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Upstate Lung & Critical Care Specialists v. Care Improvement Plus Practitioners, LLC

United States District Court, D. South Carolina, Spartanburg Division

June 6, 2017

CARE IMPROVEMENT PLUS PRACTITIONERS, LLC, d/b/a Care Improvement Plus, Defendant.




         Plaintiff Upstate Lung & Critical Care Specialists, P.C. (Plaintiff) filed this lawsuit as a breach of contract action against Defendant Care Improvement Plus Practitioners, LLC (Defendant). The Court has jurisdiction over the matter under 28 U.S.C. § 1332. Pending before the Court is Defendant's motion to dismiss the Amended Complaint pursuant to Federal Civil Procedure Rule 12(b)(6), or, in the alternative, for summary judgment under Federal Civil Procedure Rule 56 (Defendant's motion). Because Defendant's motion presents materials outside the pleadings and the Court has considered these materials, the Court will treat Defendant's motion as one for summary judgment, pursuant to Federal Civil Procedure Rule 12(d). Having carefully considered Defendant's motion, the response, the reply, the record, and the applicable law, the Court will deny Defendant's motion.


         In the Amended Complaint, Plaintiff avers the parties entered into a contractual agreement in 2009 “for [Plaintiff] to provide healthcare services for the benefit of the Defendant's insureds and the Defendant to pay [Plaintiffs] claims for such services." ECF No. 20 5; ECF No. 20-1. Plaintiff also claims the parties negotiated and drafted a subsequent agreement in 2010, and contends that contract should be controlling in this action. ECF No. 20 ¶¶ 6-8; ECF No. 20-2; ECF No. 31 at 2. According to Plaintiff, Defendant “failed to perform its obligations under said agreement by not paying [Plaintiff] for healthcare services that have been provided on behalf of Defendant" in the amount of $329, 783.12. ECF No. 20 11.

         Both the 2009 and 2010 contracts relate solely to services under Medicare Part C, which is Medicare Advantage; and the contracts expressly state that, before Plaintiff can assert any claim in court, it must submit any appeals or disputes with respect to the payment of a claim to Defendant and follow the claim appeal process established by Defendant. ECF No. 20-1 3.7(c); ECF No. 20-2 6.4.1. These contracts incorporate the Care Improvement Provider Manual, which sets forth the review and appeal process that must be followed for denied claims as a prerequisite to any judicial action. ECF No. 59-6 at 62. The Amended Complaint alleges Plaintiff has “fully performed its obligations pursuant to the aforementioned agreements, ” ECF No. 20 10, but contains no further allegations regarding whether Plaintiff timely pursued any claims through the mandatory contractual appeal process.

         On June 7, 2016, Defendant filed a motion to dismiss Plaintiff s Amended Complaint under Rule 12(b)(6). ECF No. 24. After being fully briefed on that motion, the Court dismissed the motion without prejudice so the parties could conduct discovery on the limited matter of whether Plaintiff fully exhausted its administrative remedies with respect to the claims at issue. Upon completion of this period of discovery, Defendant filed this motion, ECF No. 59, to which Plaintiff filed a response, ECF No. 63, and Defendant filed a reply, ECF No. 64. The Court, having been fully briefed on the relevant issues, is now prepared to discuss the merits of Defendant's motion.


         Summary judgment is appropriate only “if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(a). In deciding whether a genuine issue of material fact exists, the evidence of the non-moving party is to be believed and all justifiable inferences must be drawn in his favor. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 255 (1986). The moving party has the burden of proving summary judgment is appropriate. Once the moving party makes this showing, the opposing party is unable to rest upon mere allegations or denials, but rather must, by affidavits or other means permitted by the Rule, set forth specific facts showing that there is a genuine issue for trial. See Fed. R. Civ. P. 56; see also Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). A party asserting that a fact is genuinely disputed must support the assertion by “citing to particular parts of materials in the record, including depositions, documents, electronically stored information, affidavits or declarations, stipulations (including those made for purposes of the motion only), admissions, interrogatory answers, or other materials.” Fed.R.Civ.P. 56(c)(1)(A). A litigant is unable to “create a genuine issue of material fact through mere speculation or the building of one inference upon another.” Beale v. Hardy, 769 F.2d 213, 214 (4th Cir. 1985).

         Therefore, “[m]ere unsupported speculation . . . is not enough to defeat a summary judgment motion.” Ennis v. Nat'l Ass'n of Bus. & Educ. Radio, Inc., 53 F.3d 55, 62 (4th Cir. 1995).

         “[W]here the record taken as a whole could not lead a rational trier of fact to find for the non-moving party, disposition by summary judgment is appropriate.” Teamsters Joint Council No. 83 v. Centra, Inc., 947 F.2d 115, 119 (4th Cir. 1996). “Summary judgment is proper only when it is clear that there is no dispute concerning either the facts of the controversy or the inferences to be drawn from those facts.” Pulliam Inv. Co. v. Cameo Props., 810 F.2d 1282, 1286 (4th Cir. 1987). The Court must determine “whether the evidence presents a sufficient disagreement to require submission to a jury or whether it is so one-sided that one party must prevail as a matter of law.” Anderson, 477 U.S. at 251-52.


         In Defendant's motion, it declares Plaintiff's claim for breach of contract should be dismissed because Plaintiff neglected to plead that it complied with the mandatory claim appeal process in the contract, and thus has no right to bring a claim in court. Additionally, Defendant contends Plaintiff's Amended Complaint should be dismissed because it fails to satisfy basic pleading requirements. In the alternative, Defendant avers the Court should grant it summary judgment because, after extensive discovery on the dispositive issue of whether Plaintiff ...

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