LD v. United Behavioral Health

District Court, N.D. California·Decided March 11, 2021·No. 4:20-cv-02254·Unknown

Opinion

CASE NO. 4:20-cv-02254 YGR ORDER DENYING MOTION TO DISMISS Plaintiffs, v. Re: Dkt. No. 75

UNITED BEHAVIORAL HEALTH, ET AL., Defendants.

Plaintiffs1 bring this putative class action against defendants United Behavioral Health (“United”) and MultiPlan, Inc. (“MultiPlan”) for claims arising out of United’s alleged failure to reimburse their claims for Intensive Outpatient Program (“IOP”) services at the Usual, Customary, and Reasonable Rate (“UCR”) that non-party Summit Estate, Inc. provided to plaintiffs. Plaintiffs allege that defendants’ conduct caused them injury, because it forced them to pay any amounts that United failed to reimburse for the IOP services. After the Court granted in part and denied in part defendants’ motions to dismiss the First Amended Complaint (“FAC”), with leave to amend, plaintiffs filed a Second Amended Complaint (“SAC”), in which they assert, on their own behalf and on behalf of a proposed class of similarly-situated subscribers of insurance policies administered by United, claims under the Employee Retirement Income Security Act of 1974 (“ERISA”) and the Racketeer Influenced and Corrupt Organizations Act (“RICO”). United filed an answer to the SAC. Now pending is MultiPlan’s motion to dismiss the claim under RICO Section 1962(c) that plaintiffs assert against it in the SAC on the ground that it continues to be inadequately pleaded.

1 Plaintiffs are LD, DB, BW, RH, and CJ. Plaintiffs have used pseudonyms to protect the Having carefully considered the pleadings and the parties’ briefs, and for the reasons set forth below, the Court DENIES MultiPlan’s motion to dismiss.2 A. Initial Complaint In the initial complaint, plaintiffs alleged as follows: Plaintiffs are members of active health insurance policies administered by United. Compl. ¶ 2, Docket No. 1. Every such policy “provided coverage for out-of-network benefits for mental health and substance use disorder treatment at usual, customary, or reasonable rates.” Id. ¶ 6. United describes UCR rates on its website as being “based on what other health care professionals in the relevant geographic areas or regions charge for their services.” Id. ¶ 8. Before obtaining IOP services from Summit Estate, an out-of-network provider, plaintiffs signed a contract with Summit Estate that makes them “responsible for amounts not paid by United.” Id. ¶ 27. Summit Estate contacted United to verify out-of-network benefits and United represented during these calls (“VOB calls”) that the IOP services in question would be paid “at UCR rates.” Id. ¶ 26. Based on the “plain language” of the plans, “it was understood by all parties that 100% of UCR was equivalent to 100% of the billed charges of Summit Estate.” Id. ¶¶ 174, 187, 200, 212, 224. United “through plan documents, marketing materials, EOBs, and other materials” represented to plaintiffs that their plans would pay for out-of-network IOP services “at the UCR amount according to an objective, empirical methodology.” Id. ¶ 104. After receiving the IOP services, claims were submitted to United for payment according to the “out-of-network rate.” Id. ¶ 8. Instead of “paying UCR,” United engaged Viant, a non- party and MultiPlan’s subsidiary, to “negotiate” reimbursements. Id. ¶ 18. Viant has “financial incentives” to negotiate low reimbursements. Id. ¶¶ 40, 46. Viant’s negotiations resulted in offers to Summit Estate to reimburse for IOP services at an amount below the UCR, and United paid the plaintiffs’ claims at the reduced Viant amount. Id. ¶¶ 36-38. Neither United nor Viant disclosed

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

LD v. United Behavioral Health, (N.D. Cal. 2021).

LD v. United Behavioral Health (LD v. United Behavioral Health) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

Related