MSPA Claims I, LLC v. Tenet Fla., Inc.

318 F. Supp. 3d 1349
CourtDistrict Court, S.D. Florida
DecidedMarch 29, 2018
DocketCase No. 17-20039-CIV-WILLIAMS
StatusPublished

This text of 318 F. Supp. 3d 1349 (MSPA Claims I, LLC v. Tenet Fla., Inc.) is published on Counsel Stack Legal Research, covering District Court, S.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
MSPA Claims I, LLC v. Tenet Fla., Inc., 318 F. Supp. 3d 1349 (S.D. Fla. 2018).

Opinion

KATHLEEN M. WILLIAMS, UNITED STATES DISTRICT JUDGE

*1351THIS MATTER is before the Court on Defendants' Motion to Dismiss Plaintiff's Second Amended Complaint (DE 21). Plaintiff filed a response in opposition to the motion (DE 26), and Defendants filed a reply (DE 28). For the reasons set forth below, Defendant's motion to dismiss is granted.

I. BACKGROUND

This case is a putative class action purportedly arising out of the Medicare Secondary Payer Act, 42 U.S.C. § 1395y (the "MSPA"). Plaintiff MSPA Claims I, LLC (the "Assignee Plaintiff") alleges that Defendants Tenet Florida, Inc. and St. Mary's Medical Center, Inc. (the "Provider Defendants") failed to reimburse Florida Healthcare Plus ("FHCP")-the assignor Medicare Advantage Organization ("MAO")-for conditional payments made on behalf of Medicare beneficiaries who were separately covered by a private insurer qualifying as a primary payer under the MSPA. In addition to the MSPA Claim (Count I), the Second Amended Complaint includes a claim under the Florida Deceptive and Unfair Trade Practices Act ("FDUTPA") (Count II), a claim for unjust enrichment ("Count III"), and two claims for declaratory relief (Counts IV and V).

a. The Medicare Secondary Payer Act

The specific structure of Medicare payments under the MSPA is explained in detail in Plaintiffs' complaint. In general terms, the MSPA makes Medicare a "secondary payer" to other sources of coverage, and entitles them to reimbursement from a "primary payer"-once liability has been established with regard to that other entity-for any conditional payments made by Medicare on behalf of the beneficiary. The Act provides for a "private cause of action for damages" in the event that a primary payer fails to fulfill its reimbursement obligations under the MSPA. (See DE 17 ¶¶ 33-42).

The Plaintiff is a limited liability company that receives assignments from various entities to pursue claims arising out of the MSPA. Plaintiff argues that it has standing to bring these claims under the private right of action authorized by the MSPA because an MAO-FHCP-has assigned its recovery rights to Plaintiff.1 An MAO is a private insurer who has entered into a contract with the United States Centers of Medicare and Medicaid Services ("CMS") to provide traditional Medicare coverage to Medicare beneficiaries. They receive a fixed payment from Medicare for each Medicare-covered enrollee, and then directly pay providers for any services rendered to those individuals. Depending on the services required during the coverage period, the MAO then absorbs the profit or loss based on the differential between the payments made to providers and the fixed payment received from Medicare. Because they provide traditional Medicare services, MAOs are entitled to "exercise the same rights to recover from a primary plan, entity or individual that the Secretary exercises under the MSP regulations." 42 C.F.R. § 422.108(f) ). (See DE 17 ¶¶ 24-32).

*1352b. The Hospital Services Agreement

Separate and apart from their rights and obligations under the MSPA, an MAO may enter into agreements with medical providers regarding the provision of covered services to the MAO enrollees. Those agreements are not governed by the MSPA, but are private contractual agreements regarding the relationship between the two entities involved. In this case, FCHP entered into a Hospital Services Agreement (the "Services Agreement") with Tenet Florida, Inc. on behalf of St. Mary's Medical Center on July 16, 2013. (DE 17 ¶ 56). That agreement governed the relationship between FCHP and the Provider Defendants, and, among other things, explained the payment mechanism for services provided to MAO enrollees and set out the manner in which the Parties were entitled to resolve any disputes relating to their arrangement. (DE 17 ¶¶ 57-60).

On September 3, 2013, an FHCP enrollee was involved in an automobile accident and received medical treatment at St. Mary's. (DE 17 ¶¶ 44-45). The enrollee was covered both by FCHP and by a private, no-fault insurer-Allstate Fire and Casualty Insurance Company ("Allstate")-at the time those services were rendered. (DE 17 ¶¶ 43, 46). St. Mary's billed both FHCP and Allstate for the medical treatment in the amount of $2086.00. (DE 17 ¶¶ 47-49). FHCP made a payment of $285.75, and Allstate made a payment of $1,251.60. (DE 17 ¶¶ 48-49). St. Mary's then reimbursed FCHP in the full amount of its conditional payment-$285.75-based upon the payment by Allstate as a primary payer under the MSPA. (DE 17 ¶ 53).

II. LEGAL STANDARD

a. Article III Standing

"Article III of the Constitution limits the judicial power of the United States to the resolution of Cases and Controversies." Hein v. Freedom from Religion Found., Inc. , 551 U.S. 587, 597-98, 127 S.Ct. 2553, 168 L.Ed.2d 424 (2007) (internal quotations and citations omitted). Because Federal courts are courts of limited jurisdiction, they are "obligated to inquire into subject matter jurisdiction ... whenever it may be lacking." Univ. of S. Alabama v. Am. Tobacco Co. , 168 F.3d 405, 410 (11th Cir. 1999) (citing, among others, Fitzgerald v. Seaboard Sys. R.R. , 760 F.2d 1249, 1251 (11th Cir.1985) (per curiam); see also Save the Bay, Inc. v. United States Army , 639 F.2d 1100, 1102 (5th Cir. 1981) (per curiam) (holding that courts must constantly examine the basis of their jurisdiction before proceeding to the merits); Cuban Am. Bar Ass'n v. Christopher , 43 F.3d 1412, 1422 (11th Cir. 1995) (noting that " '[b]efore rendering a decision ... every federal court operates under an independent obligation to ensure it is presented with the kind of concrete controversy upon which its constitutional grant of authority is based.").

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318 F. Supp. 3d 1349, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mspa-claims-i-llc-v-tenet-fla-inc-flsd-2018.