California Spine and Neurosurgery Institute v. United Healthcare Services, Inc. et al.

I. BACKGROUND

Plaintiff is a medical provider. Defendant is a health insurance company. Compl. (Dkt. No. 1-1) ¶ 5. Plaintiff provided medical services to Patient, an insured of Defendant.1 Compl. ¶¶ 5, 26. Plaintiff alleges that, in order to decide

1 Due to privacy concerns and the Health Insurance Portability and Accountability Act (“HIPPA”), the parties are not naming the Patient. whether to provide services to Patient, Plaintiff’s representative spoke with Defendant’s representative “regarding the manner in which [Plaintiff] would be paid for services.” Id. ¶ 27. Plaintiff asked Defendant what the was “the Patient’s responsibility versus the Defendant’s responsibility for paying” for the services; if Defendant pays based on “usual, customary, and reasonable” (“UCR”) rates for 4 specific procedure codes and related codes; and if Defendant uses a Medicare fee schedule for those codes. Defendant answered the questions, including by confirming that Defendant pays the UCR rate and does not base payment on the Medicare fee schedule. Id. ¶¶ 28-33. In reliance on Defendant’s representations, Plaintiff provided the services to Patient. Id. ¶ 40. Plaintiff billed Defendant $85,000 for…