JOHN A. GIBNEY, JR., District Judge.
In 2015, a child died at Henrico Doctors' Hospital
Multiplan has moved to dismiss for failure to state a claim, arguing that the Hospital has not identified any provision of the PFA that it breached and that the PFA insulates it from liability. Because the Hospital plausibly pleads that Multiplan breached the PFA, the Court will deny Multiplan's motion to dismiss.
The Hospital and Multiplan entered into the PFA on August 1, 2002. Under the PFA, the Hospital agreed to provide healthcare services and accept reimbursement from Multiplan's "Payors" or "Clients" at a reduced rate. As a Multiplan Client, CoreSource has access to Multiplan's PPO Network, which includes the Hospital. CoreSource pays Multiplan to access the PPO Network "based upon on a percentage of the discount CoreSource receives from the billed charges of Participating Providers in the Multiplan PPO Network." (Dk. No. 19, at ¶ 17.)
In 2015, a child died in the Hospital's neonatal intensive care unit following a premature birth. When the Hospital sought reimbursement from CoreSource, CoreSource paid the Hospital $586,484.60 less than the Hospital spent on the child's care. CoreSource explained that it reduced the Hospital's reimbursement in part due to "billing errors" and as an "authorization penalty." (Id. at ¶¶ 26-27.)
The Hospital relies on two provisions of the PFA to support its claim against Multiplan. First, section 3.1(a) of the PFA provides, "[t]he Payor shall pay the Participating Provider for such services rendered in accordance with the terms and under the express conditions of this Agreement." (Dk. No. 25-1, at § 3.1(a).)
Multiplan has moved to dismiss for failure to state a claim, arguing that the Hospital has failed to identify any provision of the PFA that Multiplan breached and that the PFA shields it from liability.
To state a claim for breach of contract under Virginia law, a plaintiff must plead facts showing "(1) a legally enforceable obligation of a defendant to a plaintiff; (2) the defendant's violation or breach of that obligation; and (3) injury or damage caused by the breach of that obligation." Filak v. George, 267 Va. 612, 619, 594 S.E.2d 610, 614 (2004). Multiplan argues that the Hospital has not identified any provision of the PFA that it breached. Id.
The Hospital contends that Multiplan breached sections 3.1(a) and 4.1(i) of the PFA. First, the Hospital asserts that section 3.1(a) imposes an obligation on Multiplan to require CoreSource to pay the Hospital "in accordance with the terms and under the express conditions" of the PFA. (Dk. No. 19, at ¶ 13.) Second, the Hospital argues that section 4.1(i) obligates Multiplan to require CoreSource "to comply with all requirements and responsibilities in the PFA." (Id.)
The Hospital alleges that Multiplan breached sections 3.1(a) and 4.1(i) when it failed to require CoreSource to correctly reimburse the Hospital. Taken as true, the Hospital's allegations plausibly show that Multiplan breached sections 3.1(a) and 4.1(i) of the PFA.
Multiplan argues that section 4.1(f) of the PFA insulates it from liability in this case. Section 4.1(f) of the PFA provides, "Multiplan shall not be responsible or liable for any claims decisions or for the payment of any claims submitted by any provider ... [and] shall not be an insurer, guarantor, or underwriter of the responsibility or liability of any Client." (Dk. No. 25-1, at § 4.1(f).) The Hospital does not allege that Multiplan qualifies as "an insurer, guarantor, or underwriter of the responsibility or liability" of CoreSource. (Id.) Instead, the Hospital merely seeks to hold Multiplan liable for allegedly breaching its obligations under sections 3.1(a) and 4.1(i) of the PFA. Multiplan, therefore, cannot use section 4.1(f) as a shield to avoid liability at this juncture. See Sarasota Cty. Pub. Hosp. Dist. v. Multiplan, Inc., No. 8:18-cv-252, 2018 WL 4698459, at *4 n.4 (M.D. Fla. Oct. 1, 2018) (rejecting a similar argument advanced by Multiplan as "misguided").
Although the Court "takes no position on the ultimate validity of [the Hospital's] claim, ... the Court cannot at this juncture conclude that [the Hospital] is not entitled to relief." Seneca Ins. Co. v. Shipping Boxes I, LLC, 30 F.Supp.3d 506, 511 (E.D. Va. 2014). The Court, therefore, will deny Multiplan's motion to dismiss.
Because the Hospital plausibly pleads a breach of contract claim against Multiplan, the Court will deny Multiplan's motion to dismiss.
The Court will issue an appropriate Order.
Let the Clerk send a copy of this Opinion to all counsel of record.