New England Physical Therapy Network, P.C. v. Healthcare Value Management, Inc.

15 Mass. L. Rptr. 109
CourtMassachusetts Superior Court
DecidedAugust 21, 2002
DocketNo. 986143
StatusPublished

This text of 15 Mass. L. Rptr. 109 (New England Physical Therapy Network, P.C. v. Healthcare Value Management, Inc.) is published on Counsel Stack Legal Research, covering Massachusetts Superior Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
New England Physical Therapy Network, P.C. v. Healthcare Value Management, Inc., 15 Mass. L. Rptr. 109 (Mass. Ct. App. 2002).

Opinion

Hinkle, J.

In its amended complaint, plaintiff New England Physical Therapy Network, P.C. claims defendants systematically discounted Personal Injury Protection (“PIP”) medical expense claims based on operation of a so-called “Silent PPO.”2 Plaintiff alleges that defendants misappropriated more than $204,000 in preferred provider organization discounts and applied those discounts to Massachusetts automobile insurance PIP claims, and, as a result, insurers have paid claims at a reduced rate.

The amended complaint contains eight counts. Count I alleges breach of contract against Healthcare Value Management, Inc. (“HCVM”). Counts II and III allege breach of contract and third-party beneficiary claims against Concentra Managed Care, Inc. (“Concentra”). Counts IV and v. allege violation of G.L.c. 93A against Con centra and HCVM respectively.3 Counts VI-VIII allege breach of G.L.c. 90, §34M, breach of contract and G.L.c. 93A against Commerce Insurance Company, The Premier Insurance Company of Massachusetts, Inc. and Arbella Mutual Insurance Company (collectively, the “automobile insurers").

Defendants now seek to dismiss the amended complaint under Mass.R.Civ.P. 17(a), arguing that plaintiff is not the real party in interest. For the reasons set forth below, after a hearing, the motion is DENIED in part and conditionally ALLOWED in part.

BACKGROUND

The complaint makes the following allegations, among others.4 Plaintiff, a professional corporation, includes approximately 55 physical therapists (the “members”) licensed in Massachusetts. Complaint ¶27. On behalf of its members, plaintiff enters into preferred provider agreements with preferred provider organizations. Id.

HCVM, a health care business that operates and maintains a preferred provider organization, solicited plaintiff to have its members become preferred providers in HCVM’s preferred provider organization. Id. ¶¶6, 28. HCVM told plaintiff that it had contracted with certain clients/payors, including group health insurers, unions, employers and workers’ compensation insurers, to pay the preferred providers for the delivery of health services. Id. ¶¶28, 29.

Plaintiff executed a preferred provider agreement with HCVM under which, among other things, HCVM agreed to contract with plaintiff “to arrange for the provision of quality health care services to Preferred Provider Network members in an efficient and cost effective manner” and plaintiff agreed “to provide HCVM and its members health servicesl.]” Id. ¶¶30, 31. Plaintiffs members agreed to provide health care services at a volume discount, specifically a flat fee of $50, to HCVM’s clients/payors who complied with the terms and conditions of the preferred provider agreement. Id. ¶32. In return, HCVM’s clients/payors agreed to educate, market and create incentives to increase the volume of patients directed to plaintiff s members. Id. ¶33. HCVM agreed that its clients/payors would be bound by the terms and conditions of the preferred provider agreement and further agreed that its clients/payors would pay the preferred providers within 30 days of receipt of a preferred provider’s bill. Id. ¶¶34-35. Under the contract, HCVM’s discounts would be forfeited by clients/payors, at a participating preferred provider’s discretion, for all bills not paid within 30 days. Id. ¶35.

Plaintiff contends that the preferred provider agreement did not provide for the sale or disclosure of plaintiffs members’ discounts to clients who did not comply with the terms and conditions of the preferred provider agreement, to managed care discount brokers, such as Concentra, or to the defendant automobile insurers to be applied to automobile medical expense claims. Id. ¶36.

After executing the preferred provider agreement with plaintiff, HCVM allowed Concentra, a managed care company that provides cost containment and fully integrated care management to insurance companies, to access a database containing discount rate information for HCVM’s preferred providers, including plaintiffs members. Id. ¶¶7, 37. HCVM disclosed this information to Concentra for a fee as part of a broker agreement. Id. ¶37.

Based on the language of the preferred provider agreement, HCVM was obligated to ensure that its clients/payors adhered to the terms and conditions of the preferred provider agreement. Id. ¶38. Plaintiff contends that HCVM’s broker agreement with Concentra provides for compliance with the HCVM preferred provider agreement. Id. As a result, plaintiff claims that its members are intended third-party beneficiaries of HCVM’s broker agreement with Concentra. Id.

Concentra then entered into agreements with the defendant automobile insurers to allow Concentra to reprice medical bills or obtain discount rates, using the volume discount information obtained from HCVM. Id. ¶39.

Concentra processes medical expense claims through its cost containment system (“CC System”), a [111]*111software program capable of reviewing medical charges. Id. ¶40. The CC System has two features: a Preferred Provider Repricing System (“PPO Repricing System”) and a Usual Customary Repricing System. Id. The PPO Repricing System is a database which applies PPO discounts to indemnity insurance medical expense claims. Id. ¶41. Plaintiff claims that the PPO Repricing System is designed to apply retrospectively preferred provider organization discounts to indemnity medical expense claims despite the fact that the indemnity insurer has no contract or entitlement to the discount. Id.

Concentra established a managed care automobile program, the Voluntary Network Access Program (the “VNA Program”), to market its preferred provider organization discounts to the defendant automobile insurers and to process personal injury protection medical bills according to a discounted payment schedule. Id. ¶42. Plaintiff contends that when Concentra implemented the VNA Program, Concentra knew that it was illegal to direct Massachusetts automobile insurance claimants to an alleged network of preferred providers. Id. ¶43.

Plaintiff alleges that the VNA Program was specifically designed to reduce automobile medical expense claims for automobile insurers where legislation or regulation had not been enacted to do so and that the VNA Program allows automobile insurers access to preferred provider organization discounts. Id. ¶44. Plaintiff also alleges that the VNA Program contains none of the steerage mechanisms of legitimate preferred provider organizations and that it does not comply with HCVM’s preferred provider agreement. Id. ¶45. Specifically, plaintiff claims that the VNA Program lacks financial incentives to increase patient volume, lacks education and marketing requirements as set forth in the preferred provider agreement and lacks identification cards for automobile insurers. Id.

Plaintiff contends that under the VNA Program, Concentra brokered plaintiffs discounts to the defendant automobile insurers for a fee of up to one third the amount of the discount. Id. ¶46.

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Cite This Page — Counsel Stack

Bluebook (online)
15 Mass. L. Rptr. 109, Counsel Stack Legal Research, https://law.counselstack.com/opinion/new-england-physical-therapy-network-pc-v-healthcare-value-management-masssuperct-2002.