ re-pricing methods as “mystery” for two reasons. First,
`again, Defendants did not produce any materials showing how their third-party Viant re-pricing
`unfolded to arrive at the low rate of payment that they arrived at, notwithstanding SCV’s and / or
`undersigned counsel’s request(s) for same. Second, Defendants’ EOB (Ex. F) is the epitome of
`naked.
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`7
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`received from SCV, T.T. suffered from multi-level cervical spondylosis, stenosis,
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`radiculopathy, and myelopathy with development of deformity. See, e.g., SCV
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`Operative Note, Ex. E. T.T. tried alternative, conservative management treatments,
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`which failed and surgical treatment was deemed medically necessary by both SCV
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`(as evidenced by, for examples, the “operative note,” “history and physical,” and
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`“letter of medical necessity for surgery” found in SCV’s claim submission package,
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`see Ex. E) and UHC (as evidenced by, for example, the pre-authorization paperwork
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`attached as Exhibit D). So, on January 25, 2018, SCV operated on T.T. to remedy
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`the medical conditions.
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` 12.
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`By letter / printout prior to the subject procedure, UHC issued
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`information to SCV approving surgical codes no December 28, 2018. As mentioned
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`above, this paperwork is attached as Exhibit D.
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` 13.
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`As mentioned above, SCV’s billed charges for the subject medical
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`services rendered to T.T. totaled $193,438.00, and a claim package was submitted
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`to UHC relating to same shortly after the subject procedure. See Ex. E. The SCV
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`cover letter to its claim submission packet (see Ex. E) makes specific reference to
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`SCV’s appropriate expectation that claim payment would unfold pursuant to the
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`Preferred Medical Claim Solutions (“PMCS”) (see Ex. C) that existed (not some
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`unknown UHC re-pricing contract that Defendants would eventually unilaterally
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`employ), which, again, such re-pricing contract (even the yet discovered re-pricing
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`contract / formula / program that Defendants employed) is separate and distinct
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`from the plan document (Exhibit A); i.e., again, resolution of Counts I-III (which
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`8
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`hinge on the appropriate re-pricing mechanism) will require little (if any) reference
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`to Exhibit A and certainly not a substantive reference to / “interpretation of” Exhibit
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`A, which such substantive reference / “interpretation of” a plan document (rather
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`than a cursory glance at a plan document, as might be required here) in order to
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`resolve a rate of payment dispute is what would militate toward “relation to”
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`defensive ERISA preemption.
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` 14.
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` At all material times, UHC was in agreement with PMCS (as UHC’s
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`affiliate and / or subcontractor and / or vendor and / or agent and / or the like) to
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`secure discounted rates from providers (like SCV), which were secured here in
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`relation to SCV.5
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` 15.
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`The PMCS allowed amount re-pricing contract (see Ex. C) 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).
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` 16.
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`Notwithstanding the existing PMCS contract / agreement in place
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`5Again, a copy of the pertinent pages of the PMCS re-pricing contract that was procured on UHC’s
`behalf (along with the PMCS “client” list listing UHC) is attached hereto as Exhibit C. Again,
`Exhibit C is incorporated fully herein by reference. Again, SCV made clear its expectation that the
`claim would be priced pursuant to this PMCS contract / agreement that were brokered by UHC
`with PMCS being UHC’s vendor, agent, or the like tasked with achieving discounted rates from
`medical providers like SCV. Exhibit C is made up of SCV’s side of the PMCS contractual
`relationship with Defendants because Defendants have not yet produced paperwork pertaining to
`their side of the PMCS contractual equation, or, for that matter, paperwork pertaining to the third-
`party Viant re-pricing ins-and-outs that Defendants unilaterally employed.
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`9
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`(which, again, was arranged by UHC with PMCS as its vendor / agent), by way of
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`EOB dated February 15, 2019, see Ex. F, on UHC letterhead, Defendants underpaid
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`the subject claim, tendering $16,125.56 predicated on some mystery third-party
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`Viant re-pricing formula falling outside Exhibit A. More specifically, Defendants
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`failed to properly pay (proper amount, that is) the codes billed by SCV in connection
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`with the medical procedure. The nakedness of the EOB (Ex. F) is plain, and this
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`“leave SCV in the evidentiary dark” problem was compounded by Defendants’
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`failure to provide SCV and undersigned counsel with requested records.
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`17.
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`This matter does not present a coverage dispute (i.e., “right of
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`payment” dispute) because Defendants properly conceded coverage via the
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`$16,125.56 partial claim payment and did not list any medical judgment related
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`basis (e.g., medical necessity or experimental / investigational) for partial payment
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`amongst the claim decision EOB codes (see Ex. F). Rather, this is a damages dispute
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`(i.e., “rate of payment” dispute) pertaining solely to the underpayment that was
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`predicated on Defendants’ aberrant claim decision-making seemingly predicated
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`on the unsubstantiated mystery Viant rate system employed (if a system even
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`exists) by Defendants. And, again, whatever mystery third-party Viant re-pricing
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`contract / formula / agreement / program that was employed by Defendants is
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`outside of Exhibit A. To be clear, and again, this dispute revolves around the re-
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`pricing established by Defendants separate and distinct from Exhibit A and SCV’s
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`contention that the re-pricing contract separate and distinct from Exhibit A that
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`should have been employed (see Ex. C). To be clear, and again, the re-pricing
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`dispute does not involve a substantive “interpretation of” (or perhaps any
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`“interpretation of”) Exhibit A.
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`18.
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`Following the adverse Defendants claim underpayment via EOB dated
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`February 15, 2019, appeals and / or reconsideration processes were thoroughly
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`carried out by SCV. SCV’s redacted appeal letters (dated February 22, 2019, and
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`April 23, 2019) are attached hereto as Exhibit G and are fully incorporated herein
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`by reference. To no avail, Defendants maintained (without any true explanation, let
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`alone production of germane documentation explaining) their unreasonably low
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`claim payment rate at every turn. Defendants’ maintaining their decision to pay an
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`unreasonably low about to SCV in relation to the subject procedure culminated with
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`Defendants’ final adverse decision letter dated May 1, 2019 (and received days
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`thereafter).
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`19.
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`To this day, Defendants continue to keep SCV in the absolute dark as
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`to how a total claim payment of $16,125.56 on a billed amount of $193,438.00 was
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`arrived at and / or is legitimate.
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`20. By
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`letter dated March 7, 2019, undersigned counsel sent
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`correspondence to UHC and Brookdale advising Defendants that he represented
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`Plaintiff, SCV. The letter contained a request for the entire administrative record /
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`claim file pursuant to the law (the United States Code and, to some extent, Florida
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`Statute) and / or the subject policy / plan documents for that matter. A redacted
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`copy of the aforementioned letter is attached hereto as Exhibit H and incorporated
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`fully herein by reference. Thereafter, Defendants provided some (but not all) of the
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`requested information, including the insurance policy attached hereto as Exhibit A.
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`21. As for documentation / information production requirements, the
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`insurance policy / contract also speaks to same. See, e.g., Ex. A at 94.
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`22. Defendants were legally obligated to either directly provide the
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`aforementioned requested documentation / information (see Ex. H) to SCV
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`pursuant to federal codes cited above, in whole or in part, and / or contractually
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`obligated.
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`23. There was marginal Defendants’ production (e.g., insurance policy /
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`Plan document), but certainly no production of the perhaps the most glaringly
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`germane documentation for this particular dispute – documentation purportedly
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`substantiating whatever third-party Viant re-pricing
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`formula Defendants
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`implemented in arriving at their unreasonably low rate of payment, for examples.
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`24.
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`So, regrettably, SCV’s (and T.T.’s) entire valuable pre-suit remedies
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`process (which such pre-suit mechanisms were designed to try to avoid lawsuits
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`like this) was squandered by Defendants by keeping SCV largely in the “evidentiary
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`blind” (certainly in the evidentiary blind as to re-pricing) due to Defendants’
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`documentation / information production failures and naked paperwork (e.g.,
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`EOB). Defendants’ failures compromised, among other things, SCV’s ability to
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`make heads-or-tails of Defendants’ unreasonably low rate of payment.
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`25. Again, if one looks at the EOB (which does not necessitate examination
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`or “interpretation of” Exhibit A), it is plain that coverage is not at issue here –
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`Defendants properly conceded coverage via initial partial payment. See Ex. F. And,
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`12
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`again, as to the HCFA codes that SCV places at issue in this lawsuit, one can also
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`look to the pre-authorization paperwork (which does not necessitate examination
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`or “interpretation of” Exhibit A) to see that coverage is not at issue here. See Ex. D
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`(as stated earlier, Exhibit D shows that the subject pre-authorization put coverage
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`issues to rest, leaving only pricing issues). Again, the sole issue here is one of
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`payment amount, so we turn now to germane insurance policy language in that vein
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`just for a baseline understanding (not at all for substantive reliance).
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`26. As to re-pricing, the insurance policy / Plan document (Ex. A)
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`provides, in pertinent part, that payment of benefits is to unfold as follows:
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`When Covered Health Services are received from a non-Network provider,
`Eligible Expenses are determined, based on:
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` -
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` Negotiated rates agreed to by the non-Network provider and either
`UnitedHealthcare or one of UnitedHealthcare’s vendors, affiliates or
`subcontractors, at UnitedHealthcare’s discretion.
`- If rates have not been negotiated, then one of the following amounts: …
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` -
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` When a rate is not published by CMS for the service and a gap methodology
`does not apply to the service, the Eligible Expense is based on 50% of the
`provider's billed charge.
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`Ex. A at 11-12.
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`27. The “negotiated rates agreed to by [SCV] and … one of
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`UnitedHealthcare’s vendors, affiliates or subcontractors” is precisely PMCS (a
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`UHC re-pricing vendor). This is where the fleeting examination of Exhibit A would
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`end in this case, which such fleeting examination does not rise to the level needed
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`to establish “relation to” ERISA defensive preemption. And, for what it is worth,
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`UHC did not even pay out at 50% of SCV’s billed charges, not even close … although
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`13
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`we submit that the re-pricing analysis stops at the negotiated vendor bit that is
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`PMCS.
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` 28.
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`Again, where (as here) a separate and distinct re-pricing contract /
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`agreement has been established, such a contract / agreement supplants the
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`insurance policy / Plan document, especially where (as here) the re-pricing vendor
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`assesses the same kind of data contemplated by the insurance policy’s / Plan
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`document’s re-pricing language. Defendants’ own conduct evidences that much at
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`least – Defendants implemented an UHC re-pricing contract / agreement / formula
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`/ program separate and distinct from Exhibit A (the mystery third-party Viant re-
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`pricing formula reflected on the EOB). The re-pricing program that Defendants
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`tried to pull off did not “relate to” the aforementioned policy re-pricing options, so
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`Defendants should not now (through their lawyers’ ex post facto arguments) be
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`heard to say that “relation to” defensive preemption applies to this dispute – at
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`minimum, what is good for the goose is good for the gander.
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` 29. Defendants’ implementation of their mystery Viant re-pricing
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`contract / agreement / formula / program is untenable because SCV did not agree
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`to same.
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` 30. Defendants erred in refusing SCV’s pre-suit requests for germane
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`documentation / information, including documentation / information concerning
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`what re-pricing / allowed amount formula Defendants employed in arriving at the
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`unreasonably low rate of payment. For example, undersigned counsel’s March 7,
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`2019, letter (Ex. H) to Defendants asked for the following:
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`(14) All guidelines, manuals, written protocol, medical treatises, medical
`literature, and / or the like upon which the claim administrator and / or
`plan administrator partially or wholly based its claim(s) decisions; (15) All
`billing paperwork, rate / fee schedules, data or formulas, third-party re-
`pricing vendor (e.g., PMCS, TRPN, MultiPlan, Viant, Optum, Zelis)
`paperwork / contracts possessed by the claim administrator and / or plan
`administrator relating to “usual, customary, reasonable” (UCR) medical
`provider charges (sometimes referred to as the “eligible expense”
`assessment), and / or any other data upon which the claim administrator
`and / or plan administrator has based its decisions as to how much
`indemnity to afford on the subject claim(s); (16) Copies of any documents
`relating to any reinsurance relating to the subject policy / plan; (17) Copies
`of any documents relating to any arrangement / agreement between the
`plan administrator and the claim administrator relating to end of year cost
`savings between the two (i.e., sharing / splitting of monies saved in relation
`to the policy / plan due to claim underpayments / denials), which such
`arrangements / agreements are often called “Level Funded Plans;” (18)
`Copies of any administrative services agreements (sometimes called Third
`Party Administrator, “TPA,” Agreements, for example) between the claim
`administrator and plan administrator; and (19) Copies of any other
`documents that the claim administrator and / or plan administrator
`partially or wholly relied on in deciding any claim(s) relating to the subject
`medical services.
`
` 31.
`
` Defendants wronged SCV in many ways, most notably by way of the
`
`significant underpayment. Defendants should have employed the PMCS re-pricing
`
`contract (Ex. C) already in place (i.e., already agreed to between the parties) to
`
`assess a proper re-priced amount; but, instead, Defendants implemented a
`
`mystery third-party Viant re-pricing system (not agreed to by SCV) separate and
`
`distinct from Exhibit A to arrive at the unreasonably low rate of payment at issue.
`
` 32. Under the PMCS re-pricing analysis (which, again, was a re-pricing
`
`contract / agreement established by UHC that SCV actually agreed to, and unlike
`
`the UHC re-pricing contract / agreement / formula / program that Defendants
`
`unilaterally employed here without SCV’s agreement), Defendants should have
`
`used an 80% / 100% re-pricing formula to calculate the allowed amount equaling
`
`
`
`15
`
`

`

`Case 6:22-cv-00828 Document 1 Filed 05/02/22 Page 16 of 27 PageID 16
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`$162,506.80 (which such amount is 80% of all non-implant HCFA line-items and
`
`100% of all implant HCFA line-items). This is the amount that the assumed patient
`
`responsibilities (capped at an annual out-of-pocket maximum) should have been
`
`deducted from. The $162,506.80 less Defendants’ prior payment (which such prior
`
`payment presumably already took patient responsibilities subject to the annual
`
`out-of-pocket maximum into consideration) leaves an outstanding balance of
`
`$146,381.24 due and owing to SCV. This amount is exclusive of attorneys’ fees,
`
`costs, interest, and / or extra-contractual exposure.6
`
`33.
`
`SCV has suffered significant financial harm no matter how one slices
`
`this situation. The financial harm by way of owed medical services monies is in
`
`excess of $75,000.00, not including interest of attorneys’ fees, costs, or interest, if,
`
`for examples, the negotiated, agreed to 80% / 100% rate system prescribed by
`
`UHC’s third-party re-pricing vendor (PMCS) is honored / enforced as it should be,
`
`or even if rates prescribed by publicly available databases assessing the charges of
`
`providers of like kind within like geographies, like AHCA, were utilized in the re-
`
`pricing assessment or even, at the very least, 50% of billed charges had been paid.
`
`See n. 6, supra.7
`
`
`6 Even if the trier of fact someday somehow finds PMCS re-pricing inapplicable, Defendants still
`breached the insurance policy / Plan document by (a) plainly not following geographically derived
`pricing databases available in the public domain, such as the Agency for Health Care
`Administration (“AHCA”). See, e.g.,
`and
`http://www.floridahealthfinder.gov/LandingPages/HospitalASC.aspx
`http://www.floridahealthfinder.gov/CompareCare/SelectChoice.aspx , and / or (b) not, at the
`very least paying 50% of SCV’s billed charges.
`
`7 To be clear, it is SCV’s position that the PMCS re-pricing contract (see Ex. C) supplanted the Plan
`document’s re-pricing formula (see ¶¶ 26-28, 32, supra) and should have dictated the re-pricing
`of the subject claim. If, however, this Court somehow determines that the PMCS re-pricing
`
`
`
`16
`
`

`

`Case 6:22-cv-00828 Document 1 Filed 05/02/22 Page 17 of 27 PageID 17
`
` 34.
`
`SCV exhausted the pre-suit appeal process to the best of its ability,
`
`hindered by Defendants’ wrongful refusal to provide administrative records /
`
`claim file / germane documentation required by federal codes (and / or, for that
`
`matter, like records available per insurance contract or Florida Statute requiring
`
`explanation / substantiation to the recipient of an adverse benefits determination,
`
`here SCV), in an effort to accomplish Defendants’ doing the right thing (i.e.,
`
`properly compensating SCV) sans litigation, to no avail. Hence, this lawsuit as
`
`SCV’s regrettable last resort.
`
`COUNT I – BREACH OF RE-PRICING CONTRACTS / AGREEMENTS
`(CLAIM UNDERPAYMENT)
`
`
`SCV re-alleges Paragraphs 1 through 34 (namely, as it pertains to this Count,
`
`Paragraphs 8-19, 24-29, 31-33) as if fully set forth herein, and further alleges as
`
`follows.
`
`35.
`
`At all material times to this action and in exchange for a valuable
`
`premium, Defendants provided health insurance to T.T. under the Plan document
`
`(Exhibit A).
`
`36.
`
`The subject medical services were covered under the Plan document,
`
`as evidenced by, for examples, (a) Defendants’ partial payment relating to same,
`
`(b) the issued EOB (Ex. F), (c) pre-authorization paperwork (Ex. D) approving the
`
`subject HCFA codes (Ex. E), and (d) et cetera. A fuller discussion as to why
`
`
`contract is untenable, SCV respectfully requests the ability to amend the Complaint’s
`underpayment counts (Counts I-III) to sound in the Plan document language found in Paragraph
`26 above because Defendants’ unreasonably low rate of payment did not follow geographically-
`oriented re-pricing databases and / or did not amount to 50% of SCV’s billed charges.
`
`
`
`17
`
`

`

`Case 6:22-cv-00828 Document 1 Filed 05/02/22 Page 18 of 27 PageID 18
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`coverage is not at issue in this pure pricing dispute can be found in the above
`
`common allegations, namely Paragraphs 9-10.
`
`37.
`
`Defendants erred in deciding to not fully compensate SCV by only
`
`tendering a $16,125.56 underpayment in relation to $193,438.00 in billed charges
`
`predicated on Defendants’ mystery third-party Viant re-pricing contract /
`
`agreement / formula / program separate and distinct from Exhibit A. As to all
`
`codes set forth on the HCFA (Ex. E), Defendants should have honored the re-
`
`pricing contract (PMCS) included in Exhibit C that the parties had actually already
`
`agreed to. Defendants’ payment amount comes nowhere close to the re-pricing
`
`formula prescribed by PMCS (80% HCFA non-implant codes / 100% HCFA
`
`implant codes). See ¶ 32, supra. Defendants’ payment amount is accordingly in
`
`breach of the subject re-pricing contracts (Ex. C).8
`
`38.
`
`Defendants’ $146,381.24 payment shortage (see Paragraph 32 above)
`
`does not constitute a usual, customary, reasonable re-priced / “eligible expense”
`
`no matter how one views the situation. First, for example, a third-party repricing
`
`vendor who UHC co