Grider v. Keystone Health Plan

CourtCourt of Appeals for the Third Circuit
DecidedAugust 28, 2007
Docket07-1231
StatusPublished

This text of Grider v. Keystone Health Plan (Grider v. Keystone Health Plan) is published on Counsel Stack Legal Research, covering Court of Appeals for the Third Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Grider v. Keystone Health Plan, (3d Cir. 2007).

Opinion

Opinions of the United 2007 Decisions States Court of Appeals for the Third Circuit

8-28-2007

Grider v. Keystone Health Plan Precedential or Non-Precedential: Precedential

Docket No. 07-1231

Follow this and additional works at: http://digitalcommons.law.villanova.edu/thirdcircuit_2007

Recommended Citation "Grider v. Keystone Health Plan" (2007). 2007 Decisions. Paper 483. http://digitalcommons.law.villanova.edu/thirdcircuit_2007/483

This decision is brought to you for free and open access by the Opinions of the United States Court of Appeals for the Third Circuit at Villanova University School of Law Digital Repository. It has been accepted for inclusion in 2007 Decisions by an authorized administrator of Villanova University School of Law Digital Repository. For more information, please contact Benjamin.Carlson@law.villanova.edu. PRECEDENTIAL

UNITED STATES COURT OF APPEALS FOR THE THIRD CIRCUIT

Nos. 07-1231, 07-1232 and 07-1270

NATALIE M. GRIDER, M.D.; KUTZTOWN FAMILY MEDICINE, P.C.

v.

KEYSTONE HEALTH PLAN CENTRAL, INC.; THOMAS F. BICKMAN; HIGHMARK, INC.; JOHN S. BROUSE; CAPITAL BLUECROSS; JAMES M. MEAD; JOSEPH PFISTER

Keystone Health Plan Central, Inc.; Capital BlueCross; James M. Mead; Joseph Pfister, Appellants, No. 07-1231

Highmark, Inc.; John S. Brouse, Appellants, No. 07-1232

*CROWELL MORING LLP; KATHLEEN TAYLOR SOOY; MICHAEL L. MARTINEZ, Appellants, No. 07-1270 (*Pursuant to F.R.A.P. 12(a)) On Appeal from the United States District Court for the Eastern District of Pennsylvania (D.C. No. 01-cv-05641) District Judge: Honorable James Knoll Gardner

Argued June 19, 2007 Before: McKEE, FISHER and CHAGARES, Circuit Judges.

(Filed: August 28, 2007)

Malcolm J. Gross Gross, McGinley, LaBarre & Eaton 33 South 7th Street P.O. Box 4060 Allentown, PA 18105

Kathleen T. Sooy (Argued) Clifton S. Elgarten Tracy A. Roman Crowell & Moring 1001 Pennsylvania Avenue, N.W. Washington, DC 20004-2505 Attorneys for Appellants (No. 07-1231), Keystone Health Plan Central, Inc., Capital BlueCross, James M. Mead and Joseph Pfister

2 Daniel I. Booker Donna M. Doblick James C. Martin (Argued) Reed Smith 435 Sixth Avenue Pittsburgh, PA 15219

Sandra A. Girifalco Stradley, Ronon, Stevens & Young 2600 One Commerce Square Philadelphia, PA 19103 Attorneys for Appellants (No. 07-1232), Highmark, Inc. and John S. Brouse

Clifton S. Elgarten Tracy A. Roman Crowell & Moring 1001 Pennsylvania Avenue, N.W. Washington, DC 20004-2505 Attorneys for Appellants (No. 07-1270), Crowell Moring LLP, Kathleen Taylor Sooy and Michael L. Martinez

Louis C. Bechtle Conrad, O’Brien, Gellman & Rohn 1515 Market Street, 16th Floor Philadelphia, PA 19102

3 Joseph A. O’Keefe O’Keefe & Sher 15019 Kutztown Road Kutztown, PA 19530

Francis J. Farina 577 Gregory Lane Devon, PA 19333

Kenneth A. Jacobsen (Argued) 12 Orchard Lane Wallingford, PA 19086 Attorneys for Appellees, Natalie M. Grider, M.D., and Kutztown Family Medicine, P.C.

OPINION OF THE COURT

FISHER, Circuit Judge.

This appeal requires us to explore the limits of the All Writs Act, 28 U.S.C. § 1651(a), as it relates to actions by one federal court that may affect those in a different federal court. Specifically, in this case, Dr. Natalie Grider and Kutztown Family Medicine P.C., representing a class of approximately 6,000 doctors in Central Pennsylvania, filed a suit against Keystone Health Plan Central, Inc. (“Keystone”); Keystone’s two former fifty-percent owners, Highmark, Inc. (“Highmark”)

4 and Capital Blue Cross (“Capital”); and each company’s chief executive officer, Joseph Pfister, John Brouse, and James Mead. The suit alleges that Keystone’s claims handling practices violated the Racketeer Influenced and Corrupt Organizations Act (“RICO”), 18 U.S.C. §§ 1961 - 1968, and Pennsylvania’s “prompt pay” statute, 40 Pa. Stat. §§ 991.2101 ! 991.2193. Around that time, similar nationwide claims were consolidated by a Multidistrict Litigation (“MDL”) panel in the United States District Court for the Southern District of Florida (“Florida MDL”), which declined to add the Grider case as an tag-along action because it was at a more advanced stage in its proceedings. Recently, however, as the parties in the Florida MDL moved towards a comprehensive settlement agreement, the United States District Court for the Eastern District of Pennsylvania issued an injunction under the All Writs Act prohibiting the Grider Defendants from settling or attempting to settle claims in the Florida MDL that would have the effect of also settling the claims in Grider. The question presented to us is whether this is a permissible exercise of power under the All Writs Act. For the reasons that follow, we conclude that it is not, and we will therefore vacate the injunction issued by the District Court.

I.

A. The Grider Case

This case involves a certified class of approximately 6,000 doctors in Central Pennsylvania who were providers with the Keystone health maintenance organization (“HMO”), which operates exclusively in Central Pennsylvania. These doctors had

5 signed contracts with Keystone to provide medical services to patients who subscribed to the Keystone HMO. To receive reimbursement for services they provided to subscribers, the doctors submitted claims on forms provided by Keystone, using a standardized set of numerical codes provided by the American Medical Association, which are referred to as “CPT codes.” These codes are provided for virtually every medical procedure in order to avoid variations in descriptions given by doctors. Because each code only represents a single procedure, one visit to a doctor may result in a reimbursement claim containing multiple CPT codes. A typical claim form, for instance, may have one code for the office visit itself, and another for the administration of a particular test.

During the class period certified by the District Court, when a doctor within Keystone’s network submitted one of these claim forms, it was processed through a company named Synertech, Inc. (“Synertech”). Synertech is located in Central Pennsylvania, and used a proprietary software system owned by Tingley, Inc. to process these claims.

In addition to being reimbursed on a fee-for-service basis, many doctors in Keystone’s network also received reimbursements for certain pools of patients ! usually employees of a large employer ! under contractual “capitation” arrangements with Keystone. Approximately 28% of the certified class members in this case are family practice providers, most of whom were under contractual capitation arrangements with Keystone. Under these capitation agreements, doctors are paid a set monthly fee in exchange for providing basic medical services ! such as examinations and

6 treatment for minor illnesses ! to a pool of patients. More complicated medical procedures not on the list of capitation services are supposed to be billed to Keystone and paid on a fee- for-service basis.

On October 5, 2001, the Plaintiffs in this case filed an action in Pennsylvania state court, which the Defendants promptly removed to the United States District Court for the Eastern District of Pennsylvania. The suit alleges that Keystone violated RICO by not processing and paying claims as it had promised to do in its contracts and other communications with the doctors in its network.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Klay v. United Healthgroup, Inc.
376 F.3d 1092 (Eleventh Circuit, 2004)
State of Alabama v. U.S. Army Corps of Engineers
424 F.3d 1117 (Eleventh Circuit, 2005)
Kline v. Burke Construction Co.
260 U.S. 226 (Supreme Court, 1922)
Vendo Co. v. Lektro-Vend Corp.
433 U.S. 623 (Supreme Court, 1977)
Crosley Corporation v. Hazeltine Corporation
122 F.2d 925 (Third Circuit, 1941)
In Re Managed Care Litigation
236 F. Supp. 2d 1336 (S.D. Florida, 2002)
In Re Lease Oil Antitrust Litigation No. II
48 F. Supp. 2d 699 (S.D. Texas, 1998)
Carlough v. Amchem Products, Inc.
10 F.3d 189 (Third Circuit, 1993)
In re Baldwin-United Corp.
770 F.2d 328 (Second Circuit, 1985)
Reiter v. Sonotone Corp.
442 U.S. 330 (Supreme Court, 1979)

Cite This Page — Counsel Stack

Bluebook (online)
Grider v. Keystone Health Plan, Counsel Stack Legal Research, https://law.counselstack.com/opinion/grider-v-keystone-health-plan-ca3-2007.