Mspa Claims 1, LLC v. Halifax Health, Inc.
Mspa Claims 1, LLC v. Halifax Health, Inc.
Opinion of the Court
This matter comes before the Court without a hearing on the Motion to Dismiss (Doc. 16) filed by the Defendant, Halifax Hospital Medical Center
*1337I. Background
According to the allegations of the Complaint (Doc. 1-1 at 8-30) in this purported class action, which are accepted in pertinent part as true for purposes of resolving this motion, MSPAC is the assignee of Florida Healthcare Plus, Inc. ("FHPI"), a Medicare Advantage Organization ("MAO"). In May of 2013, one of FHPI's enrollees-whose name is being kept confidential-received medical items and services at the hospital operated by Halifax. (Complaint at 17-18). Halifax billed and received payment for those items and services from both FHPI and from 21st Century Preferred Insurance Company ("21st Century"), which was primarily liable. (Complaint at 18). 21st Century, which was the enrollee's no-fault PIP insurer, paid $10,000 to Halifax on November 6, 2013. (Complaint at 18). FHPI paid the full amount of its enrollee's charges-$31,722.23-to Halifax on December 16, 2013, rather than the $21,722.23 remaining after 21st Century's payment. (Complaint at 18). On May 12, 2014, Halifax sent a reimbursement check to MSPAC for $9,750.
On January 3, 2017, MSPAC filed this suit in the Circuit Court of the Eleventh Judicial Circuit, in and for Miami-Dade County, Florida. (Doc. 1 at 1). On February 23, 2017, the case was removed to the United States District Court for the Southern District of Florida. (Doc. 1). On October 16, 2017, pursuant to Halifax's motion, the case was transferred to this Court.
In Count I of the Complaint, MSPAC asserts a claim under 42 U.S.C. § 1395y(b)(3)(A), the Medicare Secondary Payer ("MSP") Act's private cause of action, alleging that Halifax violated the Act by failing to reimburse it within 60 days of FHPI's payment. (Complaint at 26). MSPAC seeks to recover double the amount that it was entitled to receive in reimbursement-i.e. , $20,000-subject to a setoff for the $9,750 eventually paid by Halifax. (Complaint at 27). Based on these same allegations, MSPAC also asserts a claim under the Florida Deceptive and Unfair Trade Practices Act ("FDUTPA"),
II. Legal Standards
A. Motions to Dismiss
Federal Rule of Civil Procedure 8(a)(2) requires "a short and plain statement of the claim showing that the pleader is entitled to relief" so as to give the defendant fair notice of what the claim is and the grounds upon which it rests, Conley v. Gibson ,
The plaintiff must provide enough factual allegations to raise a right to relief above the speculative level, Twombly,
In Ashcroft v. Iqbal ,
B. Medicare as Secondary Payer
Originally, Medicare paid for all medical treatment within its scope and left private insurers to pick up whatever expenses remained. See Humana Medical Plan, Inc. v. Western Heritage Insurance Company ,
To accomplish this, 42 U.S.C. § 1395y(b)(2)(A) forbids Medicare from making payments-with one exception-for any item or service when payment has been made (or can reasonably be expected to be made) by another form of insurance, such as a group health plan, worker's compensation law, or automobile insurance. (These other forms of insurance are referred to as "primary plans." 42 U.S.C. § 1395y(b)(2)(A).) The one exception is found in 42 U.S.C. § 1395y(b)(2)(B), which authorizes Medicare to make a "conditional payment" if a primary plan "has not made or cannot reasonably be expected to make payment with respect to such item or service promptly". Any such payments are "conditioned on reimbursement" to Medicare. 42 U.S.C. § 1395y(b)(2)(B)(i). A primary plan-and an entity that receives payment from a primary plan-must reimburse Medicare for any conditional payment "if it is demonstrated that such primary plan has or had a responsibility to make payment with respect to such item or service." 42 U.S.C. § 1395y(b)(2)(B)(i).
To facilitate recovery of conditional payments, the MSP provides for a government action against any entity that was responsible for payment under a primary plan, 42 U.S.C. § 1395y(b)(2)(B)(iii), and subrogates the United States to the rights of a Medicare beneficiary to collect payment under a primary plan for items already paid by Medicare, § 1395y(b)(2)(B)(iv). The MSP also creates a private right of action with double recovery to encourage private *1339parties who are aware of non-payment by primary plans to bring actions to enforce Medicare's rights. See § 1395y(b)(3)(A).
Glover v. Liggett Group, Inc. ,
C. MAOs
Parts A and B of the Medicare Act are fee-for-service provisions that entitle eligible persons to have the Center for Medicare and Medicaid Services ("CMS") directly pay medical providers for their hospital and outpatient care. Under Part C-the Medicare Advantage program-Medicare-eligible individuals may elect to have an MAO (rather than CMS) provide Medicare benefits. See Western Heritage at 1235,. An MAO is a private insurance company that administers the provision of Medicare benefits pursuant to a contract with CMS.
III. Analysis
A. Count I
A provision of Medicare Part C titled "Organization as secondary payer" provides that
Notwithstanding any other provision of law, a Medicare [Advantage] organization may (in the case of the provision of items and services to an individual under a Medicare [Advantage] plan under circumstances in which payment under this subchapter is made secondary pursuant to section 1395y(b)(2) of this title) charge or authorize the provider of such services to charge, in accordance with the charges allowed under a law, plan, or policy described in such section-
(A) the insurance carrier, employer, or other entity which under such law, plan, or policy is to pay for the provision of such services, or
(B) such individual to the extent that the individual has been paid under such law, plan, or policy for such services
42 U.S.C. § 1395w-22(a)(4). Some MAOs have argued that this provision creates an implied federal cause of action to recover secondary payments, but courts have repeatedly rejected this argument. See Western Heritage ,
In Western Heritage , however, the United States Court of Appeals for the Eleventh Circuit held that MAOs may sue under the MSP Act's private cause of action, 42 U.S.C. § 1395y(b)(3)(A), which provides as follows:
There is established a private cause of action for damages (which shall be in an amount double the amount otherwise provided) in the case of a primary plan which fails to provide for primary payment (or appropriate reimbursement) in accordance with paragraphs (1) and (2)(A).
In Count I, MSPAC asserts a double-damages claim under the MSP private cause of action. Halifax seeks dismissal on the grounds that MSPAC can only proceed under 42 U.S.C. § 1395y(b)(3)(A) against a primary plan, not a provider such as Halifax.
B. Preemption
Halifax argues that MSPAC's state law claims for reimbursement in counts II and III are preempted because the MSP Act governs the reimbursement of overpayments. (Doc. 16 at 20). However, Halifax does not cite to any case law so holding
C. Count II-FDUTPA
FDUTPA creates a private right of action for "[u]nfair methods of competition, unconscionable acts or practices, and unfair or deceptive acts or practices in the conduct of any trade or commerce."
the advertising, soliciting, providing, offering, or distributing, whether by *1341sale, rental, or otherwise, of any good or service, or any property, whether tangible or intangible, or any other article, commodity, or thing of value, wherever situated. "Trade or commerce" shall include the conduct of any trade or commerce, however denominated, including any nonprofit or not-for-profit person or activity.
In response, MSPAC cites to cases holding that a defendant's improper billing practices can constitute trade or commerce under the Act. See Alhassid v. Bank of America, N.A.,
In the instant case, the Plaintiff has alleged that Halifax double billed FHPI and 21st Century for the services provided-as opposed to, for example, an allegation that Halifax engaged in improper practices while attempting to collect someone else's debt. As such, the Court finds that Halifax's alleged conduct falls within the FDUTPA definition of "trade or commerce." The motion will be denied as to Count II.
D. Count III-Unjust Enrichment
The elements of a claim for unjust enrichment under Florida law are: (1) the plaintiff conferred a benefit on the defendant, who had knowledge of the benefit; (2) the defendant accepted and retained the benefit; and (3) under the circumstances it would be inequitable for the defendant to retain the benefit without paying for it. Duncan v. Kasim, Inc. ,
In Flint v. ABB, Inc. ,
An unjust enrichment occurs when the defendant holds something that belongs to the plaintiff or receives, without legal cause, a transfer of goods or services from the plaintiff. The law of unjust enrichment is concerned solely with enrichments that are unjust independently of wrongs and contracts. When the plaintiff relies on a breach of contract to supply the "unjustness" of the defendant's holdings, the right on which he or she relies arises from the breach of contract, not from an unjust enrichment; analogously, when the plaintiff relies on a wrong to supply the "unjust factor," the causative event is a wrongful enrichment rather than an unjust enrichment. See Peter Birks, Unjust Enrichment and Wrongful Enrichment ,79 Texas L.Rev. 1767 , 1783 (2001).
*1342
MSPAC responds that Flint , Tenet Healthcare , and the other cases cited by Halifax are "based exclusively on a single Texas law review article lacking any foundation in Florida law." (Doc. 29 at 13). MSPAC is only partially correct. The cases cited by Halifax do indeed rely on the Birks article (or on cases that rely on it). However, while that article was published in a Texas law review, it is national in scope, citing to various Restatements and to English civil law, not decisions of Texas courts. See
With that said, this Court previously declined to recognize the distinction between unjust and wrongful enrichment on the grounds that no Florida court has ever done so. See State Farm Fire & Cas. Co. v. Silver Star Health and Rehab, Inc. ,
As noted above, MSPAC alleges that Halifax billed and received payment from both FHPI and from 21st Century for the treatment provided to FHPI's enrollee. (Complaint at 18). MSPAC never explicitly alleges that Halifax billed FHPI for the entire cost of the treatment even after 21st Century paid the first $10,000. In analyzing whether MSPAC stated a claim under FDUTPA, which requires unfair or deceptive conduct, the Court drew an inference from these allegations that FHPI was a victim of double billing. However, in the absence of that inference, MSPAC's allegations can be read as simply asserting that FHPI made a mistaken overpayment for which Halifax has refused to make a full reimbursement. Such allegations state a claim for unjust enrichment.
Accordingly the motion will be denied as to Count III.
IV. Conclusion
In consideration of the foregoing, it is hereby
ORDERED that the Motion to Dismiss (Doc. 16) is GRANTED IN PART AND DENIED IN PART . Count I is DISMISSED WITH PREJUDICE . In all other respects, the motion is DENIED.
DONE and ORDERED in Chambers, Orlando, Florida on March 2, 2018.
Although the case caption reads "Halifax Health, Inc.", the Defendant contends (and the Plaintiff does not dispute) that its correct name is "Halifax Hospital Medical Center d/b/a Halifax Health." (Doc. 16 at 1)
Halifax retained $250 as an "administrative fee" and continues to do so despite a demand from MSPAC. (Complaint at 18).
Halifax also challenges MSPAC's entitlement to maintain this matter as a class action. The Court declines to consider these arguments at this stage of the proceedings. In addition, Halifax raises, in its reply, an argument that MSPAC was not assigned the state law claims it asserts in counts II and III, and therefore it lacks standing. (Doc. 34 at 9). Because MSPAC has not had an opportunity to address this argument, the Court will not consider it in this opinion.
Halifax describes the issue as one of standing-i.e., that MSPAC lacks standing to raise a claim under this cause of action. (Doc. 16 at 10). But the doctrine of standing focuses on the injury suffered by the plaintiff rather than the identity of the defendant. See, e.g., Lujan v. Defenders of Wildlife ,
In the alternative, Halifax had argued that FHPI's $10,000 overpayment was not a conditional payment, and therefore was not one for which a remedy would be available under the MSP Act, because that act bars MAOs from making payments where "payment has been made or can reasonably be expected to be made" by a primary payer such as 21st Century-which, in this case, had already paid the $10,000. Because the Court concludes that MSPAC cannot proceed under its chosen cause of action in Count I, it does not reach this argument.
Halifax cites to Western Heritage for this proposition, but the passage it cites to is merely a recitation of the proceedings in an earlier state court case addressing a different issue. Id. at 1232. The Western Heritage court did not itself address preemption. Halifax also cites to United States v. Rhode Island Insurers' Insolvency Fund ,
Reference
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- MSPA CLAIMS 1, LLC v. HALIFAX HEALTH, INC
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