Teamcare Infusion Orlando, Inc. v. Humana Health Plans of Puerto Rico, Inc.

296 F. Supp. 3d 429
CourtUnited States District Court
DecidedNovember 14, 2017
DocketCivil No. 14–1741(DRD)
StatusPublished

This text of 296 F. Supp. 3d 429 (Teamcare Infusion Orlando, Inc. v. Humana Health Plans of Puerto Rico, Inc.) is published on Counsel Stack Legal Research, covering United States District Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Teamcare Infusion Orlando, Inc. v. Humana Health Plans of Puerto Rico, Inc., 296 F. Supp. 3d 429 (usdistct 2017).

Opinion

DANIEL R. DOMÍNGUEZ, U.S. District Judge

Pending before the Court are Defendants' Motion for Summary Judgment (Docket No. 83), Plaintiff's Response to Motion for Summary Judgment (Docket No. 94), and finally Defendants' Reply to Plaintiff's Response to Motion for Summary Judgment (Docket No. 101). For the reasons set forth below, Defendants' Motion for Summary Judgment is hereby GRANTED .

I. FACTUAL AND PROCEDURAL HISTORY

On September 1, 2008, Humana Health Plans of Puerto Rico, Inc. ("Humana Health"), Humana Health Insurance of Puerto Rico, Inc. ("Humana Insurance") (jointly, "Humana") and Team Care Infusion Orlando, Inc. ("Teamcare") entered into an Ancillary Services Agreement ("Agreement"). (Docket No. 86, Exhibit B). Pursuant to the terms of the Agreement, Teamcare was authorized to provide services to Humana members enrolled in the Government of Puerto Rico's Reform Program and the Medicare Programs. (Id. ) The two plans are from separate jurisdictions. The Reform program is from the Government of Puerto Rico laws and regulations, while the Medicare Program is federal in nature. The Agreement states that all payment of claims shall be made in accordance with applicable Commonwealth of Puerto Rico and federal statutes and regulations, applicable to each one of the two sovereign governments. (Id. ) Additionally, the Agreement specifies that a provider may challenge any denial or payment of a claim to Humana within 45 days of payment. (Id. ) If the provider challenges a claim, Humana will review the claim and render a final decision with respect to the claim within 30 days of receipt of such information. (Id. )

On March 4, 2011, Teamcare filed an administrative complaint against Humana Health before the Health Insurance Administration of Puerto Rico ("ASES" by its Spanish acronym), in which Plaintiff asserted that Humana Health breached the terms of the Agreement by not paying certain claims from October 2009 to July *4322010. (Docket No. 86, Exhibit C). Teamcare alleged that according to the terms of the Agreement between the parties "TeamCare would provide specialty pharmacy services for members of Humana, more specifically Puerto Rico Reforms members." (Id. ) Additionally, Plaintiff alleged that "[d]uring the time that TeamCare provided services (medications) to the Reform members that Humana was responsible to manage, Humana continuously breeched the terms of said agreement..." (Id. ) Teamcare requested damages for $105,623.73, which according to the administrative complaint, "represents only the contractual fees for services that TeamCare provided to members of Humana's Reform Program." (Id. at 2). Finally, the administrative complaint contained a handwritten address at the end of its second page specifying that Teamcare's address was in Sanford, Florida. (Id. ) On March 21, 2011, ASES issued a Notification of Complaint to the parties and set a deadline for Humana to file its answer. (Docket No. 102, Exhibit P).

Subsequently, on June 16, 2011, Teamcare's President, Mark Schneider, and Humana representatives attended a status conference at ASES. (Docket No. 86, Exhibit D). During the hearing, Teamcare provided Humana with a document that contained a list of unpaid claims, which Humana agreed to evaluate. (Id. )

In response, on September 26, 2011, Humana Health provided to Mr. Schneider an Excel spreadsheet evaluating the claims Teamcare previously delivered (the "First Evaluation".) (Docket No. 86, Exhibit E). The First Evaluation analyzed fifty five (55) individual Reform claims for services from 2009 and 2010. (Id. ) Additionally, Humana detailed in the First Evaluation whether each claim had been paid, paid in part, denied, and denied in part, in addition to the reasons for denial. (Id. ) Following Humana's position, on January 3, 2012, Mr. Schneider of Teamcare wrote an email to Humana stating that the First Evaluation contained information that did not merit denials and cited the outstanding balance due to Teamcare in the spreadsheet. (Docket No. 86, Exhibit H). Mr. Schneider also requested copies of the cancelled checks that were referenced in the spreadsheet. (Id. ) In response, Humana provided to Mr. Schneider copies of the cancelled checks. (Docket No. 86, Exhibit J).

On November 1, 2013, more than ten months thereafter, ASES issued a Resolution dismissing Teamcare's administrative complaint for procedural inactivity since July 25, 2011. (Docket No. 86, Exhibit K). The ruling contained an additional notice informing the party adversary affected by the decisions of its right to seek reconsideration within twenty (20) days or appeal ASES's determination before the Puerto Rico Court of Appeals within thirty (30) days. (Id. ) ASES notified the Resolution to Humana's representatives and to Teamcare's Puerto Rico representative at his local address. (Id. at 2).

Next, on October 1, 2014, Teamcare filed the present action for breach of contract against Humana. (Docket No. 1). On December 4, 2014, Humana responded to the complaint by filing a Motion to Dismiss based primarily on res judicata grounds and, in the alternative, that the claim was time barred. (Docket No. 24). While the Motion to Dismiss was pending, on May 27, 2016, Teamcare provided Humana with another list of the claims at issue for Humana to review. (Docket No. 86, Exhibit L). Accordingly, on July 11, 2016, Humana sent Teamcare another Excell spreadsheet evaluating the claims delivered to them (the "Second Evaluation".) (Docket No. 86, Exhibit M). On September 4, 2014, this Honorable Court issued an opinion denying *433in part and holding in abeyance in part Defendants' Motion to Dismiss . (Docket No. 35). Specifically, this Court held that, although all the requirements for res judicata were met in this case, there was a public policy exception in Puerto Rico to its application in situations where, as here, a case was dismissed for lack of prosecutions. (Id. ) Additionally, this Court found that the three year statute of limitations period established in Article 1867 of the Civil Code of Puerto Rico, 31 L.P.R.A. § 5297 was tolled in the instant case by the filing of the administrative complaint before ASES. (Docket No. 46).

Accordingly, the parties proceeded to conduct discovery. Humana served Teamcare with a series of interrogatories asking Teamcare to "provide copy of the claims", "evidence of submission of each claim to Humana" and "a copy of any response and/or denial of payment issued by Humana for each claim". (Docket 86, Exhibit N at 5). Moreover, Humana asked Teamcare to state whether it was in agreement with Humana's evaluation of each claim and, if not, to provide the reasons for disagreement and specific evidence to support its position. (Id. at 6). Teamcare responded to Humana interrogatories by providing the following documents: (i) failure to pay claims, including HCFA forms, (ii) EOPs, (iii) Account Receivable Reports and related documents evidencing payment and non-payment of claims, (iv) correspondence between the parties, and (v) miscellaneous documents supporting Plaintiff's claims. (Docket 86, Exhibit O).

On June 16, 2017, Humana filed a Motion for Summary Judgment . (Docket No. 83). Teamcare then filed its Response to the Motion for Summary Judgment

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Bluebook (online)
296 F. Supp. 3d 429, Counsel Stack Legal Research, https://law.counselstack.com/opinion/teamcare-infusion-orlando-inc-v-humana-health-plans-of-puerto-rico-inc-usdistct-2017.