Premier Comp Solutions LLC v. UPMC

163 F. Supp. 3d 268, 2016 U.S. Dist. LEXIS 19785, 2016 WL 640538
CourtDistrict Court, W.D. Pennsylvania
DecidedFebruary 18, 2016
Docket2:15cv703
StatusPublished
Cited by3 cases

This text of 163 F. Supp. 3d 268 (Premier Comp Solutions LLC v. UPMC) is published on Counsel Stack Legal Research, covering District Court, W.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Premier Comp Solutions LLC v. UPMC, 163 F. Supp. 3d 268, 2016 U.S. Dist. LEXIS 19785, 2016 WL 640538 (W.D. Pa. 2016).

Opinion

Memorandum Opinion

David Stewart Cercone, United States District Judge

I. Introduction

Plaintiff, Premier Comp Solutions, LLC (“Premier” or “Plaintiff’) initiated this action by filing a seven (7) count Complaint against Defendants, UPMC (“UPMC”), UPMC Benefit Management Services, Inc. (“UPMC-BMS”), UPMC Health Benefits, Inc.1 (“UPMC-HB”) (collectively the “UPMC Defendants”), and MCMC, LLC (“MCMC”) (collectively the “Defendants”) alleging violations of Sections 1 and 2 of the Sherman Act, 15 U.S.C. §§ 1 et seq., violation of Section 12 of the Clayton Act, 15 U.S.C. § 22, and common law Unfair Competition. Premier contends, inter alia, that the Defendants conspired to drive Premier from the market in workers’ compensation cost containment services. The UPMC Defendants and MCMC have filed separate Motions to Dismiss, Premier has responded and the matter is now before the Court.

II. STATEMENT OF THE CASE

Premier provides cost containment services to workers’ compensation insurers [271]*271and third party administrative (“TPA”) service providers in twenty-one (21) states including Pennsylvania. Am. Compl. ¶¶ 20, 21 & 25. The services provided by Premier include:

(1) Panel Development — Premier develops customized panel listings of healthcare providers to be used by employees with work-related injuries or illnesses. The panels are posted at the employer’s workplace and are comprised of healthcare providers who are geographically located near the workplace;
(2) Injury Management — Premier provides the injured workers with assistance in scheduling appointments for medical treatment with panel providers, and provides the employer and claims adjuster with information regarding diagnosis, treatment and work status;
(3) Medical Bill Review — Medical Bill Review and Repricing (“Repricing”) includes reviewing the provider’s documentation to assure it supports the billed charges, reducing the provider’s bills to the amounts allowed under the appropriate state’s workers’ compensation fee schedules. Premier reprices the provider’s bills and generates Explanation of Reimbursement (“EOR”) forms which reflect the provider’s billed charges, workers’ compensation fee schedule reductions, medical review reductions, Preferred Provider Organization (“PPO”) discounts and amounts payable to the provider.
(4) Physical Therapy and Diagnostic Network Access — Premier is a party to direct discount contracts with several healthcare providers who render services in the fields of physical therapy and MRI/CT, which allows Premier to offer discounts below the mandated workers’ compensation fee schedules to its clients for such services.

Am. Comp. ¶28. Premier also has Preferred Provider Organization (“PPO”) network access contracts with the Coventry Health Care (“Coventry”) network and the Prime Health Services (“Prime”) network which allows Premier to obtain PPO discounts for its repricing clients on medical services rendered by network providers. Am. Compl. ¶¶ 21, 23 & 24.

UPMC-BMS, doing business as Work-Partners, provides TPA and other services related to workers’ compensation claims to insured and uninsured employers. Am. Comp. ¶ 17. In 2010, UPMC-HB, also doing business as WorkPartners, was approved as a workers’ compensation insurance carrier in Pennsylvania and began to sell workers’ compensation insurance, as well as to provide other related services, to employers in Pennsylvania. Am. Comp. ¶¶ 18 & 55.

MCMC, a wholly-owned subsidiary of York Risk Services Group (‘York”), and with the exception of WorkPartner’s TPA clients Allegheny County, the Port Authority, the City of Pittsburgh and the Pennsylvania Turnpike Commission, has always provided repricing services for WorkPart-ners and UPMC-HB. Am. Comp. ¶¶ 19 & 32. Premier alleges that MCMC provides repricing services to WorkPartners’ and UPMC-HB’s self-insured employers under the provisions of a 2009 contract which requires MCMC to pay WorkPartners a percentage of the access fee which MCMC charges UPMC-HB and the self-insured employers for access to the UPMC preferred provider network. Am. Comp. ¶ 99. This kickback arrangement increases the medical costs incurred by WorkPartners’ and UPMC-HB’s self-insured employers. Id.

[272]*272In April of 2006, Premier entered into a Medical Review and Repricing Agreement (the “Repricing Agreement”) with Work-Partners under which it agreed to review and reprice medical bills submitted by WorkPartners in accordance with the Pennsylvania Workers’ Compensation Act (the “Act”). Am. Comp. ¶¶ 52 & 53, and Exhibit 1. The Repricing Agreement was to remain in effect “until terminated by either party.. .at any time, provided that at least 30 days advance notice is given.” Am. Comp. Exhibit 1, p. 3. The parties to the Repricing Agreement, further agreed to:

... hold in confidence any information obtained by relating to the business of the other and agrees to instruct its agents, employees, representatives, and independent contractors to keep all such information strictly confidential. Each party agrees that it will not directly or indirectly disclose, communicate, divulge, furnish to or use for the benefit of itself, or any other person, firm or corporation, any of the trade secrets, designs, improvements, inventions, data, information, or know-how, belonging to the other which may be communicated to it or which it may learn by virtue of its activities under this Agreement.

Am. Comp. ¶ 54, and Exhibit 1.

UPMC-HB’s workers’ compensation insurance policies were sold through insurance brokers, many of whom sell workers’ compensation policies on behalf of other insurance companies. Am. Comp. ¶ 57. Many of the insurance brokers and carriers recommend that their insured employer clients use Premier’s cost containment services. Am. Comp. ¶¶ 57 & 58.

In August of 2010, Premier began providing cost containment services to Work Partners, including panel development, appointment scheduling, injury management, and physical therapy (“PT”) and diagnostic (“MRI/CT”) network services for employers who were insured by UPMC-HB. Am. Comp. ¶29. Premier alleges that Work-Partners, as a competitor of Premier, continued to develop its own panels for UPMC-HB’s insureds located in close proximity to UPMC’s hospitals and physician practices. Am. Comp. ¶¶ 29-31. In July of 2012, WorkPartners and UPMC-HB decided to use Premier’s PT and MRI/CT network for the majority of their other employer clients and insureds. Am. Comp. ¶ 60. Accordingly, Premier was required to provide WorkPartners and UPMC-HB with its then current listing of PT and MRI/CT network providers and to update the list when necessary. Id.

In February, 2014, WorkPartners asked Premier to provide it with an “excel extract. . .with our employer clients and the providers that are listed on their panels.” Am. Comp. ¶ 62; Exhibit 2. WorkPartners also requested that Premier perform an extensive medical bill review and repricing test audit to determine whether Premier or MCMC, UPMC-HB’s repricing vendor at that time, provided the best service and the most savings. Am. Comp. ¶ 64.

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163 F. Supp. 3d 268, 2016 U.S. Dist. LEXIS 19785, 2016 WL 640538, Counsel Stack Legal Research, https://law.counselstack.com/opinion/premier-comp-solutions-llc-v-upmc-pawd-2016.