Baptist Hosp. of Miami, Inc. v. Medica Healthcare Plans, Inc.

376 F. Supp. 3d 1298
CourtDistrict Court, S.D. Florida
DecidedApril 29, 2019
DocketCase No. 18-cv-25460-UU
StatusPublished
Cited by5 cases

This text of 376 F. Supp. 3d 1298 (Baptist Hosp. of Miami, Inc. v. Medica Healthcare Plans, Inc.) is published on Counsel Stack Legal Research, covering District Court, S.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Baptist Hosp. of Miami, Inc. v. Medica Healthcare Plans, Inc., 376 F. Supp. 3d 1298 (S.D. Fla. 2019).

Opinion

Ursula Ungaro

THIS CAUSE comes before the Court upon the Report and Recommendation, issued by Magistrate Judge John O'Sullivan on March 26, 2019 (D.E. 39). Judge O'Sullivan recommended that the Court deny Defendant Medica Healthcare Plans, Inc.'s Motion to Compel Arbitration and Stay the Litigation (D.E. 9).

The Parties' objections to the Report were due by April 9, 2019, and neither party has filed objections. See LoConte v. Dugger , 847 F.2d 745 (11th Cir. 1988), cert. denied , 488 U.S. 958, 109 S.Ct. 397, 102 L.Ed.2d 386 (1988) (holding that failure to file timely objections bars the parties from attacking factual findings on appeal). The matter is thus ripe for disposition.

THIS COURT has made a de novo review of the entire file and record herein, and, being otherwise fully advised in the premises, it is hereby

ORDERED and ADJUDGED that the Magistrate Judge O'Sullivan's Report and Recommendation, (D.E. 39), is RATIFIED, AFFIRMED and ADOPTED. Defendant Medica Healthcare Plans, Inc.'s Motion to Compel Arbitration and Stay the Litigation (D.E. 9) is DENIED. It is further

ORDERED AND ADJUDGED that Defendant Medica Healthcare Plans, Inc. SHALL file its Answer to the Complaint no later than Wednesday, May 8, 2019 .

DONE AND ORDERED in Chambers at Miami, Florida, this 29th day of April, 2019.

REPORT AND RECOMMENDATION

JOHN J. O'SULLIVAN, CHIEF UNITED STATES MAGISTRATE JUDGE

THIS MATTER comes before the Court on the defendant, Medica Healthcare Plans, Inc.s' Motion to Compel Arbitration and Stay the Litigation (DE# 9, 1/4/19). This matter was referred to the undersigned *1301by the Honorable Ursula Ungaro, United States District Judge for the Southern District of Florida (DE# 14, 1/8/19). Having carefully considered the motion, the Plaintiffs' Response in Opposition to Defendant's Motion to Compel Arbitration [D.E. 9] (DE# 18, 1/18/19) and the defendant Medica Healthcare Plans, Inc's Reply in Support of Motion to Compel Arbitration and Stay the Litigation, the parties' exhibits, the court file and the applicable law, the undersigned recommends that the defendant Medica Healthcare Plans, Inc.s' Motion to Compel Arbitration and Stay the Litigation (DE# 9, 1/4/19) be DENIED.

I. INTRODUCTION

The plaintiffs, Baptist Hospital of Miami, Inc., South Miami Hospital, Inc., Doctors Hospital, Inc., Homestead Hospital, Inc., and West Kendall Hospital, Inc. (collectively "plaintiffs" or "Baptist Hospitals") filed an action in state court against the defendant to recover more than $ 800,000 for alleged medically necessary and covered services provided to Medicare beneficiaries enrolled in Medica's Medicare Advantage plans ("Medica Members") between January 2017 and January 2018 pursuant to the Medical Hospital Provider Agreement with an effective date of January 1, 2005 between the defendant and the plaintiff hospitals ("2005 Medica Hospital Provider Agreement"). The plaintiffs allege four counts in their complaint: 1) breach of contract (Count I), unjust enrichment/breach of implied-in-law contract (Count II), promissory estoppel (Count III), and claim for benefits under contract by assignee (Count IV).

The defendant, Medica Healthcare Plans, Inc. ("defendant" or "Medica") removed the action to federal court pursuant to the Federal Officer Statute because Medica claims it was acting on behalf of the Centers for Medicare and Medicaid Services as a Medicare Advantage Organization ("MAO") and that the Court has supplemental jurisdiction over any related state law claims.

The defendant argues that the plaintiffs' claims are subject to mandatory arbitration pursuant to a provision in the 2005 Medical Hospital Provider Agreement that requires the plaintiffs to comply with any manuals or publications maintained by Medica, as amended and revised from time to time. Medica contends that the current and operative manual that applies to contracted providers for members of Medicare Advantage plans generally, and Medica Members specifically, is the 2018 UnitedHealthcare Care Provider Administrative Guide (the "2018 UHC Provider Guide") which contains an arbitration provision. Baptist Hospital maintains that the operative manual for its claims is the 2017 UHC Provider Guide, which does not contain an arbitration provision, because Baptist Hospitals' claims pre-date the April 1, 2018 effective date of the 2018 UHC Provider Guide.

Baptist Hospitals oppose arbitration on three grounds: 1) the 2005 Medica Hospital Provider Agreement does not contain an arbitration provision; 2) the 2018 UHC Provider Guide is an unenforceable modification to the 2005 Medica Hospital Provider Agreement; and 3) the 2018 UHC Provider Guide does not cover the benefit claims at issue because Baptist Hospitals' claims predate its effective date of April 1, 2018 and the 2017 UCH Provider Guide does not contain an arbitration provision.

II. FACTUAL BACKGROUND

In its Complaint that was filed in state court on November 14, 2018, Baptist Hospitals seek payment for denied benefit claims for services provided to Medicare beneficiaries pursuant to the 2005 Medica *1302Hospital Provider Agreement with Medica. Baptist Hospitals allege that the 2005 Medica Hospital Provider Agreement "obligated Medica to 'compensate [the Hospitals] for [Covered] Services furnished to [Medica's] members pursuant to this agreement and the rates and charges set forth [in it]." Complaint at ¶ 8 (DE# 1-1, 12/28/18). Baptist Hospitals seek to recover approximately $ 800,000 for claims between January 2017 and January 2018 for the alleged medically necessary and covered services provided to Medica Members. See Complaint at ¶¶ 13-101 (DE# 1-1, 12/28/18).

It is undisputed that the 2005 Medica Hospital Provider Agreement does not contain an arbitration provision. See Motion at 5 (DE# 9, 1/4/19). Medica relies on Section 3.2 of the 2005 Medica Hospital Provider Agreement, which implicitly incorporates the definition of "Hospital Manual" found in Section 1.24, and states:

3.2 Cooperation and Compliance. Provider agrees to use commercially reasonable efforts to cooperate with Plan's policies and procedures, including, without limitation, the Hospital Manual, the Peer Review/Quality Management Program, the Quality Assurance and Utilization Management Program.

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376 F. Supp. 3d 1298, Counsel Stack Legal Research, https://law.counselstack.com/opinion/baptist-hosp-of-miami-inc-v-medica-healthcare-plans-inc-flsd-2019.