Guardsmark, Inc. v. Blue Cross & Blue Shield of Tennessee

206 F.R.D. 202, 2002 U.S. Dist. LEXIS 3614, 2002 WL 378067
CourtDistrict Court, W.D. Tennessee
DecidedFebruary 21, 2002
DocketNo. 01-2117-D/A
StatusPublished
Cited by14 cases

This text of 206 F.R.D. 202 (Guardsmark, Inc. v. Blue Cross & Blue Shield of Tennessee) is published on Counsel Stack Legal Research, covering District Court, W.D. Tennessee primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Guardsmark, Inc. v. Blue Cross & Blue Shield of Tennessee, 206 F.R.D. 202, 2002 U.S. Dist. LEXIS 3614, 2002 WL 378067 (W.D. Tenn. 2002).

Opinion

[204]*204ORDER GRANTING DEFENDANT’S MOTION TO COMPEL PLAINTIFFS TO PRODUCE AUDIT FINDINGS, REPORTS, AND RELATED AUDIT INFORMATION

ALLEN, United States Magistrate Judge.

Before the court is the motion by defendant herein for an order compelling plaintiffs to produce audit findings, reports and related audit information prepared by Watson Wyatt & Company, Brown & Nelson, Insurance Claims Auditing and Professional Services, Plaintiffs and any other persons who have audited Blue Cross’ administration of Plaintiffs’ health plan. For the reasons hereinafter set forth, defendant’s motion is GRANTED.

Placing This Dispute in Context

Plaintiff Guardsmark, Inc. (“Guardsmark”) is a large national corporation, apparently with its headquarters in Memphis, Tennessee, and has at least 6,800 employees (Complaint, p. 10). On or about February 12, 1996, Guardsmark (desiring'to provide group medical insurance for its employees, and seeking to comply with the provisions of 29 U.S.C. §§ 1001, et seq., known as “ERISA” 1 ), entered into an “Agreement to Provide Certain Administrative Services Only” (“Agreement”) with Memphis Hospital Service and Surgical Association, Inc. Briefly, the agreement would establish a group medical insurance plan for Guardsmark’s employees, which plan Memphis Hospital Service and Surgical Association, Inc. would, for a fee, administer. Guardsmark would be responsible for the payment of the medical bills of such employee members (Agreement, Exh. A to Complaint). Memphis Hospital Service and Surgical Association, Inc. would actually pay the claims, and then submit monthly reports thereof, providing the basis by which it would be reimbursed by Guardsmark, and by which it would receive payment for its services. Ultimately defendant Blue Cross and Blue Shield of Tennessee assumed all of the rights, duties, obligations, and liabilities of Memphis Hospital Service and Surgical Association, Inc., as it relates to the agreement with Guardsmark. Defendant will hereafter be referred to as “Administrator”.

According to Guardsmark, it “experienced significant problems with (the Administrator’s) administration of the (Agreement), which became more evident as problems arose in 1998 and 1999” (Complaint, p. 7). These problems, or “deficiencies” resulted in Guardsmark’s termination of the Agreement, effective on October 31, 1999 (Complaint, p. 7). There was, pursuant to the terms of the Agreement, a - “run-out” period, lasting through January 31, 2000, during which the Administrator was to “provide the continuation of claims administration ... for claims incurred prior to the cancellation date for a period of three months, and any claims administrative services associated with continuation of group health care benefits” (Agreement, Section 9).

According to the Agreement, the Administrator was obligated to, among other things:

“P. Upon reasonable notice, permit and cooperate with, (sic) the Employer to accomplish such audits (by third-party or in-house) of Administrator’s records (reasonable sample size) related to the reports provided pursuant to this Agreement, Administrator’s claims processing, discounts, credits/administrative fees, provider charges, covered charges, amounts paid, amount of service, non-covered amounts, savings, (sic)group net pay and discounts retained by Administrator, as Employer may reasonably require to discharge its duties, (sic) under ERISA, (sic) monitor Administrator’s performance hereunder, and (sic) respond to Employee and/or government inquiry.”

(Agreement, Sec. 2P).

According to the Complaint, there were numerous letters and conferences between Guardsmark and the Administrator (before and after the termination of the Agreement) regarding these “problems” or “deficiencies”. One such meeting apparently occurred sometime prior to August 16, 1999 (Ex. D and E to Complaint).

As previously indicated, Guardsmark, on October 31, 1999, terminated its Agreement [205]*205with defendant Administrator, but defendant Administrator was required, by the Agreement, to continue handling claims administration for the “run-out” period through January 31, 2000.

At some time prior to April 13, 2000, Guardsmark (through Milton J. Schachter, Assistant Vice President and Manager of Health Benefits Design)2 contacted Watson, Wyatt and Company (“Watson Wyatt”), an auditing firm with significant experience with medical claims audits (Affidavit of Laura Sy, Exh. B). On April 13, 2000, Ted Nussbaum (of Watson Wyatt)3 wrote a letter to Schachter, setting forth his company’s standard claims audit process, and alternative approaches to auditing the three years in question (prior to November 1, 1999)(Exh. B). Fees are quoted in this letter. Watson Wyatt’s capabilities are set forth, as well as a list of prior customers, and the educational background of Watson Wyatt’s management team. In short, this letter was a “sales pitch”. The purpose of this audit, as indicated in the letter, was to examine the accuracy and appropriateness of defendant’s claims payments, and (if errors were found) to confer with defendant in an effort to reach agreement (as to each error) “on the scene”, so to speak. It should be noted that the format of this proposed audit fits closely with the requirements of Section 2P of the Agreement. It should be further noted that nowhere in the Nussbaum letter is there any mention of any expressed need by Guards-mark to prepare for pending litigation, or to determine whether litigation was appropriate4.

On May 5, 2000, Gareth C. Levitón (General Counsel for Guardsmark) wrote Ms. Laura Sy (Regional Counsel for defendant Blue Cross-Blue Shield of Tennessee), indicating that Guardsmark had hired Watson Wyatt “to conduct an audit of claims processed and paid by Blue Cross Blue Shield of Tennessee on behalf of Guardsmark, Inc. and the Guardsmark, Inc. Medical Plan Trust Fund during the calendar years 1997, 1998, and 1999.” (Affidavit of Laura Sy, Ex. C). He indicated that Watson Wyatt would require “access to the paid claim files for their audit”, and requested that defendant provide Watson Wyatt with a computer tape (containing exhaustive information, listed in an attachment to the letter) of all claims paid in each of these three years. Leviton’s letter stated that he “expect[ed] your organization will assist them by making any and all necessary information available to them on a timely basis ... [and] ... look[ed] forward to Blue Cross’s complete cooperation with this matter”.

The clear inference to be drawn from this letter is that Guardsmark was relying on Section 2P of the old Agreement, the language of which could reasonably be interpreted as requiring cooperation by defendant (even though the Agreement had, by that time, technically been terminated). This inference is a reasonable one, in light of the context of the relationship between plaintiffs and defendant (involving the winding up of the previous contractual relationship and the final “settling up” of accounts). This inference is supported by the tenor of the letter from Ms. Jane L. Lassner (of Watson Wyatt) to Ms. Sondra Rawls, at defendant’s Memphis office, dated May 23, 2000, setting forth the details of the intended audit (Affidavit of Laura Sy, Exh. D).

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Bluebook (online)
206 F.R.D. 202, 2002 U.S. Dist. LEXIS 3614, 2002 WL 378067, Counsel Stack Legal Research, https://law.counselstack.com/opinion/guardsmark-inc-v-blue-cross-blue-shield-of-tennessee-tnwd-2002.