throbber
Filing# 148807095 E-Filed 05/02/2022 07:38:12 PM
`
`IN THE CIRCUIT COURT OF THE SEVENTEENTH JUDICIAL CIRCUIT
`IN AND FOR BROWARD COUNTY, FLORIDA
`COMPLEX BUSINESS DIVISION
`
`JURY TRIAL DEMANDED
`
`Case No.
`
`ENVISION HEALTHCARE CORP.,
`ENVISION PHYSICIAN SERVICES, LLC,
`ALL WOMEN'S HEALTHCARE, INC.,
`AMSURG ALTAMONTE SPRINGS
`ANESTHESIA, LLC, AMSURG CITRUS
`ANESTHESIA, LLC, AMSURG MELBOURNE
`ANESTHESIA, LLC, AMSURG PORT
`ORANGE ANESTHESIA, LLC, AMSURG
`ROCKLEDGE FL ANESTHESIA, LLC,
`AMSURG TAMPA BAY ANESTHESIA, LLC,
`ANESTHESIA ASSOCIATES OF OCALA,
`LLC, ANESTHESIOLOGISTS OF GREATER
`ORLANDO, INC. F/K/A
`ANESTHESIOLOGISTS OF GREATER
`ORLANDO, M.D., P.A., ANESTHESIOLOGY
`ASSOCIATES OF TALLAHASSEE, INC.,
`BAY AREA ANESTHESIA, LLC, BETHESDA
`ANESTHESIA ASSOCIATES, INC., BOCA
`ANESTHESIA SERVICE, INC., CHILDREN' S
`ANESTHESIA ASSOCIATES, INC. F/K/A
`CHILDREN'S ANESTHESIA ASSOCIATES,
`P.A., COASTAL ANESTHESIOLOGY
`CONSULTANTS, LLC, DRS. ELLIS, ROJAS,
`ROSS & DEBS, INC. D/B/A KENDALL
`ANESTHESIA ASSOCIATES, FLAMINGO
`ANESTHESIA ASSOCIATES, INC.,
`GREATER FLORIDA
`ANESTHESIOLOGISTS, LLC,
`JACKSONVILLE BEACHES ANESTHESIA
`ASSOCIATES, INC., JUPITER ANESTHESIA
`ASSOCIATES, L.L.C., MSC ANESTHESIA,
`INC., NORTH FLORIDA ANESTHESIA
`CONSULTANTS, INC., NORTH FLORIDA
`PERINATAL ASSOCIATES, INC.,
`NORTHWOOD ANESTHESIA ASSOCIATES,
`LLC, PORT ST. LUCIE ANESTHESIA, LLC,
`SHERIDAN CHILDREN' S HEALTHCARE
`SERVICES, INC., SHERIDAN HEALTHCORP,
`INC., SHERIDAN HOSPITALIST SERVICES
`OF FLORIDA, INC., SHERMAN INPATIENT
`SERVICES, LLC, SOUTHEAST PERINATAL
`ASSOCIATES, INC., and ST. LUCIE
`ANESTHESIA ASSOCIATES, LLC,
`
`Plaintiffs,
`
`V
`
`*** FILED: BROWARD COUNTY, FL BRENDA D. FORMAN, CLERK 05/02/2022 07:38:10 PM.****
`
`

`

`UNITED HEALTHCARE INSURANCE CO.,
`UNITEDHEALTHCARE OF FLORIDA,
`INC., NEIGHBORHOOD HEALTH
`PARTNERSHIP, INC., and
`UNITEDHEALTH GROUP, INC.,
`
`Defendants.
`
`COMPLAINT
`
`Plaintiffs (collectively,"Envision"),by and through undersigned counsel, bring this
`
`action againstDefendants United HealthCare Insurance Co. ("UnitedHealthCare Insurance" or
`
`"United PPO"), UnitedHealthcare of Florida, Inc. ("UnitedHealthcareof Florida" or "United
`
`HMO"), Neighborhood Health Partnership,Inc.,and UnitedHealth Group, Inc. (collectively,
`
`"United")and allegeas follows:
`
`Introduction
`
`1.
`
`United, the country'slargestcommercial health insurance company, engages in a
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`nationwide pattern and practiceo f intentionallyunderpayingfrontline healthcare providersto
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`boost its profits.United's scheme is simple:issue drasticallyreduced "take it or leave it"
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`reimbursement rates during contract negotiationsto force providersout of its networks, rather
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`than pay them fair and reasonable rates for their services,includingsavinglives duringan
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`unprecedentedpandemic. Once United successfullyforces a providerout of network, United
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`then intentionallyand significantlyunderpays the now "out-of-network" provider,often at rates
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`even lower than the contract rates offered. United then lines its pocketswith the money that
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`providershave worked tirelesslyto earn, money the providersdeserve.
`
`2.
`
`Contrary to United's rhetoric that it only cares about reducing member healthcare
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`costs, patientshave had to pay more for their healthcare as a result of United's scheme, while
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`having less access to their providersof choice.
`
`3.
`
`United exploitsthe resultingnetwork access and adequacy issues,and related
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`patientconfusion and frustration,to pressure health systems and facilities into its network of
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`providers.It is hardlya coincidence that United has been implementing this scheme against
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`2
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`

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`medical groups nationwide while it has simultaneouslygrown its own healthcare providergroup
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`(Optum, Inc.)into the largestphysicianpracticeorganizationin the United States,accounting for
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`most ofUnited's
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`annual profits.United has speciallytargetedlargemedical
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`groups like Envision that are owned by privateequityfirms and whose transformational
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`investments in making physician-centeredhealthcare more efficient threaten United's planned
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`business model of unfairlyreapingexorbitant profitsfrom the healthcare system duringa
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`pandemic and beyond. In doing so, United has harmed not only long-standingbusiness
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`relationshipsand business prospects, but also providersand patients.
`
`4.
`
`Envision now seeks to recover from United the millions of dollars in
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`underpayments for the medical care and treatment provided to United members whose
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`commercial health plans were insured,operated,and/or administered in the State of Florida
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`between January 1,2021 and December 31, 2021 by United or its Florida affiliates,including,
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`but not limited to, emergency medicine, anesthesiology,radiology,neonatology,hospitalist
`
`medicine, trauma and surgicalcare, and related healthcare services. Envision also seeks
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`disgorgementof the profitsby which United has been unjustlyenriched;actual damages to
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`Envision's business relationsh*sand market value caused by United's unlawful acts; punitive
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`damages; attorney'sfees,costs, and prejudgment interest;and such other relief as this Court
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`deems justand proper.
`
`5.
`
`This action concerns the rate of payment, not the rightto payment, which United
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`has alreadyconfirmed by making partialpayments to Envision. Envision does not seek damages
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`for,and excludes any claims for,denial of benefits or coverage under any Employee Retirement
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`Income SecurityAct of 1974 ("ERISA") plan. This action also excludes any claims under
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`programs and plans,such as Medicare Advantage. Envision reserves all
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`rightsto raise those claims in other actions.
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`Parties
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`6.
`
`Plaintiff Envision Healthcare Corporation is a family of healthcare companies that
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`offers healthcare-related services to consumers, hospitals,healthcare systems, health plans,and
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`3
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`

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`local,state, and federal governmental entities. Envision Healthcare is a corporationorganized
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`and existingunder the laws of Delaware with a principalplace of business at 1A Burton Hills
`
`Blvd.,Nashville,Tennessee 37215.
`
`7.
`
`Plaintiff Envision PhysicianServices,LLC, a subsidiaryof Envision Healthcare
`
`Corp., is a multispecialtyphysiciangroup and healthcare management team. Envision Physician
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`Services is a limited liabilitycompany organizedand existingunder the laws of Delaware, with a
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`princ*alplaceofbusiness at 1A Burton Hills Blvd.,Nashville,Tennessee 37215.
`
`8
`
`The followingPlaintiffs are indirect wholly owned subsidiaries of Envision
`
`Healthcare Corp. that staff healthcare facilities throughoutFlorida: All Women's Healthcare,
`
`Inc.,Amsurg Altamonte SpringsAnesthesia,LLC, Amsurg Citrus Anesthesia,LLC, Amsurg
`
`Melbourne Anesthesia, LLC, Amsurg Port Orange Anesthesia, LLC, Amsurg Rockledge FL
`
`Anesthesia,LLC, Amsurg Tampa Bay Anesthesia,LLC, Anesthesia Associates of Ocala, LLC,
`
`Anesthesiologistsof Greater Orlando, Inc. f/k/a Anesthesiologistsof Greater Orlando, M.D.,
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`P.A., Anesthesiology Associates of Tallahassee,Inc.,Bay Area Anesthesia, LLC, Bethesda
`
`Anesthesia Associates,Inc.,Boca Anesthesia Service,Inc.,Children's Anesthesia Associates,
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`Inc. f/k/a Children's Anesthesia Associates,P.A., Coastal AnesthesiologyConsultants,LLC,
`Drs. Ellis,Rojas,Ross & Debs, Inc. d/b/a Kendall Anesthesia Associates,Flamingo Anesthesia
`
`Associates,Inc.,Greater Florida Anesthesiologists,LLC, Jacksonville Beaches Anesthesia
`Associates,Inc.,JupiterAnesthesia Associates,L.L.C., MSC Anesthesia,Inc.,North Florida
`
`Anesthesia Consultants,Inc.,North Florida Perinatal Associates, Inc.,Northwood Anesthesia
`
`Associates,LLC, Port St. Lucie Anesthesia,LLC, Sheridan Children's Healthcare Services,Inc.,
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`Sheridan Healthcorp,Inc., Sheridan HospitalistServices of Florida,Inc., Sherman Inpatient
`
`Services,LLC, Southeast Perinatal Associates, Inc.,and St. Lucie Anesthesia Associates, LLC.
`
`9-
`
`Defendant United HealthCare Insurance Co. is the largestcommercial healthcare
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`insurer in the United States and provideshealth insurance to customers throughoutFlorida,
`
`includingin Broward County. United HealthCare Insurance is a corporationorganized and
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`4
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`existingunder the laws of Connecticut with a principalplaceof business at 185 Asylum Street,
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`Hartford, Connecticut 06103.
`
`10.
`
`Defendant UnitedHealthcare o f Florida,Inc. is licensed as a health maintenance
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`organization("HMO") pursuant to Chapter 641 of the Florida Statutes and providesinsurance
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`and/or administrative services to managed healthcare and related benefits plans with members
`
`throughoutFlorida,includingBroward County. UnitedHealthcare of Florida is a corporation
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`organizedand existingunder the laws of Florida with a princ*al placeo f business at 495 North
`
`Keller Road, Suite 200, Maitland, Florida 32751.
`Defendant Neighborhood Health Partnership,Inc. is also licensed as an HMO
`
`11.
`
`pursuant to Chapter 641 of the Florida Statutes and providesinsurance and/or administrative
`
`services to managed healthcare and related benefits plans with members throughout Florida,
`
`includingBroward County. Neighborhood Health Partnershipis a corporationorganizedand
`existingunder the laws of Florida with a principalplaceof business at 3100 SW 145th Avenue,
`
`Suite 200, Miramar, Florida 33027.
`
`12.
`
`Defendant UnitedHealth Group, Inc. is the parent company of United HealthCare
`
`Insurance Co. and Optum, Inc., a company that owns medical facilities and operates the largest
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`physicianpracticeorganizationin the United States,which competes with Envision.
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`UnitedHealth Group is a corporationorganizedand existingunder the laws of Delaware with a
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`princ*alplaceofbusiness at 9900 Bren Road East, Minnetonka, Minnesota 55343.
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`Jurisdiction and Venue
`
`13.
`
`This Court has jurisdictionpursuant to Fla. Stat. § 26.012(2)because the amount
`
`in controversy exceeds $30,000, exclusive of interests,costs, and attorney'sfees.
`
`14.
`
`Venue is appropriatein the Seventeenth Judicial Circuit for Broward County,
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`Florida because the causes of action arose at least in part in Broward County; United transacted
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`business in Broward County; some of the conduct allegedherein occurred in Broward County;
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`and Defendant Neighborhood Health Partnershiphas an office for transaction of its customary
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`business in Broward County.
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`5
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`15.
`
`This case should be assignedto the Complex Business Division because the case
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`arises from the sale of services by more than a hundred business entities,discoverywill be
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`expansive,coveringthousands of underpaidbills for services,and the amount in controversy
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`exceeds $150,000, exclusive ofinterest,costs, and attorney'sfees.
`
`Envision Delivers High-Quality,Patient-Focused Care
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`Factual Allegations
`
`16.
`
`Envision,through its affiliated and subsidiarymedical groups, is a leading
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`national medical group that delivers physicianand advanced practiceproviderservices,primarily
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`in the areas o f emergency and hospitalistmedicine, anesthesiology,radiology/teleradiology,and
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`neonatology across the United States.
`
`17.
`
`More than 6,000 Envision physiciansand advanced practiceprovidersprovide
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`care in Florida-1
`
`18.
`
`Specifically,Envision providesemergency medicine services in hospital
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`emergency rooms throughout Florida,providing lifesavingmedical care to patientsregardlessof
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`their abilityto pay, consistent with the Emergency Medical Treatment and Active Labor Act and
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`other laws. During the current globalpandemic, for example, Envision's frontline workers have
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`cared for roughly one out of every 10 hospitalizedCOVID-19 patientsin the United States.
`
`More generally,Envision cares for more than 19.3 million annual emergency room visits
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`nationwide,providingcritical services in life-threateningsituations on a dailybasis.
`
`19.
`
`Envision anesthesiologistsand certified registerednurse anesthetists perform
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`criticallyimportantanesthesia services in numerous hospitalsand facilities throughoutFlorida,
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`includingmost of the major hospitalsand other clinical sites throughoutthe state. Envision
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`clinicians staff over 550 anesthesia programs and cover 2.9 million annual anesthetic cases
`
`nationally,which are a vital component ofmany surgicaland critical care services.
`
`1 Envision Healthcare Renews Multiyear Agreement with Florida Blue to Provide Florida
`Patients Access to In-Network Care,EnvisionHealtheare Corp. (Dec. 20,2021),
`https://www.evhc.net/news-resources/in-the-news/2021/envision-healthcare-renews-multiyear-
`agreement-with-florida-blue.
`
`6
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`

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`20.
`
`Envision neonatologistsprovide a full scope of women's and children's services,
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`providingneonatal services at Level I-IV neonatal intensive care units ("NICUs") in Florida and
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`nationally.Envision providescare for high-riskbabies and mothers, including90 women's and
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`children's programs and approximately200,000 annual NICU patientdays nationwide. Quality
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`neonatal care is important to improving premature infant survival rates and subsequent child
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`development.
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`21.
`
`Envision's clinical and support teams collaborate with hospitalsand health
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`systems across the nation to integrateservices,enhance qualityof care, elevate patient
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`experience,and improve clinical outcomes.
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`22.
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`Envision seeks to maintain network relationshipswith health plansnationallyso
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`that patientsreceive a qualityhealthcare experiencefrom Envision clinicians from start to finish,
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`and are not burdened by bills and out-of-pocketexpenses that result when their preferred
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`caregiverhas been kicked out of their insurance network, which causes patientconfusion and
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`frustration and, in turn, may dissuade patientsfrom seeking the care they need.
`
`23.
`
`While Envision providersparticipatednationwide with United for years and made
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`significantrate and other contract concessions to maintain that status, United put profitsahead of
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`patientsand "offered" to allow Envision to remain in-network only if Envision providersagreed
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`to take significantlyreduced reimbursement that United knew Envision providerscould not
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`accept, forcingEnvision out ofnetwork as part of a scheme to inflate United's profitsand grow
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`its Optum business.
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`United Uses Unfair Tactics to Shortch,IngeDoctors
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`24.
`
`United has a lengthyhistoryof manipulatingreimbursement rates and
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`methodologies for its own gain at the expense of healthcare providers.
`
`25.
`
`In 2009, UnitedHealth Group was forced to pay $350 million to patientsand
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`physiciansto settle claims that one of its subsidiaries manipulated the database used by United
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`HealthCare Insurance to set payment rates for out-of-network services by intentionallyskewing
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`"usual and customary" rates downward. As a result of a related settlement of another lawsuit
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`7
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`

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`arisingout of the same conduct, UnitedHealth Group was requiredto fund $50 million to
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`develop what became the FAIR Health database.
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`26.
`
`In May 2015, United agreedto spend $11.5 million to resolve claims that it used
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`down-coding software algorithms,stall tactics,and other unfair business practicesto underpay
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`healthcare providersin Connecticut, New York, North Carolina, and Tennessee.
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`27.
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`In September 2015, United agreedto pay $9.5 million to settle claims that it
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`systematicallyunderpaid out-of-network California medical providers.
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`28.
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`More recently,during the current COVID-19 pandemic, The New York Times
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`uncovered that United was routinelypaying doctors less than the cost of suppliesfor COVID-19
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`tests, leadingsome doctors to foregotesting.2
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`29.
`
`The American Academy of Pediatrics later revealed that United also paid millions
`
`ofprovidersless than the costs of administeringCOVID-19 vaccines and was the only national
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`carrier that refused to pay at least the federal rate. These revelations prompted a congressional
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`investigationinto United's below-market reimbursement tactics.3
`
`30.
`
`In June 2021, stillin the midst ofthe COVID-19 pandemic,United HealthCare
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`Insurance announced a new policyby which it could retroactivelydeny coverage for emergency
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`room visits it believes were not actuallyan emergency-4After an outpouring of criticism,United
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`delayed implementationof the policy.5
`
`2 SarahKRff, Burned by Low Reimbursements, Some Doctors Stop Testingfor Covid,-NY .
`Times (Feb.3,2021), https://www.nytimes.com/2021/02/03/upshot/covid-testing-children-
`pediatricians.html.
`3 Nona Tepper, UnitedHealth to repay providersshortchangedfor COVID vaccine
`administration,Modern Healthcare (Oct.21,2021),
`https://www.modernhealthcare.com/payment/unitedhealth-cover-providers-covid-vaccine-
`underpavments.
`4
`-NonaTepper, United unveils policy to retroactivelydeny patient ED claims,Modern
`Healthcare (Jun.4,2021), https://www.modernhealthcare.com/payment/united-unveils-policy-
`retroactively-deny-patient-ed-claims.
`? How we're assessing emergency departmentfacilitycommercial claims, UnitedHealthcare
`(Jun.2021),https://www.uhcprovider.com/en/resource-library/news/2021-network-bulletin-
`featured-articles/0621-ed-facility-commercial-claims.html.
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`8
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`31.
`
`In July2021, as the opioidepidemic continued to worsen, United ended out-of-
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`network coverage for non-emergency services that take place outside a member's service area.
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`This policychange was reportedlydesignedto save money on substance abuse rehabilitation
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`centers, many of which are clustered in justa few geographicareas, and which often
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`intentionallyremove patientsfrom their usual environments to foster better clinical outcomes.6
`
`32.
`
`In August 2021, United HealthCare Insurance and another UnitedHealth Group
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`subsidiaryagreedto pay over $15 million to settle allegationsby the U.S. Department of Labor
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`that it wrongfully reduced reimbursements for out-of-network mental health services.
`
`7
`
`33.
`
`Envision is no stranger to United's unfair and abusive business practices.In
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`2006, a Florida-based Envision affiliate successfullysued a United HealthCare Insurance
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`subsidiaryfor underpaying Envision's out-of-network rates after United chose not to renew their
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`8-network agreement. (SheridanHealthCorp,Inc. v. Neighborhood Health Partnership,Inc.,
`No. 06-08940 CACE (Broward Cty. Cir. 2006).) In 2009, Envision obtained summary judgment
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`requiringUnited to pay the full amount of the billed charges for services provided to United's
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`members, consistent with the parties'implied-in-fact contract that United entered throughits
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`conduct acceptingEnvision's continuingoffer to providemedical services to United's members.
`
`34.
`
`In 2018, Envision again sued United HealthCare Insurance, this time for violating
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`the terms oftheir in-network agreement and attemptingto withhold over $100 million to offset
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`purportedoverpayments from years prior.(EnvisionHealthcare Corp. v. United HealthCare
`
`Insurance Co., No. 0: 18-cv-60530-UU (S.D. Fla. 2018).) The case was subsequentlyreferred to
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`arbitration and remains pending.
`
`6
`NonaTepper, UnitedHealth's limits on out-of-networkcare seen as surprisebillingban
`reaction, Modern Healthcare (July7,2021),
`https://www.modernhealthcare.com/insurance/unitedhealths-limits-out-network-care-seen-
`surprise-billing-ban-reaction.
`7 United Behavioral Health, United Healthcare Insurance Co. Plans to Pay $15.6m, Take
`Corrective Actions AfterFederal, State Investigations,lj.SDepartment ofbbor (Aug. 11,
`2021),https://www.dol.gov/newsroom/releases/ebsa/ebsa20210812.
`
`9
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`

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`35.
`
`As relevant to this case, United has also engaged in a pattern and practiceof
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`unilaterallyterminatingor refusingto renew providernetwork agreements to force providersout
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`of network, so that it call pay artificiallylow rates. This directlyand immediately harms medical
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`groups like Envision by failingto provide reasonable rates for its services,negativelyimpacting
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`the value of Envision and its affiliated and subsidiarypractices,and negativelyimpacting
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`Envision's business relationsh*swith hospitalclients and prospects. This conduct also
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`ultimatelyharms United's customers by limitingtheir access to high qualitycare and raisingco-
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`pays, deductibles,and/or co-insurance as more care is provided by out-of-network providers.
`
`36.
`
`United's strategy of forcingprovidersout-of-network is widely recognized.For
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`example, an April2021 New York Times article noted that "United has become increasingly
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`aggressivein its stance toward largephysiciangroups .
`
`. ., dropping a number ofthem from its
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`network."8 In October 2021, the American SocietyofAnesthesiologistswrote the Acting
`
`Assistant Attorney General of the U.S. Department of Justice's Antitrust Division on behalf of its
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`over 54,600 members "to express its concerns with the conduct of UnitedHealth Group []that is
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`terminatingparticipatingprovideragreements with anesthesia practicesacross the country at a
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`high rate with exclusionaryintent and consequences."9
`
`37.
`
`Both pending litigationand press coverage make clear that United has employed
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`this termination strategy to support unilateral impositionof unreasonable rates for services
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`provided,benefittingUnited while harming doctors who spend their time in the field helping
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`patients.Providers have been forced to sue United across the country to recoup the millions in
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`damages caused by United terminatingnetwork agreements and underpayingout-of-network
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`rates, and have consistentlysucceeded in doing so. News stories similarlyconfirm United's
`
`8 Letter from Dr. Beverly K. Philip,ASA President to Richard Powers, Esq., Acting Asst. Att'y
`General, U.S. DOJ (Oct.7, 2021),https://www.asahq.org/-
`/media/sites/asahq/files/public/newsroom/news/unitedhealth-group-anti-competitive-behavior-
`letter-to-doj.pdf.
`'Reed Abelson, Doctors Accuse United Healthcare of StiflingCompetition,-NY . Times (Apr. 1,
`2021),https://www.nytimes.com/2021/04/Ol/health/unitedhealthcare-lawsuit.html.
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`10
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`decision to end network relationshipswith other largeprivate-equity-backedprovidergroups
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`such as TeamHealth and U.S. Anesthesia Partners,forcingthem out of network so that United
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`can unilaterallyimpose unreasonable rates for services provided.
`
`38.
`
`United's pattern of misconduct has reportedlyearned it the nickname "evil
`
`empire" among some practitioners,and it is not difficult to see why.
`
`10 United's business
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`practicesultimatelyincrease costs and deprivepatientsof their rightto choose their doctors.
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`Patients trust doctors,not insurance executives,when making decisions about their health and
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`the well-beingof their families. When United forces providersout of network, patientsface
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`higherout-of-pocketcost-sharingrequirementsfor usingsuddenly out-of-network providers,
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`while being left with fewer in-network providersto access. Providers in turn can effectivelylose
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`access to United's members, particularlyin areas where United's members represent a
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`substantial share of commercially insured patients,which many providergroups need to serve to
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`remain economicallyviable.
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`United Siphons Away Sham Savings
`
`39.
`
`In connection with its termination strategy, United has further increased its profits
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`at the expense of patientsvia its so-called "Shared Savings" program. Once United forces a
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`providerout of network, United pays the provider less than its billed charges,and then charges
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`the patient'semployer/healthplan a commission or surchargefor the "savings"from the
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`difference between the provider'sbilled chargesand what United decides to pay. This "savings"
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`is illusory,as United has no intention of paying the billed charges for the out-of-network services
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`and vehemently denies entitlement to payment of those charges.For example,if a provider's
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`out-of-network rate for a given service is $1,000, and United unilaterallydecides to pay only
`
`$200 to the provider,United collects a percentage ofthe $800 difference from the employer as
`
`its "share" ofthe purportedsavings.
`
`10 Nona Tepper, UnitedHealthcare pays providers below standard rates for COVID-19 vaccines,
`Modern Healthcare (Sept.3, 2021),
`https://www.modernhealthcare.com/payment/unitedhealthcare-pays-providers-below-standard-
`rates-covid-19-vaccines.
`
`11
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`40.
`
`One lawsuit that United recentlysettled allegedthat in response to a $1,998 bill
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`from another private-equity-backedproviderthat United forced out of network, United only paid
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`the provider$363.92 and then chargedthe health plan $571.93 in Shared Savingsfees-more
`
`than United paid the provider.(Complaint,U.S. Anesthesia Partners Inc. v. UnitedHealth
`
`Group, Inc.,No. 1:21-cv-023807 46 (D. Colo. Sept.2,2021).) United's Shared Savings
`
`program providesan incentive for United to force providersout of its network, so that it can
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`unilaterallyreduce its payments below usual and customary rates, pocket a portionof the
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`purported savings(effectivelytaking funds that should have gone to the providersand that are
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`entirelybased on the providers'rates),even though United's "share" can make services more
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`expensivefor health plansthan they would have been if United had kept providersin-network.
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`Discovery will reveal how much United has made from this scheme.
`
`41.
`
`The purpose and results ofUnited's Shared Savingsprogram has not escaped
`
`notice. For example, the American Societyof Anesthesiologists'October 2021 letter to the U.S.
`
`Department of Justice explained:"Through the guise of a 'Shared Savings' program, [Unitedl
`
`has a perverse incentive to reduce the number of in-network [providers]to increase [United's]
`
`profits,while increasingthe fees and overall costs passed on to employers."?
`
`,11
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`42.
`
`On information and belief,United is takingadvantage ofthis "perverse incentive ,,
`
`to increase its profitsat the expense ofprovidersand employers. According to testimonyin a
`
`recent lawsuit,United frequentlypaid as little as 20% of clinicians' billed charges,and the
`
`Shared Savings fee that United charges employers is often greater than the amount it pays to the
`
`providerthat performed the medical procedure,effectivelytakingfunds due the provider.
`
`Further,accordingto recent news reports, United cut reimbursements to out-of-network
`
`providersby more than half from 2017 to 2020, while increasingits profitsby billions.
`
`11
`
`Letter from Dr. Beverly K. Philip,ASA President to Richard Powers, Esq.,Acting Asst. Att'y
`General, U.S. DOJ (Oct.7, 2021),https://www.asahq.org/-
`/media/sites/asahq/files/public/newsroom/news/unitedhealth-group-anti-competitive-behavior-
`letter-to-doj.pdf.
`
`12
`
`

`

`United Tries to Drive Business from Envision to Optum
`
`43.
`
`UnitedHealth Group, Inc.,the parent company ofUnited HealthCare Insurance
`
`Co., is also the parent of Optum, Inc. UnitedHealth Group reportedto its shareholders that these
`
`two subsidiaries are "distinct,but strategicallyaligned."
`
`,12
`
`44.
`
`Optum is a key part of UnitedHealth Group's business,representing
`
`approximately50% of its earnings.Optum is expectedto continue to drive UnitedHealth
`
`Group's revenues in the coming years.
`
`45.
`
`Through its division OptumCare, Optum operates the largestphysicianpractice
`
`organizationin the United States,with more than 53,000 physiciansand 1,450 clinics
`
`nationwide.
`
`46.
`
`Optum has primary care and affiliated primary care offices throughout Florida
`
`and is central and south Florida's largestproviderof primaryhealthcare services.
`
`13
`
`47.
`
`Further,through its MedExpress subsidiary,Optum operates hundreds ofurgent
`
`care centers, with approximately 10 urgent care centers in Florida.
`
`14
`
`48.
`
`Additionally,throughits SurgicalCare Affiliates subsidiary,Optum operates the
`
`largestnetwork of independentambulatory surgicalcenters and surgicalhospitalsin the United
`
`States,with over 250 surgery centers at which anesthesiologistspracticenationwide, and
`
`approximately10 surgery centers in Florida. 115
`
`49.
`
`UnitedHealth Group not only insures or administers emergency medicine,
`
`anesthesiology,radiologyand neonatology services through United PPO, United HMO, and
`
`related subsidiaries,but also acts as a referral source and a direct competitorto Envision's
`
`providersthrough its physicianpracticesand surgery centers.
`
`12 UnitedHealth Group, Annual Report (Form 10-K) (Feb. 14, 2020),
`https://www.sec.gov/ix?doc=/Archives/edgar/data/0000731766/000073176620000006/
`
`13
`
`Locations, Optum Inc.,https://wwwjsahealthcare.com/Locations/PrimaryCare.aspx?mid=15.
`14 Our growingpresence, Optum, Inc. https://professionals.optumcare.com/about/presence.html.
`id
`
`15
`
`13
`
`

`

`50.
`
`As noted by the American Societyof Anesthesiologists'October 2021 letter to the
`
`U. S. Department of Justice: "[UnitedHealth Group] is verticallyintegratedand has the ability
`
`and incentive to leverageits United HealthCare []subsidiary'sstatus as a health insurer,
`
`includingto favor [UnitedHealthGroup'sl healthcare providersubsidiaryOptum and its
`
`employed anesthesiologistsunfairly."Additionally,"Optum and [SurgicalCare Affiliateslhave
`
`financial incentives from [United HealthCarel for Optum' s employed physiciansand [Surgical
`
`Care Affiliates']surgery centers to steer patientsonly to in-network anesthesiologists."
`
`,16
`
`51.
`
`The American Society
`
`letter also observed that "[United
`
`HealthCare's] contract terminations also have the effect of reducingthe value of the impacted []
`
`,17 This "you better joinus
`practices,which may make them more willingto be acquired."1
`
`because you can't beat us" strategy has been very successful. Optum added over 10,000
`
`physiciansin 2021. Discovery is likelyto reveal that United drove down reimbursement rates
`
`and kicked providersout of network in order to acquirephysicianpracticesfor Optum, reduce
`
`competitionwith Optum, or both.
`
`52.
`
`For example,Kaiser Health News reportedin February 2020 that after a
`
`successful New Jersey physicians'practicerejectedan Optum-owned group's offer to buy the
`
`practice,United HealthCare Insurance forced the practiceout o f its network. United HealthCare
`
`Insurance then directed its members to seek care at the Optum-owned group instead:18
`
`53.
`
`On information and belief,United HealthCare Insurance providesits sister
`
`company Optum with preferentialcontract terms and reimbursement policies,without requiring
`
`the same draconian reimbursement rate reductions that United HealthCare Insurance requiresof
`
`16 Letter from Dr. Beverly K. Philip,ASA President to Richard Powers, Esq., Acting Asst. Att'y
`General, U.S. DOJ (Oct.7, 2021),https://www.asahq.org/-
`/media/sites/asahq/files/public/newsroom/news/unitedhealth-group-anti-competitive-behavior-
`letter-to-doj.pdf.
`17
`
`id
`18 Phil Galewitz, Needy Patients 'Caught In The Middle' As Insurance Titan Drops Doctors,
`Kaiser Health News (Feb.25,2020), https://khn.org/news/needy-patients-caught-in-the-middle-
`as-insurance-titan-drops-doctors/.
`
`14
`
`

`

`Envision and other providers.In so doing,UnitedHealth Group uses one of its businesses to
`
`subsidize another' s competitionagainstEnvision.
`
`54.
`
`Envision has previouslyexperiencedUnited's suspect competitiontactics. In
`
`2018, UnitedHealth Group directed Optum to submit an apparentlybogus bid for Envision's
`
`ambulatory services unit,which includes its surgery centers. Envision shared commercially
`
`sensitive information about the proposed sale with Optum, but shortlythereafter Optum backed
`
`out of the bidding process. On information and belief,Optum bid on the Envision service line to
`
`obtain sensitive information about Envision's business for the benefit of United HealthCare
`
`Insurance, which was engaged in network negotiationswith Envision at the time.
`
`United Forces Envision Out of Its Network
`
`55.
`
`Before January 1,2021, United and Envision (through one of its legacy medical
`
`groups)were partiesfor more than a decade to a Medical Group Partic*ationAgreement (the
`
`"2009 Agreement") for healthcare services nationwide, includingin Florida. Under that
`
`agreement, Envision providersparticipatedin the United network and were paid mutually
`
`agreeablenegotiatedrates.
`
`56.
`
`In 2018, while negotiatinga renewal of the 2009 Agreement, Envision accepted
`
`an offer by a privateequityfirm to take the company private,allowing it to pursue
`
`transformational opportunitiesto reduce healthcare costs.
`
`57.
`
`Shortlythereafter,United sent a letter disparagingEnvision to more than 250 of
`
`Envision's hospitalclients in an apparent effort to pressure Envision into making concessions in
`
`the renewed agreement. The letter falselyand misleadinglyasserted that "Envision's rates are
`
`drivingup the cost of health care for the people we all serve." The letter also threatened that if
`
`the network agreement lapsesand patientscontinue to receive services from Envision providers,
`
`66
`
`you may experiencea decrease in patientsatisfaction driven from higherout of pocket costs and
`
`patientconfusion."
`
`58.
`
`United then made phone calls to some of these hospitalsand threatened to
`
`terminate its contracts with the hospitalsif they continued their relationshipswith Envision.
`
`15
`
`

`

`59.
`
`In an effort to maintain its commitment to network participationand to avoid
`
`patientdisruptionand dissatisfaction whenever possible,Envision reluctantlyagreed to
`
`significantrate reductions and its network status with United continued without disruption.
`
`60.
`
`In 2020, i

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