Health Alliance Network, Inc. v. Continental Casualty Co.

354 F. Supp. 2d 411, 2005 U.S. Dist. LEXIS 1588, 2005 WL 281155
CourtDistrict Court, S.D. New York
DecidedFebruary 1, 2005
Docket01 CIV.5858 (SCR)
StatusPublished
Cited by3 cases

This text of 354 F. Supp. 2d 411 (Health Alliance Network, Inc. v. Continental Casualty Co.) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Health Alliance Network, Inc. v. Continental Casualty Co., 354 F. Supp. 2d 411, 2005 U.S. Dist. LEXIS 1588, 2005 WL 281155 (S.D.N.Y. 2005).

Opinion

MEMORANDUM DECISION AND ORDER

ROBINSON, District Judge.

I. Introduction

a. Factual Background

The Health Aliance Network, Inc. (“HAN II”) and Qualeare, Inc. (“Qualeare”; HAN II and Qualeare are collectively referred to herein as “Plaintiffs”) brought this action against Continental Casualty Company (“CCC”) and the Continental Insurance Company (“CIC”; CCC and CIC are collectively referred to herein as “Defendants”), 1 alleging breach of contract, unjust enrichment, misuse of confidential information and unfair competition.

Health Aliance Network, Inc. (“HAN I”) was a broker of managed care health services based in White Plains, NY. QualCare, Inc. (“QualCare”) and Focus Healthcare Management, Inc. (“Focus”), both based in New Jersey, administered networks of healthcare providers. CCC and CIC are insurance companies having their headquarters in Chicago, Illinois. They are affiliates, and are among the group of insurance companies that use the service mark “CNA.” CNA, which includes two separate business units called RSKCo and Commercial Insurance, administer insurance benefit plans for injured workers.

This lawsuit arises from an October 1, 1995 agreement (“Agreement”) among CNA, HAN I and Qualeare. There are three basic elements to the Agreement: HAN I and QualCare afforded CNA’s insureds, and their employees, access to various networks of healthcare providers, which are known as “preferred provider organizations” or “PPOs,” in the state of New Jersey; the healthcare providers charged discounted rates for their services, resulting in savings for CNA, whose insurance policies were paying the services; and CNA paid HAN I a percentage of the savings realized by CNA. The Agreement called for using a .combination of providers under contract with both Qualeare and Focus (Focus and QualCare are collectively referred to herein as the “Network Providers”). 2

*414 Specifically, the Agreement effectively guarantees 3 HAN I twenty-one percent of the difference in savings between the usual and customary or state mandated fee schedule and the fee schedule recommended by the applicable network provider agreement. HAN I, in turn, was obligated to share the payments it received from CNA with both Focus and QualCare. The Agreement does not, however, obligate Defendants or any of their affiliates or subsidiaries to use the Network Providers and, in fact, expressly provides that it is not an exclusive dealing arrangement. The evidence indicates that CNA did use providers not part of the Focus or QualCare networks but, of course, to the extent the Defendants used the Network Providers, CNA was required to pay HAN I the appropriate fees.

For the purposes of implementing the Agreement, Defendants retained Community Care Networks, Inc. (“CCN”) as a service partner, giving it the responsibility of performing bill review services. 4 Specifically, CCN reviewed bills generated by the Network Providers in order to determine the savings generated and fees owed to HAN I. For the period December 1995 through September 1999, CCN prepared monthly reports, which it supplied to both CCC and HAN I, of all the bills that it processed. These reports contained, for each bill, the name of the patient, the name and tax identification number of the provider, the dates of service, the bill number, the provider’s total charges, the savings attributable to CCN’s bill review, the savings attributable to the network discounts, the amount payable to the provider, and the fees payable to HAN I. CCN also prepared cumulative reports of the bills it processed for the period October 1999 through January 2001.

CCN’s reports were the method chosen by the parties to inform HAN I of the use of its networks by CNA’s insureds and, as such, to determine the amount of fees HAN I was owed. HAN I had no independent information about how much network access had occurred and did not maintain records of its own to verify the information provided by CCN each month. This division of responsibility was consistent with the terms of the Agreement. Section XII (C) of the Agreement required CNA to provide HAN I and Qualcare with the information HAN I and Qualcare required in order to confirm fees owed to them. The Agreement also required that CNA retain the service partner charged with performing data collection and bill repricing services, which in this case turned out to be CCN. Final payments to HAN I of network access fees were made by individual CNA claims examiners administering individual workers’ compensation claims assigned to them. When a claims examiner received CCN’s bills, it had the responsibility of drafting checks and paying HAN I on a claim by claim basis.

In 1997, the Plaintiffs began to investigate whether they were receiving all the fees they were entitled to under the Agreement. Their concern was sparked by an apparent disparity between the network access fees due HAN I as reported by CCN and the invoice payment data from CNA that accompanied its check payments. CNA informed HAN I that, in order for CNA to make payments on unpaid fees, HAN I needed to identify specif *415 ic network access invoices which were unpaid. HAN I then proceeded to compare invoice listings from CCN against payment data received from CNA and produced a claim-by-claim listing of invoices they believed to have been unpaid.

Plaintiffs then sent to Defendants listings of invoices from October 1, 1995 until December 31, 1997 that they believed to have been unpaid. For invoices representing unpaid claims of $1000 or more, CNA responded by producing ‘summary sheets’ that set forth, inter alia, a breakdown between the amounts it believed it had already paid, the amounts it recognized were not paid to Plaintiffs, the amounts it had paid either HAN I or CCN or Focus, and the amounts which represented claims that had already been purged from CNA’s system. In at least some of the cases flagged by Plaintiffs, CNA did not specify whether certain payments had been made to HAN I or CCN or Focus. Defendants also failed to produce definitive conclusions for all invoices of unpaid claims between $100 and $1000 that were marked by Plaintiffs as unpaid. With respect to invoices that CNA acknowledged to have been unpaid, CNA paid some, but not all. Finally, with respect to invoices for claims less than $100, CNA produced no summary sheets.

The Agreement also included a “Confidentiality” clause. Specifically, CNA agreed to treat as confidential Plaintiffs’ manuals, policies, procedures, provider listings, programs, agreements and reimbursement rates. During the course of their investigation into possible unpaid fees, Plaintiffs received documents from the Defendants that suggested to them that Defendants had disclosed to CCN the identities of Plaintiffs’ network providers in order to assist CCN in recruiting additional providers in New Jersey for their own network of health care providers for workers compensation patients.

In 1998 and 1999, both RSKCo and Commercial Insurance decided to use a single, nationwide vendor for both network access and bill review services. HAN I and Qualcare, which could offer network access only in New Jersey, were not considered.

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

Related

Cite This Page — Counsel Stack

Bluebook (online)
354 F. Supp. 2d 411, 2005 U.S. Dist. LEXIS 1588, 2005 WL 281155, Counsel Stack Legal Research, https://law.counselstack.com/opinion/health-alliance-network-inc-v-continental-casualty-co-nysd-2005.