United Teamster Fund v. MagnaCare Administrative Services, LLC

39 F. Supp. 3d 461, 59 Employee Benefits Cas. (BNA) 2120, 2014 WL 4058070, 2014 U.S. Dist. LEXIS 113307
CourtDistrict Court, S.D. New York
DecidedAugust 14, 2014
DocketNo. 13 Civ. 6062(WHP)
StatusPublished
Cited by26 cases

This text of 39 F. Supp. 3d 461 (United Teamster Fund v. MagnaCare Administrative Services, LLC) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United Teamster Fund v. MagnaCare Administrative Services, LLC, 39 F. Supp. 3d 461, 59 Employee Benefits Cas. (BNA) 2120, 2014 WL 4058070, 2014 U.S. Dist. LEXIS 113307 (S.D.N.Y. 2014).

Opinion

MEMORANDUM & ORDER

WILLIAM H. PAULEY III, District Judge:

This case involves a dispute between ERISA funds and their third-party plan administrator over compensation and the quality of services rendered. MagnaCare Administrative Services, LLC and Magna-Care, LLC (collectively “MagnaCare”) move to dismiss the Complaint. The Trustees of the United Teamster Fund (UTF) and Local 522 Welfare Fund of New York and New Jersey (collectively “The Funds”) move to dismiss MagnaCare’s Counterclaim. Alternatively, the Trustees move for summary judgment dismissing the Counterclaim. For the reasons that follow, MagnaCare’s motion to dismiss is granted in part and denied in part, the Trustees’ motion for summary judgment is granted, and the Trustees’ motion to dismiss is denied as moot.

BACKGROUND

The Funds are self-insured health benefit plans.1 In 2001, UTF’s trustees hired MagnaCare to serve as UTF’s third-party plan administrator. Local 522’s trustees engaged MagnaCare on the same terms in 2005. The Trustees terminated the contracts in early 2014. (Charles Pergue Aff. Ex. B, at 1, ECF No. 25; Pergue Aff. Ex. D, at 1.). For its services, MagnaCare received administrative fees—based on the number of eligible employees—and management fees in an undisclosed amount for processing laboratory diagnostic services claims.

A diagnostic fee schedule developed by MagnaCare set the aggregate rate the Funds paid for each laboratory diagnostic service. According to the parties’ Service Agreements (“Agreement”), each diagnostic fee included both MagnaCare’s management fee2 and the provider’s fee. But, [467]*467without the Trustees’ knowledge, Magna-Care negotiated better rates with providers and kept the difference. As a result, it retained over 65% of the diagnostic fee schedule payments without the Trustees’ knowledge. The Funds paid over $8.5 million in management fees between 2005 and 2013. These management fees were of a similar magnitude to the administrative fees paid by the Funds. Unbeknownst to the Trustees, MagnaCare also began adding a $l-$2 management fee to each durable medical equipment3 claim in late 2001, a charge absent from the Agreement. The Agreement provided that management fees and provider fees were to be paid from the Funds’ Health Benefit Claim Accounts, (Compl. Ex. 1 § 4.2(B),) and in practice all but UTF’s laboratory diagnostic provider fees were paid directly from the Health Benefit Claim Accounts, (Compl. ¶ 33). Although MagnaCare submitted monthly claims reports " to the Funds, these reports never itemized or mentioned any management fee.

Under the Agreement, MagnaCare had a duty to adjudicate claims “with the care, skill, prudence and diligence that a competent professional administrator, consistent with industry standards, would exercise with regard to an employee benefit fund subject to ERISA.” (Compl. ¶ 69 & Ex. 1 § 6(a)(i).) The Trustees point to five failures in MagnaCare’s adjudication of claims, including (1) authorizing payment of laboratory test claims submitted piecemeal that improperly maximize a provider’s fees, (2) permitting rampant overuse of claims for extended office visits, (3) authorizing payment of laboratory services not supported by the physician’s diagnosis, (4) failing to use a quality control technique known as “code pairing edits” to prevent improper payment of duplicative medical procedure claims, and (5) authorizing reimbursement of double billed claims. These errors caused the Funds to overpay claimants by more than $2.6 million.

In particular, the federal government developed “code pairing edits” as a quality control technique to improve the adjudication of Medicare claims. Certain, “global” medical procedures encompass other, minor medical procedures incident to the global procedure. When a provider seeks reimbursement for the global procedure and the subsumed, minor procedure at the same time, the code pairing edits prevent the provider from receiving double reimbursement. Fifty-nine of the code pairing edits have been adopted widely by third-party plan administrators. MagnaCare applied none of these code pairing edits to its adjudication of claims for the Funds, causing the Funds to overpay providers by more than $600,000.

Costs covered by the Workers Compensation Program are not covered by the Funds. When the Funds pay a provider for a claim that should have been covered by the Workers Compensation Plan, the Funds are entitled to a refund from the provider. But MagnaCare kept 25% of approximately 100 workers compensation [468]*468claims refunded to UTF without consulting UTF’s trustees.

MagnaCare purports to offer discounted provider rates in the Agreement. But it reimburses its network hospitals approximately 36% more for inpatient costs than the average commercial payer. This reimbursement rate caused the Funds to pay $1.3 million more than the average commercial payor.

In sum, the Funds allege that Magna-Care’s secret optimization of its fees violated MagnaCare’s fiduciary and contractual duties.

MagnaCare responds with a counterclaim alleging that the Trustees breached their fiduciary duties under ERISA by waiting thirteen years to assert their claims. MagnaCare contends the Trustees’ derelictions cost the Funds millions of dollars and that it would be inequitable to hold MagnaCare accountable for any of the Trustees’ breaches.

DISCUSSION

I. Legal Standard

To survive a motion to dismiss, “a complaint must contain sufficient factual matter, accepted as true, to ‘state a claim to relief that is plausible on its face.’ ” Ashcroft v. Iqbal, 556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007)). To determine plausibility, courts follow a “two-pronged approach.” Iqbal, 556 U.S. at 679, 129 S.Ct. 1937. “First, although a court must accept as true all of the allegations contained in a complaint, that tenet is inapplicable to legal’ conclusions, and [t]hreadbare recitals of the elements of a cause of action, supported by mere conclu-sory statements, do not suffice.” Harris v. Mills, 572 F.3d 66, 72 (2d Cir.2009) (alteration in original) (internal quotation marks and citation omitted). Second, a court determines “whether the Veil-pleaded factual allegations,’ assumed to be true, ‘plausibly give rise to an entitlement to relief.’ ” Hayden v. Paterson, 594 F.3d 150, 161 (2d Cir.2010) (quoting Iqbal, 556 U.S. at 679, 129 S.Ct. 1937).

II. MagnaCare’s Motion to Dismiss the Funds’ Complaint

The Funds bring an ERISA claim for breach of fiduciary duty and New York state law claims for breach of contract, breach of the implied covenant of good faith and fair dealing, fraud, negligent misrepresentation, conversion, unjust enrichment, and violation of the New York Deceptive Acts and Practices. MagnaCare moves to dismiss the Complaint in its entirety.

A. ERISA Claim

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Bluebook (online)
39 F. Supp. 3d 461, 59 Employee Benefits Cas. (BNA) 2120, 2014 WL 4058070, 2014 U.S. Dist. LEXIS 113307, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-teamster-fund-v-magnacare-administrative-services-llc-nysd-2014.