MARTHA VAZQUEZ, United States District Judge.
THIS MATTER comes before the Court on the Motion to Dismiss All Claims Against It filed by defendant Public Consulting Group, Inc. ("PCG"). [Doc. 7]. The Court, having considered the motion, briefs, and relevant law, and being otherwise fully informed, finds that the Motion is well-taken and will be granted.
Defendant United Behavioral Health, Inc. is a foreign corporation that does business on a national basis and is authorized to do business in New Mexico. [Complaint, Doc. 1-1 at ¶ 2]. Defendant United HealthCare Insurance Company, Inc. is a foreign insurance company that does business on a national basis and is authorized to and is doing business in New Mexico. Id. at ¶ 3. Defendants United Behavioral Health, Inc. and United HealthCare Insurance Company, Inc. conducted business in New Mexico through a "d/b/a/," Defendant Optum Health New Mexico ("OHNM") (collectively "United"). Id. at ¶ 4.
In 2009, United entered into a "Statewide Contract" with the New Mexico Human Services Department ("HSD") and its 16-member Inter-Agency Behavioral Health Purchasing Collaborative ("Collaborative") to act as New Mexico's "Statewide Entity" to establish, operate, manage, and pay for delivery of behavioral health and substance abuse services to children, families and adults enrolled through the Collaborative's various programs. Id. at ¶ 12. Pursuant to the Statewide Contract, from July 1, 2009, through June 30, 2013, United was to serve as the "Statewide Entity" to administer the delivery of behavioral health services to individuals enrolled in and eligible to receive services under the Collaborative's agency programs. Id. at ¶ 14. In turn, United, in its capacity as the Statewide Entity, entered into contracts with numerous healthcare
An express provision of the Statewide Contract obligated United to employ a person to be its dedicated Statement Contract Compliance Officer. Id. at ¶ 22. United was prohibited from assigning or delegating this key management function. Id. United's designated Compliance Officer responsible for exercising key management functions was indicted on May 28, 2014, for alleged criminal misconduct relating to allegations of falsifying records. Id. at ¶ 23. The allegations of the Complaint arise from incidents occurring from 2009 through 2012. Id.
Plaintiffs allege that United mismanaged its Statewide Contract and, in order to cover up its mismanagement, accused its healthcare providers, including Plaintiffs, of engaging in institutional fraud. Id. at ¶¶ 35, 43. Plaintiffs further allege that in 2012, United knew that HSD's newly-designed behavioral health services delivery model under New Mexico Centennial Care would be the subject of procurement in 2012 and become effective January 1, 2014. Id. at ¶ 40. Under the new Centennial Care Model, United would no longer be the Statewide Entity for delivery of all behavioral health and substance abuse services for the Collaborative. Id. United wanted new contracts with HSD after its Statewide Contract expired on June 30, 2013. Id. Plaintiffs allege that in order to achieve its New Mexico contract and company revenue goals, United needed an exit strategy from its Statewide Contract that would expire June 30, 2013. Id. at ¶ 41. As one component of United's strategy, United sought and received, effective September 4, 2012, a six-month extension on its Statewide Contract through December 31, 2013. Id. at ¶ 42. Another component of United's strategy was to cover up its defective data and claims processing system and its mismanagement of state and federal money by blaming its subcontracted providers, including Plaintiffs, for billing errors that United characterized as "institutional fraud." Id. at ¶ 43.
On or about October 25, 2012, Defendant Elizabeth A. Martin, the Chief Executive Officer of OHNM, made a written proposal to the Collaborative representing that United could solve the made-up "institutional fraud" problem by terminating United's existing contracted "bad actors," including Plaintiffs, and substituting Arizona providers to "assume wholesale management" of New Mexico's behavioral health services. Id. at ¶¶ 5, 44.
The written proposal suggested that United "import from a neighboring state accredited provider(s) of greater or equal size fully vetted by the State," and represented that United's Arizona network of behavioral health providers could assume wholesale management to maintain uninterrupted delivery of behavior health and substance abuse services to United's Enrollees in New Mexico. Id. at ¶ 47.
Defendant Martin also asked the Collaborative for "legal clarification of who owns the dollars if recovery ensues" over concerns that there was no incentive for United to deal with the made-up "institutional fraud" if United did not get a cut of any recovery. Id. at ¶ 45. On May 13, 2013, United, the Collaborative and HSD executed the Professional Services Contract, Contract Amendment No. 15, which provided that United was entitled to receive up to 40% of all state funds recovered from any United subcontracted provider that United accused of fraud. Id. at ¶ 46.
The Complaint alleges that in December 2012 and January 2013, United conducted "pre-audit investigations" of several of its subcontracted behavioral health care and
Based on United's pre-audit summary, in February 2013, HSD contracted with defendant Public Consulting Group, Inc. ("PCG") to conduct a confidential audit of 15 of United's subcontracted providers, including Plaintiffs, at a cost to New Mexico of $3 million. Id. at ¶ 37. These 15 subcontracted providers constituted approximately 87% of the Collaborative's spending for Medicaid and state-funded non-Medicaid behavioral health and substance abuse services. Id.
Plaintiffs allege that although the PCG audit was supposed to be confidential between the Collaborative and PCG, United actually participated "in partnership" with PCG to audit United's subcontracted providers. Id. at ¶ 38.
Based on "information and belief," plaintiffs further allege that:
Plaintiffs allege that United, HSD and PCG developed a scorecard for each provider, rating them between 1 ("Compliant") and 4 ("Significant Non-Compliance"), then used scorecards to categorize the providers in Risk Tiers from 1 through 4 in the PCG Audit as follows:
Id. at ¶ 56.
The "confidential" final audit report, dated June 21, 2013, found, inter alia, the following:
a. United overpaid fifteen of its subcontracted providers approximately $37.3 million over the period of July 2009-January 2013. United's overpayment amounted to approximately 15% of the money New Mexico annually paid to United. Id.
b. United's claims processing system was not capable of timely and properly adjudicating provider claims. United's promise to use "best practices" in encounter and claims processing in compliance with federal and state statutory and regulatory schemes was not implemented. Id. at ¶ 38.
Plaintiffs allege that PCG ranked none of Plaintiffs higher than a 3. Id. at ¶ 57. Although PCG determined that all fifteen of the audited providers failed the audit, it nonetheless concluded that: "PCG's Case File Audit did not uncover what it would consider to be credible allegations of fraud, nor any significant concerns related to consumer safety." Id. at ¶ 58.
The Complaint alleges that three days later, on June 24, 2013, it was publically announced that HSD received "credible allegations of fraud" concerning 15 of United's contracted non-profit providers of behavioral health services, including Plaintiffs, "which HSD spun as the providers having actually defrauded the Medicaid program out of $36 million over a three-year period." Id. at ¶ 39. The allegations affected 40% of United's Enrollees, and involved 87% of the money spent through the Collaborative by United. Id.
On June 24, 2013, HSD officials met with all 15 behavioral healthcare providers, including Plaintiffs, and notified them that HSD was going to suspend payments to all 15 providers immediately based upon a "credible allegation of fraud" pursuant to 42 C.F.R. § 455.23(a)(1). Id. at ¶ 61. HSD suspended in excess of $11,500,000 in payments due and owing to Plaintiffs for services rendered to United Enrollees. Id. at ¶ 62. HSD's June 24, 2013, suspension letters to each provider stated that the suspension of payments was "temporary" and would be in effect until (1) prosecuting authorities determined there was insufficient evidence of fraud or alleged fraud or willful misrepresentation by the provider, (2) legal proceedings related to the provider's alleged fraud or willful misrepresentation were completed, or (3) the provider applied for, and received, a "good cause" release of suspended payments pursuant to 42 C.F.R. § 455.23(c). Id. at ¶ 63.
Plaintiffs submitted timely "good cause" requests for release of the suspended payments, which HSD denied. Id. at ¶¶ 64-65.
MFCU concluded its investigations of Plaintiffs Easter Seals El Mirador and The Counseling Center, Inc. in 2014; Plaintiffs Border Area Mental Health, Inc., Counseling Associates, Inc., Families & Youth,
As a result, Plaintiffs allege they are owed payments totaling $11.5 million. Id. at ¶ 62.
On June 23, 2016, Plaintiffs filed suit in the First Judicial District Court of New Mexico, Santa Fe County, against United Behavioral Health and United Healthcare Insurance Company, doing business as OHNM, Elizabeth Martin, Chief Executive Officer of OHNM, Andrew Sekel, Chief Executive Officer of OptumHealth Behavioral Solutions, and Timothy S. Miller, regional manager for OHNM, collectively referred to as the "United Defendants," in addition to the PCG, the entity that was hired to conduct the audits of Plaintiffs. [Doc. 1-1]. On November 3, 2016, the United Defendants removed the action to this Court. [Doc. 1].
In their Complaint, Plaintiffs allege claims against PCG for (1) tortious interference with contractual relations, (2) prima facie tort, (3) civil conspiracy, and (4) violations of the New Mexico Unfair Practices Act. [Doc. 1-1]. PCG moved to dismiss all four claims. [Doc. 8].
On July 18, 2017, the Court entered a Stipulated Order granting in part PCG's Motion to Dismiss and dismissing with prejudice Plaintiffs' Unfair Practices Act claim against PCG. [Doc. 44].
Under Rule 12(b)(6), a Court may dismiss a complaint for "failure to state a claim upon which relief can be granted." Fed. R. Civ. P. 12(b)(6). "The nature of a Rule 12(b)(6) motion tests the sufficiency of the allegations within the four corners of the complaint after taking those allegations as true." Mobley v. McCormick, 40 F.3d 337, 340 (10th Cir. 1994). The sufficiency of a complaint is a question of law, and when considering a Rule 12(b)(6) motion, the Court must accept as true all well-pled factual allegations in the complaint, view those allegations in the light most favorable to the non-moving party, and draw all reasonable inferences in the plaintiff's favor. See Tellabs, Inc. v. Makor Issues & Rights, Ltd., 551 U.S. 308, 322, 127 S.Ct. 2499, 168 L.Ed.2d 179 (2007); Smith v. United States, 561 F.3d 1090, 1098 (10th Cir. 2009) (citation omitted), cert. denied, 558 U.S. 1148, 130 S.Ct. 1142, 175 L.Ed.2d 973 (2010).
A complaint need not set forth detailed factual allegations, yet a "pleading that offers labels and conclusions or a formulaic recitation of the elements of a cause of action" is insufficient. Ashcroft v. Iqbal, 556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009) (citing Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007)). "Threadbare recitals of the elements of a cause of action, supported by mere conclusory statements, do not suffice." Id.
To survive a motion to dismiss pursuant to Rule 12(b)(6), a plaintiff's complaint must contain sufficient facts that, if assumed to be true, state a claim to relief that is plausible on its face. See Twombly, 550 U.S. at 570, 127 S.Ct. 1955; Mink v.
Robbins v. Okla., 519 F.3d 1242, 1247 (10th Cir. 2008) (quoting Twombly, 550 U.S. at 570, 127 S.Ct. 1955).
PCG contends Plaintiffs' remaining claims should be dismissed because (1) the Complaint fails to state a claim against PCG for intentional interference with contractual relations; (2) Plaintiffs' prima facie tort claim fails to allege that PCG acted lawfully and with specific intent to harm Plaintiffs; and (3) Plaintiffs' claim for civil conspiracy is not actionable.
In order to state a claim for intentional interference with existing contracts, a plaintiff must allege:
Deflon v. Sawyers, 139 N.M. 637, 137 P.3d 577, 643 (2006) (citing Ettenson v. Burke, 130 N.M. 67, 17 P.3d 440, 446 (2001)). "In New Mexico, it is not easy for a plaintiff to succeed on a tortious-interference-with-contract claim." Carreon v. Goodtimes Wood Products, Inc., 2011 WL 9686895, at *2 (D.N.M. Mar. 22, 2011).
PCG contends the well-pled facts of the Complaint (a) fail to establish the existence of a contract between Plaintiffs and HSD; (b) fail to plausibly state that PCG caused, induced or persuaded HSD's determination; and (c) fail to state that PCG acted with improper motive and without justification or privilege.
The Complaint alleges that Plaintiffs provided behavioral healthcare services to New Mexico Medicaid beneficiaries through contracts with the New Mexico HSD and other state agencies. [Doc. 1-1, ¶ 5]. However, the Court is unable to infer the existence of any valid and enforceable contracts from this vague reference. See Burnett v. Mortg. Elect. Registration Sys., Inc., 706 F.3d 1231, 1241 ("Legal conclusions can provide the framework of a complaint, [but] they
The New Mexico Supreme Court has stated:
Wolf v. Perry, 339 P.2d 679, 682 (N.M. 1959) (citations omitted) (emphasis added).
The Complaint alleges that:
Importantly, the allegations in paragraphs ¶¶ 35 and 37 of the Complaint — taken as true — establish that HSD had already decided what its determination would be well before PCG was hired in February 2013 to conduct an audit. Taking these well-pleaded factual allegations as true, Plaintiffs could not prevail on a claim for intentional interference with contractual relations, because "[t]here must be some voluntary conduct on the part of the defendant, some overt act which influences the promisor to breach his contract." Wolf, 339 P.2d at 682 (emphasis added). According to the Complaint, HSD had already decided it was going to terminate the agreements before PCG was retained.
Further, the allegations in paragraphs 55 and 72 — that PCG agreed in advance that it would find credible allegations of fraud against Plaintiffs — are contradicted by the following factual allegations in the Complaint:
These paragraphs establish that, contrary to the allegations in paragraphs 55 and 72 of the Complaint, PCG's audit concluded there were no credible allegations of fraud or any significant concerns related to safety, and that HSD — not PCG — ordered these conclusions removed from the report when it was released to the public. Accordingly, the Court finds that the Complaint fails to allege "some overt act which influence[d] the promisor to breach [its] contract." Wolf, supra.
PCG argues that Plaintiffs have failed to allege any facts supporting the fifth element of a claim for intentional interference with contractual relations — that PCG induced the breach without privilege
Martin v. Franklin Capital Corp., 145 N.M. 179, 195 P.3d 24, 27 (2008) (citations and quotation marks omitted). The Complaint alleges that, "Upon information and belief, Defendants acted with an improper motive to destroy Plaintiffs' businesses and other improper motives yet to be discovered." [Doc. 1-1, ¶ 72]. However, the Complaint pleads no factual basis for this allegation, nor does it contain any factual allegations that shed light on the issue of what would motivate PCG — a third-party out-of-state consulting firm — to destroy Plaintiffs' businesses.
Similarly, the Complaint states that PCG and other Defendants "used improper means including but not limited to fabricating allegations of Medicaid fraud against Plaintiffs and violating standard auditing practices to support Defendants' pre-determined outcome that HSD would make a finding of `credible allegations of fraud' against Plaintiffs, suspend payments due and owing to them, and refer them to MFCU for investigation." Id. at ¶ 72. However, this statement is contradicted by paragraph 58 of the Complaint, which alleges that "PCG's Case File Audit did not uncover what it would consider to be credible allegations of fraud, nor any significant concerns related to consumer safety." Id. at ¶ 58. Because the Complaint fails to set forth sufficient facts to state a plausible claim for intentional interference with existing contracts, PCG's Motion to Dismiss this claim must be granted.
In order to state a claim for prima facie tort, Plaintiffs must allege: 1) an intentional and lawful act; 2) an intent to injure the plaintiff; 3) injury to the plaintiff as a result of the intentional act; and 4) the absence of justification for the injurious act. Kitchell v. Public Serv. Co. of New Mexico, 126 N.M. 525, 972 P.2d 344, 348 (1998) (emphasis added).
The Complaint fails to allege that the prima facie tort claim arises from, or is based on lawful conduct by PCG. [Doc. 1-1 ¶¶ 75-80]. To the contrary, in asserting their claims for tortious interference with contractual relations and civil conspiracy, Plaintiffs allege PCG acted unlawfully. Id. Plaintiffs' prima facie tort claim is based on the same conduct alleged in the other claims. Accepting as true Plaintiffs' allegations that PCG acted unlawfully, then they cannot allege the same conduct was lawful in their prima facie tort claim. See Hill v. Cray Research, Inc., 864 F.Supp. 1070, 1078 (D. N.M. 1991) (holding that if defendants' termination of plaintiff's employment was in breach of an implied contract or a tortious wrongful discharge, and thereby in either instance unlawful, the first element of the prima facie tort claim — lawful conduct — could not be met).
Additionally, to plead a viable claim for prima facie tort, Plaintiffs must allege that PCG acted intentionally with a specific intent to injure them. Schmitz v. Smentowski, 109 N.M. 386, 785 P.2d 726, 737 (1990) (holding that prima facie tort
Plaintiffs have not satisfied the pleading requirement for the prima facie tort claim, and, in light of the factual statements they make in their claims for intentional interference with contract and civil conspiracy — i.e. that PCG acted unlawfully — they cannot state a claim for prima facie tort. Therefore, the claim must be dismissed.
Plaintiffs allege Defendants "conspired with HSD and the Collaborative to interfere with Plaintiffs' contractual relationships with HSD and other state agencies and to commit prima facie tort," and are therefore "jointly and severally liable for each other's, HSD's and the Collaborative's wrongful conduct in interfering with Plaintiff's contractual relationships with HSD and other State agencies and prima facie tort." Doc. 1-1 at ¶¶ 81-82. They claim entitlement to actual and punitive damages. Id. at ¶¶ 83-84. PCG seeks dismissal of the conspiracy claim.
To establish a defendant's liability for a civil conspiracy, plaintiffs must allege and prove:
Ettenson v. Burke, 130 N.M. 67, 17 P.3d 440, 445 (2000) (citations omitted) (emphasis added). PCG argues that since Plaintiffs' claims for tortious interference with contract and prima facie tort are subject to dismissal, the civil conspiracy, too, must be dismissed. The Court agrees. The Court's determination herein that the Complaint fails to state a viable claim against PCG for either tortious interference with contract or prima facie tort leaves Plaintiffs with no viable claim against PCG that would "give rise to a civil action of its own." Id. Accordingly, the civil conspiracy claim against PCG must also be dismissed.
As set forth above, the well-pleaded facts of the Complaint, taken as true, do not establish any basis for Plaintiffs' claims for intentional interference with contractual relations, prima facie tort or civil conspiracy. Accordingly, the Instant Complaint must be dismissed in its entirety.