Fisher v. Blue Cross & Blue Shield

879 F. Supp. 2d 581, 2012 WL 2922723, 2012 U.S. Dist. LEXIS 99521
CourtDistrict Court, N.D. Texas
DecidedJuly 17, 2012
DocketCivil Action No. 3:10-CV-2652-L
StatusPublished

This text of 879 F. Supp. 2d 581 (Fisher v. Blue Cross & Blue Shield) is published on Counsel Stack Legal Research, covering District Court, N.D. Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Fisher v. Blue Cross & Blue Shield, 879 F. Supp. 2d 581, 2012 WL 2922723, 2012 U.S. Dist. LEXIS 99521 (N.D. Tex. 2012).

Opinion

MEMORANDUM OPINION AND ORDER

SAM A. LINDSAY, District Judge.

Before the court is Plaintiffs[’]/Counter Defendants’ Motion for Partial Dismissal of Counterclaims, filed October 12, 2011. After carefully considering the motion, response, reply, record, and applicable law, the court grants in part and denies in part Plaintiffs[’]/Counter Defendants’ Motion for Partial Dismissal of Counterclaims.

I. Factual and Procedural Background

Plaintiffs Neil L. Fisher, M.D., doing business as Paragon Anesthesia Associates, P.A. (“PAA”); Paragon Office Services, LLC (“POS”); Paragon Ambulatory Health Resources, LLC (“PAHS”); Paragon Ambulatory Physician Services, LLC (“PAPS”); and Office Surgery Support Services, LLC (“OSS”) (collectively, “Plaintiffs” or “Paragon”) filed a civil action against Defendant Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (“Defendant” or “BCBSTX”) on November 17, 2010, in the 298th Judicial District Court for Dallas County, Texas. Defendant removed the state court action to this court on December 30, 2010, alleging that diversity of citizenship exists between the parties and that the amount in controversy exceeds $75,000, exclusive of costs and interest.

The court sets forth the background facts as asserted in Plaintiffs’ Second Amended Complaint (“Complaint”) and Defendant’s Answer to Plaintiffs’ Second Amended Complaint, Third Party Complaint, Counterclaims, and Request for Declaratory Judgment (“Answer”).1 Plaintiffs provide anesthesia services to obstetricians and gynecologists who perform in-office surgeries, such as endometrial ablations, which are procedures to remove or destroy the inner lining of the uterus. Compl. ¶ 9. PAA entered into a Group Managed Care Agreement that expressly provides for the payment of professional anesthesia services furnished by an anesthesiologist.2 Compl. ¶ 12. Plaintiffs assert that PAPS entered into Par-Plan provider agreements with Defendant [585]*585and that POS, PAHS, and OSS have implied contracts with BCBSTX for the payment of professional anesthesia and equipment services. Id. Plaintiffs allege that since 2004, Defendant has paid Paragon for anesthesia services, but beginning in July 2010, it began to: (1) deny further payments to Paragon, and (2) recoup amounts previously paid to Paragon. Compl. ¶ 14. Plaintiffs contend that in July 2010, the Blue Cross Special Investigations Department conducted an evaluation of services furnished by Paragon from January 1, 2004, through June 30, 2010, and since the evaluation, Defendant has violated the parties’ express and implied contracts and state law by, inter alia, (1) refusing to pay for services and retaining money that Defendant had already received for such services, and (2) demanding return of monies paid to Paragon. Compl. ¶ 15. Paragon asserts that there is no dispute that their anesthesia services are covered services or that BCBSTX has received money from its insureds to pay for those services. Compl. ¶ 13. Paragon contends that they are not challenging Defendant’s benefits determination or the scope of any plan’s coverage. Compl. ¶ 13. Plaintiffs argue that they are entitled to collect for the professional anesthesia services they provided based on the parties’ agreements, their course of dealing, and Defendant’s past payments for such services. Compl. ¶ 12.

Defendant contends that its agreement with PAA was such that PAA was allowed to direct bill the anesthesiology services provided to surgeons and patients in “non-facility settings,” that is, the offices of the surgeons. Answer ¶¶ 96, 98. Physicians were also allowed to direct bill their services and the use of their office “non-facility settings” under their own agreements, if any, with BCBSTX. Answer ¶ 97. Defendant asserts that PAA provided in-network services in “non-facility settings” for surgeons and patients and billed BCBSTX directly for them, and PAHR provided those services out-of-network3 and billed BCBSTX directly for them. Answer ¶ 99. Defendant contends that POS, PAPS, and OSS provided similar services as PAA and PAHR.

Defendant contends that at all times relevant to this lawsuit it maintained a requirement, set forth in a manual or policy titled “Surgical Procedures Performed in the Physician’s and Other Professional Provider’s Office” (“Provider Manual”), that a provider not bill for the services, supplies, and equipment, which are considered the “technical component” rather that the “professional component” of an anesthesiologist’s work. Answer ¶ 100. Defendant states that as an in-network provider, PAA was permitted to bill BCBSTX directly for the professional component of the anesthesiologist’s services, that is, the anesthesiologist’s time; however, all other “services, supplies, and equipment” (the technical component) could not be billed directly to BCBSTX. Answer ¶ 103. BCBSTX maintains that Plaintiffs were required to follow this Provider Manual requirement in submitting their bills, and Plaintiffs ignored and violated this requirement by independently billing BCBSTX for items such as nursing and preparation assistance, supplies, and equipment. Answer ¶ 105. As a result, BCBSTX asserts that it inadvertently paid Plaintiffs for services and “non-facility setting” costs to which they were not entitled due to Plaintiffs’ inclusion of billing codes for physician services, technical services, and “non-facility setting” costs in their direct billing.

[586]*586The crux of Plaintiffs’ claims is that they were denied payment for anesthesia services and equipment provided to BCBSTX’s insureds. Conversely, Defendant alleges that Plaintiffs were overpaid for anesthesia services due to the improper manner in which they submitted claims to BCBSTX. Plaintiffs move pursuant to Federal Rules of Civil Procedure 12(b)(1), 12(b)(6), and 12(b)(7) to dismiss BCBSTX’s claims under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq., and its declaratory judgment claim.

II. Legal Standards

A. Rule 12(b)(1) — Lack of Subject Matter Jurisdiction

A federal court has subject matter jurisdiction over civil cases “arising under the Constitution, laws, or treaties of the United States,” or over civil cases in which the amount in controversy exceeds $75,000, exclusive of interest and costs, and in which diversity of citizenship exists between the parties. 28 U.S.C. §§ 1381, 1332. Federal courts are courts of limited jurisdiction and must have statutory or constitutional power to adjudicate a claim. See Home Builders Ass’n of Mississippi, Inc. v. City of Madison, 143 F.3d 1006, 1010 (5th Cir. 1998). Absent jurisdiction conferred by statute or the Constitution, they lack the power to adjudicate claims and must dismiss an action if subject matter jurisdiction is lacking. Id.; Stockman v. Federal Election Comm’n, 138 F.3d 144, 151 (5th Cir.1998) (citing Veldhoen v. United States Coast Guard, 35 F.3d 222

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Bluebook (online)
879 F. Supp. 2d 581, 2012 WL 2922723, 2012 U.S. Dist. LEXIS 99521, Counsel Stack Legal Research, https://law.counselstack.com/opinion/fisher-v-blue-cross-blue-shield-txnd-2012.