Modern Orthopaedics of NJ v. Premera Blue Cross

CourtDistrict Court, D. New Jersey
DecidedNovember 3, 2025
Docket2:25-cv-01087
StatusUnknown

This text of Modern Orthopaedics of NJ v. Premera Blue Cross (Modern Orthopaedics of NJ v. Premera Blue Cross) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Modern Orthopaedics of NJ v. Premera Blue Cross, (D.N.J. 2025).

Opinion

NOT FOR PUBLICATION

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW JERSEY

MODERN ORTHOPAEDICS OF NJ,

Plaintiff, Case No. 2:25-cv-01087 (BRM) (JSA)

v. OPINION

PREMERA BLUE CROSS,

Defendant.

MARTINOTTI, DISTRICT JUDGE Before the Court is a Motion to Dismiss filed by Defendant Premera Blue Cross (“Premera”), seeking to dismiss Plaintiff Modern Orthopaedics of NJ’s (“Modern Ortho”) Amended Complaint. (ECF No. 22.) Modern Ortho filed and opposition to Defendant’s Motion alongside a cross-motion to confirm the arbitration award. (ECF No. 27.) Premera filed a reply brief, responding to Modern Ortho’s opposition. (ECF No. 28). Having reviewed and considered the submissions filed in connection with the motion and having declined to hold oral argument pursuant to Federal Rule of Civil Procedure 78(b), for the reasons set forth below and for good cause appearing, Defendant’s Motion to Dismiss is GRANTED. I. BACKGROUND A. Factual Background For the purpose of this motion to dismiss, the Court accepts the factual allegations of the Amended Complaint as true and draws all inferences in the light most favorable to the Plaintiff. See Phillips v. Cty. of Allegheny, 515 F.3d 224, 228 (3d Cir. 2008). The Court also considers any “document integral to or explicitly relied upon in the complaint.” In re Burlington Coat Factory Secs. Litig., 114 F.3d 1410, 1426 (3d Cir. 1997) (quoting Shaw v. Dig. Equip. Corp., 82 F.3d 1194, 1220 (1st Cir. 1996)). Assuming all facts alleged by the Plaintiff are true. Two years ago, an orthopedic surgeon, Dr. David Ratliff, performed surgery on a patient insured by Premera at St. Joseph’s University.

(Modern Ortho’s Brief in Opposition to Motion to Dismiss and in Support of Cross Motion to Confirm Arbitration (ECF No. 27-1) at 3.) Dr. Ratliff was employed by Modern Ortho. (Id.) Though St. Joseph’s University was an in-network facility, Modern Ortho is an out-of-network healthcare provider. (Id.) This discrepancy led to the party’s current payment dispute. (Id.) at 4. After treating the patient, Modern Ortho sent a bill for $18,203.00 to Premera. Premera approved a single payment of $1,489.38. (Compl. (ECF No. 1) at ¶¶ 8–9.) Pursuant to the federal No Surprises Act (“NSA”), 42 U.S.C. § 300gg-111(c)(1), the parties proceeded to negotiate payment. (ECF No. 27-1 at 3.) They failed to reach an agreement within the statutory thirty (30) day negotiation period, so Modern Ortho initiated Independent Dispute Resolution (IDR) proceedings in an attempt to recoup what it felt it was owed. (Id.)

Modern Ortho prevailed in the IDR, and was awarded $18,000, minus the $1,489.38 Premera had already paid. Id. at 4. It should be noted, Premera never agreed to be bound by the IDR, nor had it agreed to arbitrate any portion of the disputed coverage. (ECF No. 1 ¶ 25.) Likewise, there is no network contract between the parties. (ECF No. 27-1 at 3.) Premera therefore refuses to pay the $16,510.62 Modern Ortho attempts to collect. (Id. at 4.) Modern Ortho brought this lawsuit to confirm its IDR award.(Id.) B. Procedural History Modern Ortho filed a complaint before this court on February 7, 2025 seeking to enforce an award from a prior IDR. (ECF No. 1.) On May 27th, 2025 Premera responded to the complaint by moving to dismiss, arguing the Court lacks the power to hear this complaint under the Federal Arbitration Act (“FAA”), as the complaint alleged. (Premera’s Brief in Support of Motion to Dismiss (ECF No. 22-2).) Modern Ortho opposed this motion to dismiss on July 21, 2025, arguing that the FAA did provide a basis to confirm the arbitration award and—even if it did not—the

NSA itself implied a private right of action for the Court to enforce the award. (ECF No. 27-1 at 2.) Therefore, Modern Ortho simultaneously filed a cross motion to confirm the arbitration award. (ECF No. 27.) Premera responded, supporting its motion to dismiss and opposing the new cross motion on August 4, 2025. (Premera’s Response in Support of Motion to Dismiss Complaint (ECF No. 28).) II. LEGAL STANDARD A. Rule 12(b)(6) In deciding a motion to dismiss pursuant to Fed. R. Civ. P. 12(b)(6), a district court is “required to accept as true all factual allegations in the complaint and draw all inferences from the facts alleged in the light most favorable to [the non-moving party].” Phillips v. Cnty. of Allegheny,

515 F.3d 224, 228 (3d Cir. 2008). “[A] complaint attacked by a Rule 12(b)(6) motion to dismiss does not need detailed factual allegations.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555 (2007) (citations omitted). However, “a plaintiff’s obligation to provide the ‘grounds’ of his ‘entitle[ment] to relief’ requires more than labels and conclusions, and a formulaic recitation of the elements of a cause of action will not do.” Id. at 555 (quoting Papasan v. Allain, 478 U.S. 265, 286 (1986)). A court is “not bound to accept as true a legal conclusion couched as a factual allegation.” Papasan, 478 U.S. at 286. Instead, assuming the factual allegations in the complaint are true, those “[f]actual allegations must be enough to raise a right to relief above the speculative level.” Twombly, 550 U.S. at 555 “To survive a motion to dismiss, a complaint must contain sufficient factual matter, accepted as true, to ‘state a claim to relief that is plausible on its face.’” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (quoting Twombly, 550 U.S. at 570). “A claim has facial plausibility when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the

defendant is liable for the misconduct alleged.” Id. at 678 (citing Twombly, 550 U.S. at 556). This “plausibility standard” requires the complaint to allege “more than a sheer possibility that a defendant has acted unlawfully,” but it “is not akin to a ‘probability requirement.’” Id. (citing Twombly, 550 U.S. at 556). “Detailed factual allegations” are not required, but “more than an unadorned, the-defendant-unlawfully-harmed-me accusation” must be pled; it must include “factual enhancements” and not just conclusory statements or a recitation of the elements of a cause of action. Id. (citations omitted). In assessing plausibility, the court may not consider any “[f]actual claims and assertions raised by a defendant.” Doe v. Princeton Univ., 30 F.4th 335, 345 (3d Cir. 2022). “Determining whether a complaint states a plausible claim for relief [is] . . . a context-

specific task that requires the reviewing court to draw on its judicial experience and common sense.” Iqbal, 556 U.S. at 679. “[W]here the well-pleaded facts do not permit the court to infer more than the mere possibility of misconduct, the complaint has alleged—but it has not ‘show[n]’— ‘that the pleader is entitled to relief.’” Id. (quoting Fed. R. Civ. P. 8(a)(2)). Indeed, after Iqbal, conclusory or “bare-bones” allegations will no longer survive a motion to dismiss: “[t]hreadbare recitals of the elements of a cause of action, supported by mere conclusory statements, do not suffice.” Id. at 678.

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