Mentis El Paso, LLP v. Health Care Service Corp.

58 F. Supp. 3d 745, 2014 U.S. Dist. LEXIS 158332, 2014 WL 5835609
CourtDistrict Court, W.D. Texas
DecidedSeptember 12, 2014
DocketNo. EP-14-CV-00196-FM
StatusPublished
Cited by2 cases

This text of 58 F. Supp. 3d 745 (Mentis El Paso, LLP v. Health Care Service Corp.) is published on Counsel Stack Legal Research, covering District Court, W.D. Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mentis El Paso, LLP v. Health Care Service Corp., 58 F. Supp. 3d 745, 2014 U.S. Dist. LEXIS 158332, 2014 WL 5835609 (W.D. Tex. 2014).

Opinion

ORDER GRANTING DEFENDANT’S MOTION TO DISMISS

FRANK MONTALVO, District Judge.

On this day, the court considered Defendant Health Care. Service Corporation’s, an Illinois Mutual Legal Reserve Company, a division of which is Blue Cross and Blue Shield of Texas (“Defendant” or “HCSC”), “Defendant’s Motion to Dismiss” (“Motion”) [ECF No. 4], filed June 3, 2014; Plaintiff Mentis El Paso, L.L.P.’s (“Plaintiff’ or “Mentis”) “Plaintiffs Response in Opposition to Defendant’s Motion to Dismiss” (“Response”) [ECF No. 15], filed July 11, 2014; and “Defendant’s Reply in Support of Motion to Dismiss” (“Reply”) [ECF No. 16], filed July 18, 2014.

I. BACKGROUND

A. Procedural Posture

Mentis filed “Plaintiffs Original Petition” (“Complaint”) in the District Court of El Paso County, Texas on April 28, 2014 in cause number 2014DCV1303.1 HCSC removed it on May 27, 2014.2 Mentis operates a post-acute care intensive neurological rehabilitation facility in El Paso, Texas.3 HCSC owns Blue Cross Blue Shield of Texas (“BCBSTX”), which is a licensed insurance provider, issuer, and/or administrator of health care plans in Texas.4

This suit arises from medical services provided in 2013 and 2014 to two patients: Patient A and Patient B, pursuant to a preferred provider agreement entered into with HCSC.5 Mentis seeks damages totaling $386,018.75 for Patient A and $386,078.00 for Patient B, in addition to attorney’s fees.6 Mentis alleges five causes of action against HCSC:7 (1) violations of the Texas Insurance Code through deceptive and unfair trade practices; (2) breach of contract; (3) violations of the Texas Insurance Code; (4) negligence and negligent misrepresentation; and (5) fraud and fraud by non-disclosure.8

Mentis alleges HCSC contracted to pay Mentis for medical treatment and services at agreed-upon rates established in the preferred provider agreement.9 Mentis [748]*748further alleges that HCSC represented to Mentis that Patients A and B had effective coverage for each admission and that benefits were available and adequate for the medical services to be provided, thereby preauthorizing all services for each admission.10 According to Mentis, it provided these services to Patients A and B and submitted claims to HCSC as required by the agreement, but was not reimbursed by HCSC.11

With regard to Patient A, HCSC initially paid for some of the services provided, but remaining claims were either unpaid or completely denied altogether.12 Mentis alleges that HCSC later recouped all of the prior payments made to Patient A, asserting that the authorized services were not medically necessary, and that the services were not covered by Patient A’s plan.13 As to Patient B, Mentis alleges HCSC either did not pay at all, or paid only a portion of the required rate, contending that Medicare is the primary provider, not HCSC, or that a Medicare denial is required in order to be reimbursed by HCSC.14 Mentis, on the other'hand, argues that HCSC is the primary and contracted provider, not Medicare.15

B. Parties’Arguments

1. HCSC’s Motion

HCSC asserts that all of Mentis’ claims are barred under the doctrine of sovereign immunity, because the patients whose care is at issue were enrolled in the Service Benefit Plan (the “Plan”), which is a health benefits plan for federal employees, retirees, and their dependents established by the Federal Employees Health Benefits Act of 1959 (“FEHBA”).16 HCSC argues that FEHBA provides a mandatory administrative remedy for benefits disputes that expressly preempts state law claims challenging determinations regarding benefits or the administration of the Plan.17 Consequently, HCSC contends the only remedy available to Mentis is to comply with FEH-BA’s mandatory administrative review process and to appeal a final decision in federal court against the federal government, not HCSC.18 HCSC maintains that any payments in the form of benefit claims, administrative costs, or judgment rendered in this case will be paid by the United States Department of the Treasury (the “Treasury”).19

Furthermore, HCSC argues that Men-tis’ second and third causes of action for breach of contract and violations of the Texas Insurance Code and Texas Prompt Pay Act are preempted by the FEHBA.20 Additionally, HCSC seeks to dismiss Men-tis’ first, fourth, and fifth causes of action, based on misrepresentation and fraud, as preempted by FEHBA and for failure to state a claim for relief under Federal Rule of Civil Procedure 12(b)(6).21

2. Mentis’ Response

Mentis concedes both patients who received treatment were covered under a [749]*749federal employee health benefit plan.22 Notwithstanding, Mentis analogizes its cause of action to state law claims covered by ERISA that were not found to be preempted.23 Moreover, Mentis states it is not suing the Plan or bringing claims against it as an assignee of the Plan beneficiary.24 Rather, Mentis is suing an in-network provider with which it has entered into a direct contract that does not involve the underlying Plan.25 Mentis contests whether any payment will come from the Treasury without the benefit of discovery.26 Moreover, Mentis argues that the FEHBA has created a remedial mechanism only for claims of covered individuals — -an enrollee, retiree, or dependent— not for claims of providers.27 Accordingly, Mentis contends that its claims against HCSC are wholly distinct from the Plan, as they are based on the preferred provider agreement and assert separate common law and statutory grounds.28

3. HCSC’s Reply

HCSC reiterates that sovereign immunity bars Mentis’ claims because any judgment resulting from this case would be paid by the Treasury, regardless of whether the contract was entered into directly by HCSC and Mentis.29 HCSC further distinguishes cases promulgated by Mentis as indicating no preemption, because those did not require the court to interpret the Plan to determine whether the patients’ treatments were covered — as would be the case here — which is preempted by FEH-BA.30 Finally, HCSC repeats that Mentis has failed to state a claim for relief where its claims for damages are more than the amounts to which it would allegedly be entitled under the preferred provider agreement, without any justification.31

II. APPLICABLE LAW

A. Standard for a Motions to Dismiss Pursuant to

Related

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Bluebook (online)
58 F. Supp. 3d 745, 2014 U.S. Dist. LEXIS 158332, 2014 WL 5835609, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mentis-el-paso-llp-v-health-care-service-corp-txwd-2014.