Case 1:22-cv-20963-KMW Document 1 Entered on FLSD Docket 03/30/2022 Page 1 of 47
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`UNITED STATES DISTRICT COURT
`SOUTHERN DISTRICT OF FLORIDA
`MIAMI DIVISION
`CASE NO.:
`
`
`DUAL DIAGNOSIS TREATMENT CENTER,
`INC. d/b/a SOVEREIGN HEALTH OF
`CALIFORNIA; SOVEREIGN HEALTH OF
`FLORIDA, INC.; SOVEREIGN HEALTH OF
`PHOENIX, INC.; SHREYA HEALTH OF
`CALIFORNIA, INC.; SHREYA HEALTH OF
`ARIZONA, INC.; MEDICAL CONCIERGE,
`INC. d/b/a MEDLINK; SATYA HEALTH OF
`CALIFORNIA,
`INC.;
`and VEDANTA
`LABORATORIES, INC.;
`
`
`
`
`BLUE CROSS AND BLUE SHIELD OF
`FLORIDA, INC.,
`
`
`
`
`
`Plaintiffs,
`
`
`vs.
`
`
`
`Defendants.
`
`/
`
`COMPLAINT FOR RECOVERY OF
`BENEFITS OWED AND FOR BREACH OF CONTRACT
`
`Plaintiffs Dual Diagnosis Treatment Center, Inc. d/b/a Sovereign Health of California
`
`(“Dual Diagnosis”); Sovereign Health of Florida, Inc. (“Sovereign Florida”); Sovereign Health of
`
`Arizona, Inc. (“Sovereign Arizona”); Shreya Health of California (“Shreya California”) Medical
`
`Concierge, Inc. d/b/a Medlink (“Medlink”); Satya Health of Florida, Inc. (“Satya”); and Vedanta
`
`Laboratories, Inc. (“Vedanta”) (collectively referred to as the “Plaintiffs”) for their complaint
`
`against Defendant Blue Cross and Blue Shield of Florida, Inc. (“BCBS-FL”) state:
`
`INTRODUCTION
`
`1.
`
`The Blue Cross Blue Shield Association, (the “Association”) and its affiliated
`
`insurance companies, including but not limited to BCBS-FL, provide health insurance coverage to
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`about one in three Americans. According to Blue Cross’s own press, ninety-one percent of health
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`care providers have contracted with Blue Cross entities to offer discounted services to Blue Cross
`
`members, and ninety-seven percent of the claims that Blue Cross pays are to such “in-network”
`
`providers.
`
`2.
`
`The several plaintiffs in this action treat individuals suffering from drug addiction
`
`and/or mental health problems. As a matter of practice, Plaintiffs obtain assignments from their
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`patients.
`
`3.
`
`Plaintiffs bring this suit to enforce their valid assignments of benefits and to
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`vindicate their rights under the Employee Retirement Income Security Act of 1974 (“ERISA”) and
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`state law, as applicable.
`
`4.
`
`In a nutshell, BCBS-FL, as a Blue Cross affiliated company, does everything it can
`
`to undermine Plaintiffs’ ability to operate as independent, out-of-network (“OON”) providers.
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`Specifically, BCBS-FL engages in the following improper conduct, all of which is prohibited by
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`ERISA:
`
`a. misleads Plaintiffs about whether claims are assignable under the governing plan
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`documents, and then later, with no explanation, refuses to pay Plaintiffs and instead
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`pays some unknown amount to the recovering addicts themselves,
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`b. refuses to honor assignments even when the underlying plan document permits
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`them, and
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`c. never plainly tells its beneficiaries that the assignments they choose to give will not
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`be honored.
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`2
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`5.
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`This scheme of deception and confusion leaves OON providers like the Plaintiffs
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`misled, confused, and often holding the bag for services rendered in good faith to suffering patients
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`—all of which unfairly increases the cost of running their businesses.
`
`6.
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`Defendant does not even attempt to hide this conduct; as one Blue Cross company
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`described it: “payments for services rendered by providers who do not contract with [Blue Cross]
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`are sent directly to our customers. Thus, out-of-network providers face the inconvenience of
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`attempting to collect payment from the customer and the accompanying possibility of incurring
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`bad debts.” See Blue Perspective: BCBSOK Position on Legislation and Regulatory Issues, Blue
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`Cross Blue Shield Oklahoma, www.bcbsok.com/grassroots/pdf/blueperspective_aob27-
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`103003.pdf (last visited October 27, 2020).
`
`7.
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`Cutting providers out of the process also saves Defendant money by leaving to
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`unsophisticated patients (i.e., recovering addicts) the responsibility of ensuring that the insurance
`
`plans have fully paid the patients’ benefit entitlements.
`
`8.
`
`By this action, Plaintiffs are seeking to recover the amounts owed by BCBS-FL for
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`services provide to the various patients referenced in this Complaint and to hold BCBS-FL
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`accountable for its violations of ERISA and State law.
`
`THE PARTIES
`
`A.
`
`Plaintiffs:
`
`9.
`
`Plaintiffs are entities that provided in- and out-patient substance abuse and/or
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`mental health treatment to various patients in California, Arizona, Florida, and other locations
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`across the United States.
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`10.
`
`Dual Diagnosis Treatment Center, Inc. d/b/a Sovereign Health of California (“Dual
`
`Diagnosis”) is a corporation duly organized and existing under the laws of California. At all
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`3
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`relevant times, Dual Diagnosis did business as “Sovereign Health of California,” and on occasion
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`under other names in accordance with its governing certifications and licensures. At all relevant
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`times, Dual Diagnosis was certified to operate and maintain behavioral health treatment facilities
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`in San Clemente, Culver City and Palm Springs California, among other locations.
`
`11.
`
`Sovereign Health of Florida (“Sovereign Florida”) is a corporation duly organized
`
`and existing under the law of Delaware, doing business as “Sovereign Health of Florida.” At all
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`relevant times, Sovereign Florida is and was licensed to operate and maintain a behavioral health
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`residential facility in Pompano Beach, Florida and provided comprehensive treatment programs
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`for mental health, addiction and other behavioral health disorders.
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`12.
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`Sovereign Health of Phoenix (“Sovereign Phoenix”) is a corporation duly
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`organized and existing under the law of Delaware. At all relevant times, Sovereign Phoenix is and
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`was licensed to operate and maintain a behavioral health residential facility in Arizona and
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`provided comprehensive treatment programs for mental health, addiction and other behavioral
`
`health disorders
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`13.
`
`Shreya Health of California, Inc. (“Shreya”) is a corporation duly organized and
`
`existing under the laws of California. At all relevant times, Shreya operated as a facility that
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`provided 24 hour therapeutically planned living and rehabilitative environment for treatment of
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`individuals with behavioral and other disorders. Shreya operated a treatment facility in San
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`Clemente, California, among other locations. Shreya provided services to several of the patients at
`
`issue in this litigation.
`
`14.
`
`Shreya Health of Arizona, Inc. (“Shreya Arizona”) is a corporation duly organized
`
`and existing under the laws of Arizona and during the relevant times, operated a substance abuse
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`rehabilitation facility located in Chandler, Arizona. At all relevant times, Shreya operated a
`
`
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`4
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`rehabilitative facility for treatment of individuals with behavioral and other disorders. Shreya
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`operated a treatment facility in Chandler Arizona, among other locations. Shreya provided services
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`to several of the patients at issue in this litigation
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`15. Medical Concierge, Inc. (“Medlink”) is a corporation duly organized and existing
`
`under the laws of California, doing business as “Medlink.” Medlink is licensed to operate and
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`maintain an adult residential facility (“ARF”) for ambulatory mentally ill adults. Medlink
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`provided services to several of the patients at issue in this litigation.
`
`16.
`
`Satya Health of California, Inc. (“Satya”) is a corporation duly organized and
`
`existing under the laws of California. At all relevant times, Satya did business as “Sovereign by
`
`the Sea II,” and on occasion under other names in accordance with its governing certifications and
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`licensures. At all relevant times, Satya was licensed to operate and maintain behavioral health
`
`treatment facilities in San Clemente, Culver City, and Palm Springs, California, among other
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`locations. Satya provided services to several of the patients at issue in this litigation.
`
`17.
`
`Vedanta Laboratories, Inc. (“Vedanta”) is a corporation that was duly organized
`
`under the laws of the Delaware. At all relevant times, Vedanta provides toxicology testing and
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`quality assurance programs. Vedanta serves clinicians and healthcare facilities. Vedanta provided
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`services to several of the patients at issue in this litigation.
`
`B.
`
`Former Patients:
`
`18.
`
`This lawsuit involves behavioral health treatment services rendered by Plaintiffs to
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`many individuals (“Former Patients”) who Plaintiffs are informed and believe, at all relevant times,
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`possessed health insurance covering some or all of the services that Plaintiffs provided.
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`19.
`
`To protect their personal health information, the Former Patients are identified by
`
`their initials. The Former Patients who had health insurance provided by an employer-sponsored
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`
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`5
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`plan, covered by ERISA include the following: Ga.Ro., Ha.La., Je.Lo., and the following Former
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`Patients have health insurance provided by an employer sponsored plan that is not covered by
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`ERISA: An.Wi., Ap.Br., Co.Cl., Da.Cu., Kr.Ja., Li.Bu., Ni.Ca., No.Bl., Ri.Di., St.Li, Xi.Ma.1
`
`C.
`
`Defendants:
`
`20.
`
`Based upon documents obtained by Plaintiffs to date, Plaintiffs are informed and
`
`believe that the health insurance of each of the Former Patients listed in paragraph 20 above was
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`obtained through what ERISA defines as an “employee benefit plan.” 29 U.S.C. § 1002(3).
`
`21.
`
`Horizon Blue Cross Blue Shield of Florida (“BCBS-FL”) has been providing health
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`insurance products and services to Florida families, including the Former Patients at issue in this
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`action.
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`22.
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`The BCBS-FL website boasts that “for more than 75 years, Florida has been our
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`one and only home. Helping you an dour communities be as healthy as they can be is our mission
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`and we will never stop finding new ways to achieve it.” Unfortunately, in this instance, BCBS-
`
`FL has not lived up to these expectations.
`
`JURISDICTION AND VENUE:
`
`23.
`
`This Court has subject matter jurisdiction over this action pursuant to 28 U.S.C.
`
`1331, 29 U.S.C. 1132(e)(1) and 28 U.S.C. 1332(a). Several of the Former Patients are seeking
`
`relief under ERISA for benefits owed and for the balance of the Former Patients, pursuant to 28
`
`U.S.C. 1332 the parties to the complaint are of diverse citizenship and Plaintiffs seek in excess of
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`$75,000 in damages.
`
`
`1 Defendant will be provided specific information as to each Former Patient, so that it can identify
`the patient and appropriate provide the administrative record in this action.
`
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`6
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`24.
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`Venue is proper in this district as pursuant to 28 U.S.C. 1132(e)(2) because much
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`of the conduct that is the subject matter of this lawsuit occurred within this District, including the
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`providing of insurance coverage under the covered plans, and the Defendant conducts business
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`within the District either directly or through wholly owned and controlled subsidiaries.
`
`A.
`
`Plaintiffs Provide Gold Standard Treatment Services.
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`RELEVANT FACTS:
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`25.
`
`Plaintiffs are leading providers of comprehensive addiction and mental health
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`treatment programs and other services to individuals in various locations across the United States.
`
`26.
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`It is widely accepted that the services rendered by Plaintiffs and similar providers
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`are extremely important. For example, according to the National Institute on Drug Abuse, every
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`$1 spent on substance abuse treatment saves $4.87 in health care costs and $7.00 in crime costs.
`
`See Nat’l Inst. on Drug Abuse, Principles of Drug Addiction Treatment: A Research-Based Guide
`
`(3d ed. 1999).
`
`27.
`
`Plaintiff’s approach to addiction and other mental health treatment was consistent
`
`with best practices in the industry. Its proven track record also earned Plaintiffs accolades from
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`trade and government groups. Dual Diagnosis, for example, received the Gold Seal of Approval
`
`from the Joint Commission, an independent not-for-profit organization that is the nation’s oldest
`
`and largest standards-setting and accrediting body in health care. And the California Board of
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`Behavioral Health Sciences, the California Association for Alcohol/Drug Educators, and the
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`National Association for Alcoholism and Drug Abuse Counsels approved Plaintiffs’ entities to
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`provide continuing education to licensed professionals.
`
`B.
`
`Plaintiffs Investigate Prospective Patients’ Health Insurance Coverage.
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`7
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`28.
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`Plaintiffs, who are for-profit enterprises, allow prospective patients to pay for their
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`services out-of-pocket or with health insurance. Unfortunately, many individuals in need of
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`treatment cannot afford to pay for Plaintiffs’ services up front. Plaintiffs are only able to treat those
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`individuals who have health insurance covering some or all of their services.
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`29.
`
`Before agreeing to treat any patient, Plaintiffs take steps to ensure that they will be
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`compensated for their services.
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`30. When a prospective patient seeks to pay with his or her health insurance, Plaintiffs
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`investigate whether and to what extent the patient’s insurance policy covers their various levels of
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`service.
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`31. When each Former Patient first sought treatment, as a matter of intended general
`
`practice described below, Plaintiffs or their agents verified that he or she was insured and
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`ascertained the scope of his or her coverage through various procedures.
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`32.
`
`Plaintiffs or its agents first secured the Former Patient’s consent to contact his or
`
`her health insurance company, along with the identifying information necessary for Plaintiffs to
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`interact with the insurer.
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`33.
`
`Plaintiffs or their agents also asked for the dedicated phone number of healthcare
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`providers associated with the Former Patient’s insurance policy (“Provider Hotline”). Plaintiffs
`
`are informed and believe that each Former Patient authorized Plaintiffs to contact the Provider
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`Hotline of a Blue Cross Defendant. Plaintiffs or their agents generally, but not always, recorded
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`this information in the top box of a comprehensive document entitled “Insurance Verification
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`Form.”
`
`34.
`
`Plaintiffs or their agents called the Provider Hotline listed on the Insurance
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`Verification Form on each Former Patient’s behalf. When it reached a BCBS-FL representative,
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`8
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`Plaintiffs or their agents relayed the Former Patient’s identifying information and requested details
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`about his or her coverage.
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`35.
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`Plaintiffs or their agents generally recorded the information learned from the Blue
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`Cross Defendant on the bottom of the Insurance Verification Form.
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`36.
`
`To attempt to complete Plaintiffs’ Insurance Verification Form, Plaintiffs or their
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`agents generally inquired exhaustively into the characteristics of the Former Patient’s health
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`insurance coverage, including with respect to:
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`a. The general characteristics of the health insurance policy (including fields
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`for effective date and renewal date, the type of plan, and whether it covers
`
`preexisting conditions, among other things);
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`b. The existence and scope of any substance abuse or mental health coverage
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`(including fields regarding deductible for in-network and out-of- network
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`services and maximum out-of-pocket payments for in-network and out- of-
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`network services, among other things);
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`c. Any precertification requirements (including fields indicating whether
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`precertification required for inpatient treatment, residential treatment,
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`partial hospitalization, intensive outpatient treatment, and/or outpatient
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`treatment by in-network and out-of-network providers); and
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`d. Copayments for each type of treatment and any limits on the length of
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`treatment.
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`37.
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`Plaintiffs or their agents generally also investigated the logistics of securing
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`authorization and payment for Plaintiffs’ services, including:
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`Case 1:22-cv-20963-KMW Document 1 Entered on FLSD Docket 03/30/2022 Page 10 of 47
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`a. How to comply with precertification requirements (including fields for pre-
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`certification company and telephone number);
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`b. The name of the insurance company and the entity to which benefit claims
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`should be submitted (including fields for insurance company and claims
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`address); and
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`c. Whether the Former Patient’s health insurance benefits were assignable.
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`The answer to this question was supposed to be recorded by circling “Yes”
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`or “No” (or “Y” or “N”) next to the word “assignable” on the Insurance
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`Verification Form.
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`38.
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`After the insurance verification process, Plaintiffs then contacted each Former
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`Patient to discuss his or her insurance policy and to make appropriate arrangements for treatment.
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`39.
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`During the verification of insurance benefits, Plaintiffs also confirm the available
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`coverage under the various plans.
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`40.
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`The verification process was performed for the benefits provided to each of the
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`patients at issue in this action and the amounts owed, per the plan verification ranged from 50-
`
`80% of the billed charges depending on the services provided and the particular plan itself.
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`41.
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`At no point in time did Horizon or any of its representatives inform Plaintiffs that
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`they were denying or underpaying the various claims at issue in this litigation based on the medical
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`necessity criteria or any other issue. Rather, Horizon simply unjustifiably refused to pay the full
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`claim, paid pennies on the dollar for various claims, and/or made improper payments to patients
`
`as opposed to Plaintiffs directly.
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`42.
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`Further, at no time has there been any claim made by Horizon that the necessary
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`services for each of the patients was not covered under the policies/plans issued. Rather, payments
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`were simply paid incorrectly, not paid at all, or significantly underpaid contrary to the requirements
`
`of the Former Patients plan documents.
`
`Each Former Patient Had “Preferred Provider Organization” Coverage for
`Substance Abuse and Mental Health Treatment Services.
`
`C.
`
`
`
`43.
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`Plaintiffs only wish to provide services that prospective patients can afford. As
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`such, as a matter of course Plaintiffs investigate whether the treatment needed by a patient
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`(including the Former Patients) was covered by insurance.
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`44. When Plaintiffs or their agents called the Blue Cross Defendants’ Provider
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`Hotlines, they learned that each Former Patient’s health insurance policy had at least the following
`
`key features: (1) coverage for substance abuse/mental health treatment offered by Plaintiffs, and
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`(2) preferred provider organization (“PPO”) coverage.
`
`45.
`
`A PPO plan covers medical expenses incurred when the insured visits either an “in-
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`network” provider (i.e., a provider who has a contractual relationship with the insurance company)
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`or an “out-of-network” provider (i.e., one who does not have a contractual relationship with the
`
`insurance company).
`
`46.
`
`PPO coverage tends to be significantly more expensive than health maintenance
`
`organization (“HMO”) coverage because it gives insureds the option to visit the providers of their
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`choice. Many insureds are nevertheless willing to pay a premium for PPO coverage to gain access
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`to a bigger and better pool of providers.
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`47.
`
`No law required the plans to offer PPO coverage instead of HMO coverage. Each
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`Plan chose to offer the more robust and expensive insurance to their employees, and each Former
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`Patient or subscriber enrolled in and paid for that premium level of coverage.
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`48.
`
`Plaintiffs are out-of-network with respect to BCBS-FL. In other words, Plaintiffs
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`are not contracted with BCBS-FL to provide services to their insureds at a discounted rate.
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`49.
`
`In short, Plaintiffs and their agents learned from the BCBS-FL representatives that
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`each Former Patient had PPO coverage for substance abuse and mental health treatments and
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`services, and that BCBS-FL was the relevant insurance company administrator, and/or contact for
`
`the Former Patient plans.
`
`The Assignments to the Patients and the Coverage Owed Under the Horizon Policies.
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`D.
`
`
`50.
`
`Plaintiffs (or their agents, on Plaintiffs’ behalf) obtained and obtain a valid
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`assignment of benefits (“Assignment”) from all patients before treating them.
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`51.
`
`The Assignments give Plaintiffs the right to be paid directly for any services
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`rendered to patients, and also entitle Plaintiffs to assert patients’ legal rights to recover benefits.
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`These legal rights include the right to file claims and appeals, to request and obtain information
`
`and documents relating to the plan, and to bring suit.
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`52.
`
`The Assignments entitle Plaintiffs to collect payment for services provided to the
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`Former Patients directly from BCBS-FL.
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`53.
`
`The Assignments also confer legal standing on Plaintiffs to assert various legal
`
`claims against the Plans and BCBS-FL, including the claims asserted in this Complaint.
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`
`
`Patient An.Wi:
`
`54.
`
`Patient An.Wi. was covered under a BCBS-FL plan at the time services were
`
`provided by Shreya Health of California and Vedanta.
`
`55.
`
`Prior to providing services, Shreya Health of California required Patient An.Wi. to
`
`execute an assignment of benefits.
`
`56.
`
`The assignment from Patient An.Wi. to Shreya Health of California, provided that:
`
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`I patient/policyholder irrevocably assign, transfer, and convey to Provider the
`exclusive rights to benefits, insurance proceeds or other moneys otherwise due to
`me for services rendered by Providers (“Benefits”) from my insurer, employee
`benefit plan, welfare benefit plan, government plan, tortfeasor or other liable third
`party (“Liable Third Parties”) and all administrative, arbitral, judicial or other rights
`I may have relating to the recovery of Benefits from Liable Third Parties
`
`57.
`
`The assignment goes on to provide that:
`
`I understand that the purpose of this Assignment of Benefits is to ensure that
`Provider is paid for services it has provided or will provide to me. Accordingly, I
`agree that any ambiguity regarding the scope of this Agreement shall be construed
`in favor of assigning Provider all rights that will assist in recovering Benefits from
`Liable Third Parties
`
` I
`
` hereby authorize my insurance benefits to be paid to provider.
`
`
`58.
`
`Vedanta Labs also required Patient An.Wi. to execute an assignment of benefits,
`
`which provided that:
`
`I irrevocably assign, transfer and convey to Vedanta the exclusive rights to benefits,
`insurance proceeds or other monies due to me for services rendered by Vedanta
`(“Benefits”) from my insurer, employee benefit plan, welfare benefit plan,
`government plan, tortfeasor or other liable third part (“Liable Third Parties” and all
`administrative, arbitral, judicial or other rights I may have relating to the recovery
`of Benefits from Liable Third Parties.
`
`
`59.
`
`In addition to the assignment from Patient An.Wi., Plaintiffs also contacted BCBS-
`
`FL directly to get details of the type of coverage Patient An.Wi. had under his plan with BCBS-
`
`FL and the payments required to be made per the plan language.
`
`60.
`
`Specifically, plaintiffs confirmed for Patient An.Wi. the following relevant plan
`
`provisions and benefits, among others:
`
`a. The type of plan – was a self-funded PPO plan;
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`b. The out of network deductible for substance abuse/mental health was $500;
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`c. The policy covers,
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`In-patient care,
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`residential
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`treatment, partial
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`hospitalization, intensive outpatient care, and outpatient care for mental
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`health/substance abuse;
`
`d. The policy pays 50% of benefits for out of network and 50% of labs;
`
`e. The plan covers Combined Alcohol and Substance Abuse, but not
`
`Combined Alcohol, Substance Abuse, and Mental Health;
`
`f. Precertification is needed for all levels of care except outpatient and there is a $500
`
`precertification penalty if it is not obtained;
`
`g. No copay for any level of care;
`
`h. Code 90849 is valid and billable; and
`
`i. No out of state restrictions on the plan.
`
`61.
`
`Importantly, BCBS-FL never provided the actual plan documents to Plaintiffs or to
`
`Patient An.Wi., despite requests to do so, and therefore, the verification process had to be done
`
`over the phone.
`
`62.
`
`In all, for Patient An.Wi., there were $43,564.80 in billed charges and BCBS-FL
`
`paid a grand total of $1,237.83, which was paid directly to Patient An.Wi. virtually assuring that
`
`Plaintiffs would not get paid the amounts owed per the plan documents. In fact, Plaintiffs were not
`
`paid anything from the amounts paid to Patient An.Wi.
`
`
`
`Patient Ap.Br.:
`
`63.
`
`Patient Ap.Br. was covered under a BCBS-FL plan at the time services were
`
`provided by Shreya Health of California.
`
`64.
`
`Prior to providing services, Shreya Health required Patient Ap.Br. to execute an
`
`assignment of benefits.
`
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`65.
`
`The assignment from Patient Ap.Br. provided that:
`
`I patient/policyholder irrevocably assign, transfer, and convey to Provider the
`exclusive rights to benefits, insurance proceeds or other moneys otherwise due to
`me for services rendered by Providers (“Benefits”) from my insurer, employee
`benefit plan, welfare benefit plan, government plan, tortfeasor or other liable third
`party (“Liable Third Parties”) and all administrative, arbitral, judicial or other rights
`I may have relating to the recovery of Benefits from Liable Third Parties
`
`66.
`
`The assignment went on to provide that:
`
`I understand that the purpose of this Assignment of Benefits is to ensure that
`Provider is paid for services it has provided or will provide to me. Accordingly, I
`agree that any ambiguity regarding the scope of this Agreement shall be construed
`in favor of assigning Provider all rights that will assist in recovering Benefits from
`Liable Third Parties
`
` I
`
` hereby authorize my insurance benefits to be paid to provider.
`
`
`67.
`
`In addition to the assignment from Patient Ap.Br., Plaintiffs also contacted BCBS-
`
`FL directly to get details of the type of coverage Patient Ap.Br. had under her plan with BCBS-FL
`
`and the payments required to be made per the plan language.
`
`68.
`
`Specifically, plaintiffs confirmed for Patient Ap.Br. the following relevant plan
`
`provisions and benefits, among others:
`
`a. The type of plan – was a self-funded PPO plan;
`
`b. The out of network deductible for substance abuse/mental health was
`
`$12,100;
`
`c. The plan covers Combined Alcohol and Substance Abuse, but not
`
`Combined Alcohol, Substance Abuse and Mental Health;
`
`d. The policy covers,
`
`In-patient care,
`
`residential
`
`treatment, partial
`
`hospitalization, intensive outpatient care, and outpatient care for substance
`
`abuse;
`
`
`
`15
`
`

`

`Case 1:22-cv-20963-KMW Document 1 Entered on FLSD Docket 03/30/2022 Page 16 of 47
`
`e. There is no annual maximum benefits under the plan;
`
`f. There are no copays on the plan
`
`g. The policy pays 100% of benefits for out of network after satisfaction of the
`
`deductible, and 50% of labs;
`
`h. There is a $500 precertification penalty if it is not obtained;
`
`i. All H codes are valid and billable, including S9480 and 90849; and
`
`j. No out of state restrictions on the plan
`
`69.
`
`Importantly, BCBS-FL never provided the actual plan documents to Plaintiffs or to
`
`Patient Ap.Br., despite requests to do so, and therefore the verification had to be done over the
`
`phone.
`
`70.
`
`In all, for Patient Ap.Br., there were $2,200 in billed charges of which BCBS-FL
`
`paid $615.01 directly to Patient Ap.Br. virtually assuring that Plaintiffs would not get paid the
`
`amounts owed per the plan documents. In fact, Plaintiffs were not paid anything from the amount
`
`paid to Patient Ap.Br.
`
`
`
`Patient Co.Cl:
`
`71.
`
`Patient Co.Cl. was covered under a BCBS-FL plan at the time services were
`
`provided by Shreya Health of California.
`
`72.
`
`Prior to providing services, Shreya Health required Patient Co.Cl. to execute an
`
`assignment of benefits.
`
`73.
`
`The assignment from Patient Co.Cl. to Shreya Health provided that:
`
`I patient/policyholder irrevocably assign, transfer, and convey to Provider the
`exclusive rights to benefits, insurance proceeds or other moneys otherwise due to
`me for services rendered by Providers (“Benefits”) from my insurer, employee
`benefit plan, welfare benefit plan, government plan, tortfeasor or other liable third
`
`
`
`16
`
`

`

`Case 1:22-cv-20963-KMW Document 1 Entered on FLSD Docket 03/30/2022 Page 17 of 47
`
`party (“Liable Third Parties”) and all administrative, arbitral, judicial or other rights
`I may have relating to the recovery of Benefits from Liable Third Parties.
`
`74.
`
`The assignment goes on to provide that:
`
`I understand that the purpose of this Assignment of Benefits is to ensure that
`Provider is paid for services it has provided or will provide to me. Accordingly, I
`agree that any ambiguity regarding the scope of this Agreement shall be construed
`in favor of assigning Provider all rights that will assist in recovering Benefits from
`Liable Third Parties.
`
`75.
`
`In addition to the assignment from Patient Co.Cl., Plaintiffs also contacted BCBS-
`
`FL directly to get details of the type of coverage Patient Co.Cl. had under her plan with BCBS-FL
`
`and the payments required to be made per the plan language.
`
`76.
`
`Specifically, plaintiffs confirmed for Patient Co.Cl. the following relevant plan
`
`provisions and benefits:
`
`a. The type of plan – was a self-funded PPO plan;
`
`b. The out of network deductible for substance abuse/mental health was $500;
`
`c. The policy covers,
`
`In-patient care,
`
`residential
`
`treatment, partial
`
`hospitalization, intensive outpatient care, and outpatient care for mental
`
`health/substance abuse;
`
`d. The policy covers both Combined Alcohol and Substance Abuse and
`
`Combined Alcohol, Substance Abuse, and Mental Health;
`
`e. There is no annual maximum benefits under the plan;
`
`f. The policy pays 50% of benefits for out of network and 50% of labs;
`
`g. All S codes are eligible, including 80305, 90837, and 82075.
`
`h. Precertification is needed for all levels of care, except routine outpatient care.
`
`Claims will be denied if preauthorization is not obtained;
`
`
`
`17
`
`

`

`Case 1:22-cv-20963-KMW Document 1 Entered on FLSD Docket 03/30/2022 Page 18 of 47
`
`i. No out of state restrictions on the plan.
`
`77.
`
`Importantly, BCBS-FL never provided the actual plan documents to Plaintiffs or to
`
`Patient Co.Cl., despite requests to do so, and therefore the verification had to be done over the
`
`phone.
`
`78.
`
`In all, for Patient Co.Cl., there were $1,965 in billed charges and BCBS-FL only
`
`paid $170.13, which was paid directly to Patient Co.Cl., virtually assuring that Plaintiffs would
`
`not get paid the amounts owed per the plan documents. In fact, Plaintiffs were not paid anything
`
`by Patient Co.Cl. from the amounts paid by BCBS-FL.
`
`
`
`Patient Da.Cu.:
`
`79.
`
`Patient Da.Cu. was covered under a BCBS-FL plan at the time services were
`
`provided by Medical Concierge/Medlink.
`
`80.
`
`Prior to providing services, Medlink required Patient Da.Cu. to execute an
`
`assignment of benefits.
`
`81.
`
`The assignment from Patient Da.Cu. to Medlink provided that:
`
`I patient/policyholder irrevocably assign, transfer, and convey to Provider the
`exclusive rights to benefits, insurance proceeds or other moneys otherwise due to
`me for services rendered by Providers (“Benefits”) from my insurer, employee
`benefit plan, welfare benefit plan, government plan, tortfeasor or other liable third
`party (“Liable Third Parties”)