United Healthcare Services Incorporated v. Advanced Reimbursement Solutions LLC

CourtDistrict Court, D. Arizona
DecidedSeptember 30, 2022
Docket2:21-cv-01302
StatusUnknown

This text of United Healthcare Services Incorporated v. Advanced Reimbursement Solutions LLC (United Healthcare Services Incorporated v. Advanced Reimbursement Solutions LLC) is published on Counsel Stack Legal Research, covering District Court, D. Arizona primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United Healthcare Services Incorporated v. Advanced Reimbursement Solutions LLC, (D. Ariz. 2022).

Opinion

1 WO 2 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA

9 United Healthcare Services Incorporated, et No. CV-21-01302-PHX-DLR (CDB) al., 10 ORDER Plaintiffs, 11 v. 12 Advanced Reimbursement Solutions LLC, 13 et al.,

14 Defendants. 15 16 17 Plaintiffs United Healthcare Services, Incorporated and UnitedHealthcare Insurance 18 Company (collectively, “United”) accuse Defendants—a medically billing company called 19 Advanced Reimbursement Solutions, LLC (“ARS”) and a host of healthcare providers who 20 contracted with ARS for billing services (“Provider Defendants”)—of healthcare fraud. At 21 issue are seven motions to dismiss filed by the Provider Defendants. (Docs. 75, 80, 81, 82, 22 87, 89, 107) ARS also filed a motion to dismiss (Doc. 76), parts of which have been joined 23 by the Provider Defendants. But ARS later filed for bankruptcy (Doc. 212), automatically 24 staying proceedings against it. See 11 U.S.C. § 362. Though the Court has considered those 25 portions of ARS’s brief joined by the Provider Defendants, ARS’s motion has been 26 terminated. (Doc. 213.) For reasons explained below, all motions to dismiss are denied.1 27

28 1 Oral argument is denied because the issues are exhaustively briefed and argument will not help the Court. See Fed. R. Civ. P. 78(b); LRCiv. 7.2(f). 1 I. Background2 2 United brings claims on its own behalf as the provider of fully insured health plans, 3 and in its capacity as claims administrator for self-funded, employer-established health 4 plans that retain United as a third-party administrator. United’s policies and plans impose 5 requirements designed to limit the cost of care. For example, plan members have cost- 6 sharing obligations, such as deductibles, co-pays, and co-insurance. United requires 7 providers to collect copayments and coinsurance and generally prohibits providers from 8 waiving those cost-sharing obligations. United also controls costs by entering into network 9 contracts with providers that set rates United will pay for services rendered. Out-of- 10 network providers have not agreed to a particular reimbursement for their services and 11 therefore can charge more that in-network providers. But to discourage members from 12 obtaining care from more expensive out-of-network providers, United typically imposes 13 higher cost-sharing obligations on members for out-of-network services. United also 14 discourages in-network providers from referring plan members to out-of-network 15 providers by requiring in-network providers to obtain either approval from United or the 16 plan member’s written consent prior to such referrals. 17 The Provider Defendants are out-of-network providers. During the relevant time 18 period, they contracted with ARS. In exchange for providing the Provider Defendants with 19 billing services, ARS received a portion of their reimbursements. United alleges that 20 Defendants submitted inaccurate, fraudulent bills designed to extract inflated payments 21 from United. For example, United accuses Defendants of inducing in-network providers 22 to refer patients to the out-of-network Provider Defendants in violation of their contracts 23 with United, coaxing plan member into obtaining out-of-network services by improperly 24 waiving their cost-sharing obligations, submitting bills with improper procedure codes and 25 that misrepresented the nature of the Provider Defendants’ facilities, knowingly submitting 26 claims for experimental, uncovered medical treatments, and misrepresenting their actual 27 2 The following background is derived from United’s complaint (Doc. 1) and 28 presumed true for purposes of this order. See Cousins v. Lockyer, 568 F.3d 1063, 1067 (9th Cir. 2009) 1 rates by instead billing at exaggerated rates required by ARS. 2 United alleges nine claims: (1) fraud; (2) negligent misrepresentation; (3) violation 3 of the Arizona Consumer Fraud Act (“ACFA”); (4) violation of the Arizona Insurance 4 Code (“AIC”); (5) tortious interference with contract; (6) unjust enrichment/money had 5 and received; (7) civil conspiracy; (8) restitution under § 502(a)(3) of the Employee 6 Retirement Income Security Act (“ERISA); and (9) declaratory and injunctive relief under 7 § 502(a)(3) of ERISA.3 The Provider Defendants move to dismiss all claims against them. 8 II. Legal Standard 9 The Federal Rules of Civil Procedure require a pleading to contain “a short and plain 10 statement of the claim showing that the pleader is entitled to relief[.]” Fed. R. Civ. P. 11 8(a)(2). “To avoid a Rule 12(b)(6) dismissal, a complaint need not contain detailed factual 12 allegations; rather, it must plead ‘enough facts to state a claim to relief that is plausible on 13 its face.’” Clemens v. DaimlerChrysler Corp., 534 F.3d 1017, 1022 (9th Cir. 2008) 14 (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544 (2007)). When ruling on a motion to 15 dismiss, the Court does not assess whether the pleading’s allegations are, in fact, true. 16 Instead, well-pled factual allegations are accepted as true and construed in the light most 17 favorable to the pleader. Cousins v. Lockyer, 568 F.3d 1063, 1067 (9th Cir. 2009). The 18 Court’s task merely is to determine whether those well-pled factual allegations plausibly 19 state a claim to relief under governing law. See Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009). 20 The federal rules set a heightened pleading standard for allegations of fraud. “In 21 alleging fraud . . . a party must state with particularity the circumstances constituting fraud 22 or mistake. Malice, intent, knowledge, and other conditions of a person’s mind maybe 23 alleged generally.” Fed. R. Civ. P. 9(b). “Averments of fraud must be accompanied by the 24 who, what, when, where, and how of the misconduct charged.” Vess v. Ciba-Geigy Corp. 25 USA, 317 F.3d 1097, 1106 (9th Cir. 2003) (quotations and citation omitted). When multiple 26 defendants are sued in connection with an alleged fraudulent scheme, there is no

27 3 The complaint contains a section entitled “fraudulent concealment,” but United has clarified in its response brief that this section does not state an independent claim; 28 instead, United makes these allegation for purposes of tolling the limitations periods for the claims it has alleged. 1 requirement that the pleader identify every instance of fraudulent conduct for every 2 defendant. Swartz v. KPMG LLP, 476 F.3d 756, 764 (9th Cir. 2007). Though “Rule 9(b) 3 does not allow a complaint to merely lump multiple defendants together,” in fraud suits 4 involving multiple defendants it is sufficient for a pleader to identify the role each 5 defendant played in the alleged fraudulent scheme. Id. at 764-65. 6 Further, in cases such as this one, involving thousands of alleged fraudulent 7 transactions, specifying each and every transaction with the particularity ordinarily 8 demanded by Rule 9(b) “is neither practical nor required.” Nutrishare, Inc. v.

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United Healthcare Services Incorporated v. Advanced Reimbursement Solutions LLC, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-healthcare-services-incorporated-v-advanced-reimbursement-solutions-azd-2022.