Midland Psychiatric Associates, Inc. v. United States

969 F. Supp. 543, 1997 U.S. Dist. LEXIS 9851, 1997 WL 381266
CourtDistrict Court, W.D. Missouri
DecidedJuly 8, 1997
Docket96-1245-CV-W-3
StatusPublished
Cited by4 cases

This text of 969 F. Supp. 543 (Midland Psychiatric Associates, Inc. v. United States) is published on Counsel Stack Legal Research, covering District Court, W.D. Missouri primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Midland Psychiatric Associates, Inc. v. United States, 969 F. Supp. 543, 1997 U.S. Dist. LEXIS 9851, 1997 WL 381266 (W.D. Mo. 1997).

Opinion

ORDER GRANTING DEFENDANT’S MOTION TO DISMISS

SMITH, District Judge.

Pending is Defendants’ Motion to Dismiss Plaintiffs First Amended Complaint. 1 For the reasons set forth below, the Motion to Dismiss is granted.

I. BACKGROUND

The following facts are gleaned from the First Amended Complaint and must be considered as true for purposes of the pending motions. The defendants are the United States (the “Government”) and Mutual of Omaha Insurance Company (“Mutual”). Plaintiff provides partial hospitalization services to nursing home residents pursuant to contracts with various hospitals (“Hospitals”). Under these contracts, Plaintiff set up partial hospitalization programs in long term care facilities and billed the Hospitals for the services provided. The Hospitals then filed claims for reimbursement from Medicare. “Partial hospitalization” is a program furnished on an outpatient basis and is designed to provide “a more intensive functioning and reduce or control a patient’s symptoms so as to prevent relapse or hospitalization.” First Amended Complaint, ¶ 8.

Partial hospitalization is covered under Part B of Medicare. 2

Part B of the Medicare Act, 42 U.S.C. § 1395j et seq., establishes a voluntary program of supplemental medical insurance covering expenses not covered by the Part A program, such as reasonable charges for physicians’ services, medical supplies, and laboratory tests. Payments for Part B expenses are made by private insurance carriers under contract to the Department of Health and Human Services, 42 U.S.C. § 1395u, and the claimant is entitled to reconsideration of the carrier’s initial denial of those claims. 42 CFR §§ 405.807-405.860 (1983).

Heckler v. Ringer, 466 U.S. 602, 609 n. 4, 104 S.Ct. 2013, 2018 n. 4, 80 L.Ed.2d 622 (1984); see also United States v. Bushman, 862 F.2d 1327, 1329 (8th Cir.1988), cert. denied, 493 U.S. 810, 110 S.Ct. 53, 107 L.Ed.2d 21 (1989). In this case, the intermediate insurance company was Mutual. In August 1993, Mutual began denying those portions of the Hospitals’ claims that were based on services supplied by Plaintiff; the denials were ostensibly based on lack of medical necessity or failure to have a doctor present during treatment. These denials were issued even though allegedly similar claims for reimbursement were approved for other providers of partial hospitalization services. In October and November of 1993, officials from Plaintiff, the Hospitals, Mutual and the Health Care Financing Administration (“HCFA”) (the Government agency charged with administering the Medicare program) met; Plaintiff and the Hospitals were assured that there were no problems with the claims submitted and the claims were reimbursable. Assurances similar to these were received as late as February 1994.

Meanwhile, in November 1993, Mutual advised one of the Hospitals that Plaintiffs program would be treated as a “new” program and would be placed on a “routine, focused review.” Instead, Mutual reviewed all charts related to reimbursement requests involving Plaintiffs services, and claims con *547 tinued to be denied. The degree of review is alleged to be improper because the manual provided to intermediaries calls for a sampling of claims as opposed to 100% review. These denials led some (if not all) of the Hospitals to terminate their contracts with Plaintiff. In addition, other hospitals that were considering entering contracts with Plaintiff decided not to do so.

Plaintiff alleges that Mutual took these actions in order to shut down Plaintiffs business as a cost-cutting effort. Accordingly, Count I alleges that Mutual intentionally interfered with Plaintiffs contracts and other business expectations. Count II alleges that the Government was negligent in its failure to properly supervise Mutual. The Defendants contend this Court lacks jurisdiction over both claims and request dismissal pursuant to Fed.R.Civ.P. 12(b)(1).

II. DISCUSSION

A. Count I

Count I alleges a common-law tort against Mutual, and jurisdiction is ostensibly based on the parties’ diversity of citizenship. The elements for tortious interference with business expectation are as follows: “(1) a contract or valid business expectancy; (2) defendant’s knowledge of the contract or relationship; (3) a breach induced or caused by defendant’s intentional interference, (4) absence of justification; and (5) damages.” Rice v. Hodapp, 919 S.W.2d 240, 245 (Mo. banc 1996). The fourth element is crucial to some of the Court’s reasoning with respect to Defendants’ motion. “A requisite element of tortious interference with a business relationship is absence of justification. A defendant cannot be held liable for interfering with a business relationship if it has an unqualified right to perform the act.” Id.

1. Statutory Bar to Review of Claims

42 U.S.C. § 405(h) is made applicable to the Medicare statutes by virtue of 42 U.S.C. § 1395ii and provides as follows: 3

The findings and decision of the Secretary after a hearing shall be binding upon all individuals who were parties to such hearing. No findings of fact or decision of the Secretary shall be reviewed by any person, tribunal, or governmental agency except as herein provided. No action against the United States, the Secretary, or any officer or employee thereof shall be brought under section 1331 or 1346 of Title 28 to recover on any claim arising under this subchapter.

This provision is significant because Plaintiff contends that Mutual intended to drive it out of business and accomplished this goal by denying reimbursement for its services. In order to prove all the elements of this tort, Plaintiff must demonstrate that Mutual acted without justification, thus requiring the Court (or a jury) to decide whether Mutual had “an unqualified right” to deny those claims. This will necessarily require the Court to decide whether the claims should or should not have been granted — or, in other words, to review the correctness of Mutual’s decision. Plaintiff understandably wants to shift the focus to Mutual’s alleged decision to drive Plaintiff out of business. However, this is an unduly narrow view of the wrongful act being challenged. The act that allegedly interfered with Plaintiff’s business expectations was the denial of claims; therefore it is the denial of claims that must be examined.

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Bluebook (online)
969 F. Supp. 543, 1997 U.S. Dist. LEXIS 9851, 1997 WL 381266, Counsel Stack Legal Research, https://law.counselstack.com/opinion/midland-psychiatric-associates-inc-v-united-states-mowd-1997.