IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA
August 31, 2011
MEDEVAC MIDATLANTIC, LLC PLAINTIFF,
KEYSTONE MERCY HEALTH PLAN, DEFENDANT.
The opinion of the court was delivered by: Rufe, J.
MEMORANDUM OPINION AND ORDER
Before the Court is Defendant Keystone Mercy Health Plan's
("KMHP") Motion to Dismiss and Strike Medevac MidAtlantic LLC's
("Medevac") Amended Complaint in Part [doc. no. 25]. KMHP seeks to
dismiss Counts I and II of Medevac's Amended Complaint under Federal
Rule of Civil Procedure 12(b)(6), and seeks to strike, under Rule
12(f), portions of Plaintiff's Amended Complaint referencing "billed
charges" and requesting attorneys' fees and costs. *fn1
Also pending is Medevac's Motion for Partial Summary
Judgment, which the Court will address by separate opinion and
Medevac's claims against KMHP, a managed care organization providing healthcare services to Medicaid beneficiaries under the Commonwealth of Pennsylvania's HealthChoices Medicaid plan, arise from KMHP's denial of partial or full payment to Medevac for the emergency air transport services it has provided to KMHP's members.
I. F ACTUAL AND P ROCEDURAL B ACKGROUND
A. The Medicaid Program
Medicaid *fn2 is a cooperative
federal-state program in which the federal government offers funding
to states that provide healthcare services to low-income individuals
and families in designated eligibility groups. *fn3
Though state participation in Medicaid is voluntary,
participating states must comply with the requirements of the Medicaid
Act and accompanying regulations, including submission of a compliant
state medical assistance plan for approval by the Secretary of the
U.S. Department of Health and Human Services, or risk losing federal
funding. *fn4 The Medicaid Act requires that
beneficiaries be permitted to receive healthcare services from
participating, qualified providers of their choice *fn5
(the "freedom-of-choice" provision), and that the state
pay those providers directly on a fee-for-service basis according to
state-established fee schedules. *fn6 States
may seek waivers from the requirements of that traditional
fee-for-service program. In particular, states may seek a waiver of
the "freedom-of-choice" provision to provide
healthcare services to Medicaid beneficiaries through managed care
systems. In such systems, private contracting managed care
organizations ("MCOs") administer the Medicaid program for their
members, contract with a network of providers, arrange for care, and
pay providers for their services. *fn7
Medicaid beneficiaries enrolled in managed care plans receive care
from only those providers designated by the MCO, except that emergency
care providers cannot be restricted. *fn8
Both the waiver itself and the contracts between MCOs and the
state must be approved by the federal government, *fn9
and the contracts must comply with a series of statutory
and regulatory requirements. *fn10
In Pennsylvania, the Department of Public Works ("DPW")
administers the state's Medicaid program *fn11
through both a traditional fee-for-service program and a
managed care program-HealthChoices-which is mandatory for
beneficiaries in some parts of Pennsylvania. *fn12
Under HealthChoices, contracting MCO's receive payment on a
capitated basis, *fn13 bearing the risk
that the costs of service may exceed the capitation payments.
*fn14 The MCOs negotiate contracts with the
providers that form the provider network. Under such contracts, the
MCOs direct their members to the network providers in exchange for
receiving discounted rates for the medical services rendered to the
members. *fn15 Non-contracting providers
furnishing services to an MCO's members are referred to as
"out-of-network" or "non-plan" providers. *fn16
Providers are not required to enter into a contract with
an MCO. *fn17
In 2006, Congress passed the Deficit Reduction Act of 2005, *fn18 effective January 1, 2007. Section 6085 of that Act amended the Medicaid Act to limit a Medicaid MCO's obligation to pay non-plan emergency providers:
Any provider of emergency services that does not have in effect a contract with a Medicaid managed care entity . . . must accept as payment in full no more than the amounts . . . that it could collect if the beneficiary received medical assistance under this subchapter other than through enrollment in such an entity. *fn19
Thus, non-plan emergency service providers *fn20
serving Medicaid enrollees are entitled to payment at
only the rate they would receive under the state's fee-for-service
B. The Dispute
KMHP administers a Medicaid managed care program under a subcontract with Keystone Health Plan East, which holds a license issued by, and a prime contract with, DPW to serve as a private Medicaid MCO under the Commonwealth's HealthChoices program. *fn21 KMHP receives payment based on a fixed fee per member, per month. *fn22
Medevac provides emergency air transportation services from trauma
scenes to medical facilities and between medical facilities.
*fn23 Though Medevac is not among KMHP's network
providers and has no contract with KMHP, *fn24
KMHP cannot, under state and federal law, restrict its
members from using Medevac's emergency services and is obligated under
the contract with DPW to pay providers for medically necessary
services, including emergency medical transportation services.
*fn25 Additionally, under Pennsylvania law,
Medevac is obligated to provide its emergency transport services
without regard to a patient's ability to pay. *fn26
Medevac's claims arise from KMHP's alleged failure to adequately
pay Medevac for emergency air transport provided to KMHP's members.
Medevac began providing emergency
services to KMHP's members in April 2006, billing KMHP its usual
and customary charges for emergency air transportation.
*fn27 Between April 2006 and fall of 2007, KMHP
paid Medevac for half of the billed amount per service.
*fn28 Then, in fall 2007, KMHP began paying only
2% of billed charges per service. *fn29 KMHP
claimed that under Section 6085 of the 2005 Deficit Reduction Act,
Medevac, as a non-network "emergency services" provider, was entitled
to payment at only Pennsylvania's fee-for-service rates-which equated
to 2% of Medevac's billed charges. *fn30
Additionally, because KMHP determined that, at the 50% reimbursement
rate, it had been significantly overpaying Medevac, it asserted the
right to recoup nearly $300,000 in overpayments made since June
2006. *fn31 Therefore, at some point after it
asserted the applicability of Section 6085, KMHP ceased making any
payments for Medevac's emergency air transport services provided to
KMHP enrollees: Each time Medevac provided emergency air transport to
KMHP's enrollees, rather than paying the bill, KMHP deducted from the
total claimed overpayment an amount equal to the 2% of the billed
charge for that particular transport service. *fn32
For example, when Medevac transported a KMHP member and
submitted a bill for $11,684 to KMHP, rather than paying the bill,
KMHP reduced Medevac's overpayment balance
by $218-2% of the billed charges. *fn33
C. Procedural History
Medevac filed a three-count complaint in the Philadelphia Court of
Common Pleas, bringing two state contract claims and a claim under the
Pennsylvania Declaratory Relief Act. KMHP removed that action to this
Court, on grounds that the complaint contained an embedded federal
question, conferring jurisdiction on this Court. *fn34
Medevac did not contest removal. *fn35
After the Court ordered additional briefing as to why
subject-matter jurisdiction was appropriate under Grable & Sons Metal
Products, Inc. v. Darue Engineering & Manufacturing, Inc.,
Parties stipulated that Medevac would be permitted to file an amended complaint, *fn37 and the Court entered the stipulation.
Medevac's Amended Complaint brings six counts: (1) a claim under 42 U.S.C. § 1983 for KMHP's violation of the timely payment provisions of the Medicaid Act; (2) a claim that KMHP breached its contract with the state, to which Medevac is a third-party beneficiary, by failing to make prompt payment to Medevac; (3) a claim under the federal Declaratory Judgment Act, seeking judgment that Medevac is not a provider of emergency services under Section 6085 of the 2005 Deficit Reduction Act; (4) a claim for unjust enrichment, seeking payment for the reasonable value of Medevac's services; (5) a claim, in the alternative to Count IV, for breach of an implied-in-fact contract for KMHP's failure to continue remitting payment at the 50% rate agreed to by the Parties; and (6) a claim under Pennsylvania's declaratory relief statute seeking, inter alia , judgment that KMHP has no right to recoup the purported "overpayments."
KMHP now moves, under Rule 12(b)(6) of the Federal Rules of Civil Procedure, to dismiss the Section 1983 claim (Count I) and the state law claim for breach of a contract on a third-party beneficiary theory (Count II). KMHP also moves, under Rule 12(f), to strike Medevac's requests for relief in the form of attorneys' fees and costs and reimbursement of "billed charges." *fn38
II. S TANDARD OF R REVIEW
In reviewing a Rule 12(b)(6) motion to dismiss for failure to
state a claim upon which relief may be granted, the Court must accept
a plaintiff's factual allegations as true and draw all logical
inferences in favor of the non-moving party. *fn39
Courts are not, however, bound to accept as true legal
conclusions couched as factual allegations. *fn40
The Complaint must set forth "direct or inferential
allegations [for] all the material elements necessary to sustain
recovery under some viable legal theory." *fn41
And the plaintiff must allege "enough facts to state a
claim for relief that is plausible on its face." *fn42
Rule 12(f) provides that a court may strike from a pleading "any redundant, immaterial, impertinent, or scandalous matter." *fn43 The purpose of the provision is to clean-up the pleadings, streamline the litigation and avoid inquiry into irrelevant matters. *fn44 Motions to strike are to be decided on the pleadings alone. *fn45
Though this Court has considerable discretion to grant or deny a motion to strike a pleading or portions thereof, such motions are highly disfavored, and even where a statement in a pleading falls within the four corners of Rule 12(f), a court should grant the motion only when "the allegations have no possible relation to the controversy and may cause prejudice to one of the parties, or if the allegations confuse the issues." *fn46 In such cases, granting a motion may save resources of the court and parties by preventing litigation of claims that will ultimately not affect the outcome. *fn47 Despite courts' distaste for striking pleadings and portions thereof, doing so is appropriate when the type or amount of relief sought is unavailable under law. *fn48
III. D ISCUSSION
A. Motion to Dismiss Medevac's Section 1983 Claim.
Under 42 U.S.C. § 1983, plaintiffs may seek relief against anyone who, under color of state law, deprives them of rights, privileges, or immunities secured by the Constitution and federal laws. *fn49 In Count I, Medevac brings claims under 42 U.S.C. § 1983, alleging KMHP, acting under color of state law, violated Medevac's right to timely payment under 42 U.S.C. §§ 1396n(b)(4) and 1396u-2(f), which are among the waiver and managed care provisions of the Medicaid Act. KMHP moves to dismiss Count I because, KMHP asserts, the relevant Medicaid provisions confer no enforceable federal rights on Medevac, and KMHP is not acting under color of state law.
Section 1983 provides a remedy for deprivation of rights secured by federal statute, not for violations of federal law. *fn50 Thus, the Court must determine not whether Medevac adequately alleges that KMHP violated Sections 1396n(b)(4) and 1396u-2(f), but whether those provisions confer on Medevac individual federal rights enforceable under Section 1983.
To evaluate that question, the Third Circuit directs that courts first determine whether the three requirements set forth by the Supreme Court in Blessing v. Firestone *fn51 are satisfied:
(1) Congress must have intended that the statute benefit the plaintiff; (2) the benefit provided must not be "vague and amorphous;" and (3) the statute must impose an "unambiguous and binding obligation" on the state. *fn52 If the Blessing test is met, courts then determine, based on the statute's text and structure, whether "Congress unambiguously conferred the rights asserted," by using "rights-creating terms." *fn53 Rights-creating terms are those that "clearly impart an individual entitlement and have an unmistakable focus on the benefitted class." *fn54
In a series of non-Medicaid cases, the Supreme Court has provided
general principles guiding the determination of whether a statute uses
rights-creating language and confers an individual, enforceable right.
In Gonzaga University v. Doe, *fn55 the Court
identified as quintessential rights-conferring language that set forth
in Titles VI of the Civil Rights Act and IX of the Education Act
Amendments of 1972: "no person . . . shall . . . be subjected to
discrimination." *fn56 It then held that the
educational records' privacy provision of the Family Educational
Rights and Privacy Act did not confer on students an individual right
to privacy of their records because it addressed the obligation of the
Secretary of Education to deny funding to schools releasing records
without students' consent. *fn57 Though the
provision mentioned students and the need for consent, because it
spoke "only in terms of institutional policy and practice, not
individual instances of disclosure," and had an
"aggregate focus," rather than a focus on of any
particular individual, it did not confer individual rights.
*fn58 Similarly, statutory provisions that provide
benefits to individuals by imposing generalized duties on a
participating state generally do not confer enforceable individual
rights. For example, in Suter v. Artist M., *fn59
a statutory requirement that states receiving federal
funding to provide foster care and adoption services make "reasonable
efforts" to avoid the need to remove a child from his home and to make
family reunification possible after placement in foster care did not
confer individual rights on children because the "reasonable efforts"
provision imposed only generalized duties on the state.
*fn60 And in Blessing, a statutory requirement
that states receiving child-welfare funds must "substantially comply"
with requirements to ensure timely payment of child support did not
confer on plaintiff-mothers an enforceable right to state assistance
in obtaining support payments because the "substantial compliance"
provision focused on the state's aggregate duties, rather than on the
needs of an individual parent; the substantial compliance requirement
functioned "'simply [as] a yardstick for the Secretary to measure
systemwide performance of the State's . . .
In the Medicaid context, both the Third Circuit and the Supreme Court have held that certain provisions of the Medicaid Act create enforceable individual rights of providers or beneficiaries. In Wilder v. Virginia Hospital Association, *fn62 the Supreme Court held that Section 1396a(a)(13)(A), which required that a state Medicaid plan "must provide . . . for payment . . . of [medical services] though the use of rates . . . [that] are reasonable and adequate to meet the costs that must be incurred by efficiently and economically operated facilities" *fn63 could be enforced by providers. *fn64 Critical to that finding was the statute's emphasis on tying reimbursement rates to providers' costs, creating an unmistakable focus on providers' needs. *fn65 Similarly, the Third Circuit, in Sabree v. Richman, *fn66 found that Sections 1396a(a)(8), (a)(10), and (a)(15) of the Medicaid Act conferred on developmentally disabled Medicaid beneficiaries an enforceable right to reasonably prompt medical assistance in an intermediate care facility ("ICF"). *fn67 The statutory provisions required that a state "must provide . . . medical assistance . . . to . . . all eligible individuals" with "reasonable promptness," and included treatment at ICFs as a type of medical assistance. *fn68 Sabree found that the plaintiffs with developmental disabilities had an enforceable right because they were the intended beneficiaries of the provisions, the rights conferred were specific and enumerated, the obligation was unambiguous and binding, and the statutory terms ("must provide . . . to all eligible individuals") were both mandatory and had an unmistakable individual focus, rather than a focus on the regulated entity. *fn69
The statutory language the Court must evaluate here falls somewhere between the boundaries outlined by these cases. Although the language of Sections 1396n(b)(4) and 1396u-2(f) appears to be similar to that found to create an enforceable individual right in Wilder and Sabree, both Sections define the purported "right" to timely payment by reference to Section 1396a(a)(37)(A), which speaks more in terms of institutional policy and practice with an aggregate focus, as in Gonzaga, Suter, and Blessing. Consequently, the Court must determine whether these sections, considered together , confer on Medevac an individual enforceable right.
Section 1396n(b)(4) allows the Secretary to waive the freedom-of-choice requirement to permit states to implement a plan that restricts providers if certain other conditions, including timely payment to providers, are satisfied. The provision states:
The Secretary . . . may waive such requirements of section 1396a of this title . . . as may be necessary for a State . . . to restrict the provider from (or through) whom an individual . . . can obtain services (other than in emergency circumstances) to providers or practitioners who undertake to provide such services and who meet, accept, and comply with the reimbursement, quality, and utilization standards under the State plan . . . if such restriction does not discriminate among classes of providers on grounds unrelated to their demonstrated effectiveness and efficiency in providing those services and if providers under such restriction are paid on a timely basis in the same manner as health care practitioners must be paid under section 1396a(a)(37)(A) of this title. *fn70
Section 1396u-2 imposes certain requirements on states that opt to provide Medicaid services through contracts with MCOs and require beneficiaries to enroll with those MCOs. *fn71
Section 1396u-2(f), entitled "Timeliness of payment," provides:
A contract . . . with a medicaid managed care organization shall provide that the organization shall make payment to health care providers for items and services which are subject to the contract and that are furnished to individuals eligible for medical assistance under the State plan . . . who are enrolled with the organization on a timely basis consistent with the claims payment procedures described in section 1396a(a)(37)(A) of this title, unless the health care provider and the organization agree to an alternate payment schedule. *fn72
Medevac argues, with some force, that the language in these subsections ("shall provide," "shall make payment to health care providers . . . on a timely basis," and "may waive . . . if providers under such restriction are paid on a timely basis") mimics the language that Sabree found conferred an enforceable right. First, the provisions providing for timely payment to providers appear intended to benefit providers. Such a provision would not benefit eligible Medicaid recipients because Medicaid recipients, in most cases, are not obligated to pay the provider directly; failure to timely pay providers would not impose payment liability on them. Moreover, timely payment by MCOs would not necessarily benefit the state or MCOs against whom the requirement is imposed. And though, arguably, such a provision benefits the Medicaid program as a whole by ensuring providers are not discouraged from participating in the state's plan, the direct benefit to providers is unmistakable. Second, just as "reasonable promptness" was found to be sufficiently definite in Sabree, so too would be a requirement for payment on a "timely basis." Third, the language is mandatory: under 1396u-2(f) a contract shall provide that payment shall be made on a timely basis, and under 1396n(b)(4), a waiver may only be granted if providers are to be paid on a timely basis. Thus, the requirements of the Blessing test are satisfied. And, pursuant to Gonzaga, the language of both provisions focuses specifically on providers and the conditions of their payment under a waiver or managed care contract, not on institutional policies or practices, or on the program in the aggregate. *fn73 Reinforcing the focus on providers, Section 1396n(b)(4) establishes reciprocal rights and obligations of participating providers: restricted providers that "meet, accept, and comply with the reimbursement, quality, and utilization standards under the State plan" are entitled to non-discriminatory treatment and payment on a timely basis. Thus, facially, the provisions use rights-creating language and therefore appear to confer an enforceable individual right to timely payment on healthcare providers.
But that does not end the inquiry. The requirement that payment to providers be "timely" is qualified: payment must be timely made "consistent with" or "in the same manner" as provided under section 1396a(a)(37)(A). That section provides that a state Medicaid plan must provide for "claims payment procedures" that:
[E]nsure that 90 per centum of claims for payment (for which no further written information or substantiation is required in order to make payment) made for services covered under the plan and furnished by health care practitioners through individual or group practices or through shared health facilities are paid within 30 days of the date of receipt of such claims and that 99 per centum of such claims are paid within 90 days of the date of receipt of such claims . . . . *fn74
The language of this provision stands in stark contrast with the
facially provider-focused language of Sections 1396n(b)(4) and
1396u-2(f). First, it does not focus on payment to individual
providers, but rather on a state's institutional payment
procedures to ensure timely payment of claims
in the aggregate , along the lines of
the statutory language in Gonzaga, Suter, and Blessing. The
requirement that a certain percentage of claims be paid within 30 or
90 days appears to serve as a benchmark for the performance of the
claims procedures; *fn75 it does not require
that all providers be paid within these time frames. In fact, Section
1396a(a)(37)(A) expressly anticipates that some claims will
not be paid within the 30 or 90 day periods, and applies
only to claims for which no further documentation is required.
Further, the focus on "claims" and the "procedures" to ensure their
payment, rather than on providers, suggests the intent is to ensure
efficient administration of undisputed claims-a process that benefits
the Medicaid program as a whole. Providers are mentioned, but only
indirectly ("claims for payment . . for services . . . furnished by
[providers]"). And while providers surely benefit from the provision,
under Gonzaga, congressional intent to benefit a class is
insufficient. Moreover, the provision frames the state's obligation
based on payment of claims in the aggregate ,
suggesting no individual provider is entitled to timely payment.
*fn76 Thus, unlike Wilder and Sabree where the
relevant provisions not only mentioned providers and beneficiaries,
but also emphasized the needs of all beneficiaries
or individual providers and beneficiaries,
*fn77 Section 1936a(a)(37)(A) does not reference
providers in such terms. The Court thus concludes, as others have
before it, *fn78
that because Section 1396a(a)(37)(A) "speak[s] only in terms of
policy and practices not individual instances of [payment],"
*fn79 it does not confer individual enforceable
rights on providers.
Having concluded that Sections 1396n(b)(4) and 1396u-2(f), at least facially, use rights-creating language, and that Section 1396a(a)(37)(A) does not, the Court must determine the impact of the prior two sections' reliance on the latter. Because the purported rights to timely payment in 1396n(b)(4) and 1396u-2(f) are defined only in terms of aggregate performance and procedural requirements in 1396a(a)(37)(A), they do not confer on providers enforceable individual rights to timely payment. The only right enforceable under Sections 1396n(b)(4) and 1396u-2(f) that the Court can discern is the right to compel compliance with those procedural requirements. *fn80 Thus, if procedures were so inadequate that the state was not hitting the benchmarks for timely payment, individual (or groups of) providers may have enforceable rights to ensure compliance with the benchmark. *fn81 But here, Medevac complains only that it has not been timely paid by KMHP within the time frames under Section 1396a(a)(37)(A), not that the state has failed to meet the aggregate timely payment requirements.
Medevac does not dispute that Section 1396a(a)(37)(A) lacks rights-conferring language; instead it insists that Section is irrelevant to this Court's inquiry because sections 1396n(b)(4) and 1396u-2(f) create stand-alone timely payment rights. But the right to payment in these sections is only a right to payment in the same manner or consistent with the timely payment provisions applicable to health care practitioners-the only providers referenced in 1396a(a)(37)(A). The limited legislative history available suggests that Congress was attempting to extend the reach of Section 1396a(a)(37)(A) to all types of providers, not to create additional rights for providers offering services under a managed care system.
For example, in 1990, Congress amended the Medicaid Act to add Section 1396n(b)(4) *fn82
when it recognized that although the statute provided for timely
payment to healthcare practitioners, it had no such provision for
hospitals and other providers. *fn83 Section
1396n(b)(4) thus "extend[ed] the prompt payment requirements to any
type of provider participating under a selective contracting
waiver." *fn84 Similarly, Congress later
extended those provisions to providers of services subject to a
state's contract with an MCO. *fn85 Nothing
in the legislative history suggests that Congress intended to create
new or greater rights to
payment than were afforded under Section 1396a(a)(37)(A) to healthcare
practitioners operating under traditional state Medicaid programs.
Accordingly, the Court finds that Medevac has not stated a § 1983 claim because neither of the statutory provisions it seeks to enforce confers on providers individual enforceable rights to timely payment. Having so concluded, the Court does not reach the question of whether KMHP acts under color of state law.
B. Motion to Dismiss Medevac's Third-Party Beneficiary Claim.
The Operating Agreement between Keystone Health Plan East and DPW requires KMHP, as a subcontractor, to make timely payment to non-plan emergency providers. *fn86 Based on this provision, Medevac brings a breach-of-contract claim on a third-party beneficiary theory. KMHP moves to dismiss because the Operating Agreement explicitly disclaims intent to create third-party beneficiaries.
Under Pennsylvania law, a contract creates a third-party beneficiary when its language affirmatively indicates mutual intent to benefit that third-party. *fn87 Pennsylvania has also adopted, as an exception to that general rule, Section 302 of the Restatement (Second) of Contracts, under which a contract can create a third-party beneficiary even in the absence of language demonstrating mutual intent. *fn88 Section 302 provides:
(1) Unless otherwise agreed between promisor and promisee , a beneficiary of a promise is an intended beneficiary if recognition of a right to performance in the beneficiary is appropriate to effectuate the intention of the parties and either
(a) the performance of the promise will satisfy an obligation of the promisee to pay money to the beneficiary; or
(b) the circumstances indicate that the promisee intends to give the beneficiary the benefit of the promised performance.
(2) An incidental beneficiary is a beneficiary who is not an intended beneficiary. *fn89
In analyzing Section 302(1) at step one, *fn90
Pennsylvania courts require that the circumstances
surrounding the contract be "compelling" before finding that
recognizing a third-party beneficiary is appropriate to effectuate the
intention of the parties. *fn91 At step two,
there must be a showing that the alleged beneficiary falls within one
of two categories under Section 302(1)(a) and (b)-creditor and donee
beneficiaries. *fn92 "If the two steps of the
test are met, the beneficiary is an intended beneficiary unless
otherwise agreed between the [contracting parties]." *fn93
Here, the Operating Agreement expressly disclaims any intent to create third-party beneficiaries, unambiguously stating: "This Agreement does not, nor is it intended to, create any rights, benefits or interest to any third party, person or organization." *fn94 Generally, a contract that expressly disclaims intent to create third-party beneficiaries cannot also be read as expressly evincing an intent to create beneficiaries. *fn95 Even under Section 302's implied intent exception, the circumstances underlying the contract give rise to intended beneficiary status only if the parties have not "otherwise agreed." *fn96 And Pennsylvania courts ordinarily give effect to such disclaimers when considering Section 302. *fn97
Medevac argues that the disclaimer must be disregarded because it
contradicts the more specific contract provisions that evince mutual
intent to benefit emergency services providers, and courts must give
effect to the specific over the general. *fn98
Medevac presents two contract provisions that it contends
demonstrate intent to benefit emergency services providers. First,
Section V.A.9 of the Operating Agreement requires KMHP to comply with
certain program standards, including the obligation to pay for
emergency services "in accordance with applicable law," with
"applicable law" defined to include all of the provisions of the
Pennsylvania Quality Health Care Accountability and Protection
Act. *fn99 Among that Act's provisions is a
requirement to pay emergency health care providers for the costs of
medically necessary emergency services. *fn100
Second, Section VII.D.6 of the Agreement requires KMHP to
timely pay non-plan emergency providers for medically necessary
services rendered to treat an emergency medical condition.
The Court does not agree that these contract provisions
demonstrate mutual intent to benefit Medevac and other providers in
its situation. A fair reading of the relevant contractual provisions
in the context in which they appear lead this Court to conclude that
they evince intent to impose on KMHP an obligation to comply with
applicable law, not an intent to specifically benefit emergency
services providers. State contracts with Medicaid MCOs must provide
for timely payment to providers, *fn102 and
Pennsylvania law requires HMOs to pay for medically necessary
emergency services provided by non-plan providers. *fn103
Contractual provisions ensuring compliance with existing
statutory or regulatory provisions do not indicate mutual intent to
benefit a non-party; they evince intent to comply with applicable
law. *fn104 Indeed, the Operating Agreement
requires the MCO to comply with all regulations
promulgated under the Medicaid Act, as well as with a number of
federal and state laws. *fn105 Under
Medevac's construction, every beneficiary of the many applicable
federal and state statutes referenced in the contract would have the
right to sue the MCO for non-compliance, creating expansive liability
under the contract, despite the disclaimer.
Medevac also argues that, under Pennsylvania law, express disclaimers are not dispositive of third-party beneficiary status. While that is true, situations in which disclaimers are not given effect are rare. Pennsylvania courts appear to disregard express disclaimers only where the purported third-party beneficiaries were the sole or primary beneficiaries of the contract's performance. *fn106 In such circumstances, recognizing the intended beneficiary is necessary to give effect to the intent of the parties to provide that benefit. The circumstances that Medevac presents here are not so compelling. Medevac does not contend the purpose of the contract is to benefit emergency providers or providers as a whole. Instead, it argues that direct payment to providers is an essential component to successful implementation of the Medicaid managed care program because the program depends on DPW making capitation payments to KMHP in exchange for KMHP's direct payment to providers, which also ensures Medicaid recipients are held harmless. That may be so, but it does not present compelling circumstances that suggest recognizing Medevac's right here is appropriate to effectuate the intent of DPW and KMHP to benefit Medevac . *fn107 Instead, direct payment to providers, like many other provisions of the contract, help effectuate the parties' intent to implement a Medicaid managed care program for the benefit of eligible Medicaid recipients. Medevac is thus an incidental, not intended, beneficiary.
Medevac also argues that a provision in the Agreement specifying that the Bureau of Hearings and Appeals is not the appropriate forum to resolve provider disputes with MCOs indicates the parties' intent that providers may "directly enforc[e] their payment rights arising under the Operating Agreement." *fn108 The Court does not find this provision is inconsistent with the disclaimer or that it presents circumstances so compelling that recognition of Medevac's beneficiary status is appropriate. That the Bureau of Hearings and Appeals will not entertain disputes does not demonstrate intent to permit direct enforcement by third parties because the parties could have anticipated means other than direct enforcement of the contract to resolve such disputes: network providers can enforce their rights directly against KMHP pursuant to their own contracts and non-network providers may bring other state law claims, as Medevac has alleged here. *fn109 Moreover, DPW itself can enforce the contract to effectuate the parties' intent. Accordingly, the Court concludes that Medevac has not alleged circumstances sufficient to overcome the express disclaimer in the Operating Agreement. *fn110
Finally, Medevac has not pleaded facts sufficient to enforce a
government contract as a third-party beneficiary,
particularly in light of the disclaimer. Pennsylvania courts have
adopted Section 313 of the Restatement (Second) of Contracts, applicable
to government contracts, *fn111
which establishes significant hurdles for non-parties seeking to
[A] promisor who contracts with a government or governmental agency to do an act for or render a service to the public is not subject to contractual liability to a member of the public for consequential damages resulting from performance or failure to perform unless
(a) the terms of the promise provide for such liability; or
(b) the promisee is subject to liability to the member of the public for the damages and a direct action against the promisor is consistent with the terms of the contract and with the policy of the law authorizing the contract and prescribing remedies for its breach. *fn112
Under Section 313, something more than an intent to benefit the non-party must be demonstrated: the contract must express intent that the promisor will be liable to members of the general public in the event of non-performance. *fn113 Otherwise, third-party beneficiaries of a Government contract are assumed to be merely incidental beneficiaries. *fn114 But Medevac has not pleaded facts suggesting any contractual intent to expose KMHP to liability. *fn115
Arguably, Section 313 precludes only claims by members of the
"general public," rather than discrete and identifiable groups of
plaintiffs. *fn116 Nevertheless, Pennsylvania
state courts appear to apply the Restatement to all
beneficiaries of government contracts even where the third-party
is a member of a small and specific sub-population that, like Medevac
here, benefits from the government contract more than the general
public. *fn117 So, too, has the Third Circuit
when applying Section 313 under federal common law. *fn118
"The fact that third parties will benefit more directly
from performance of the contract than members of the public at large
does not alter their status as incidental beneficiaries." *fn119
Accordingly, because the Operating Agreement expressly disclaims third-party beneficiaries and Medevac has neither pleaded nor presented sufficiently contradictory contract language or compelling circumstances that might warrant disregarding that disclaimer, and because Medevac has not pleaded facts sufficient for recognition as a third-party beneficiary of a government contract, the Court will dismiss this Count II without prejudice.
C. Motion to Strike.
1. Medevac's Request for Damages in the Amount of its Usual and Customary "billed charges" for pre-January 1, 2007 Charges.
KMHP moves to strike Medevac's requests for relief in the amounts actually billed to KMHP *fn120 because it asserts that Section 2116 of Pennsylvania's Health Care Accountability and Protection Act *fn121 entitles Medevac to reimbursement of only its actual costs, not its billed charges.
The Parties dispute whether Section 2116 imposes this limitation.
The provision requires that a "managed care plan shall pay all
reasonably necessary costs associated with the emergency services
provided during the period of the emergency." *fn122
On its face, the statute is ambiguous as to whether it
(1) requires payment of only actual costs of
necessary emergency services provided, or (2) requires payment of
billed charges but only for those emergency services that were
necessary. Relying on limited state case law, KMHP argues for the
former interpretation. Medevac, relying on other statutory language,
implementing regulations and administrative interpretations, argues
for the latter.
The Court will exercise its substantial discretion in considering motions under Rule 12(f) and deny the motion to strike references to billed charges because the determination whether Medevac may recover its billed charges in full (if indeed that is what it is seeking *fn123 ) requires this Court to resolve a disputed and substantial question of law. This is not an appropriate use of a Rule 12(f) motion. *fn124 And KMHP has neither suggested nor demonstrated that it will suffer any prejudice from references in the Amended Complaint to "billed charges." Upon proper motion and briefing, the Court will consider, if necessary, whether the state statutory provision limits Medevac's recovery to actual costs and the implications, if any, of that limitation. *fn125
2. Medevac's Request for Attorneys' Fees .
KMHP moves to strike Medevac's request for attorneys fees because, under Pennsylvania law, attorneys' fees are unavailable for the state contract claims (Counts II, IV and V), for claims seeking relief under the federal Declaratory Judgment Act *fn126 (Count III), and under the state declaratory judgment act (Count VI) except for claims brought against insurers acting in bad faith. The Court agrees.
Pennsylvania courts follow the "American rule" that attorneys' fees and costs are not recoverable from an adverse party unless a statute expressly authorizes the fees, there was a clear agreement among the parties to permit such recovery, or some other exception applies. *fn127
Consequently, in breach of contract matters, fees are unavailable absent an agreement between the contracting parties. *fn128 Here, Medevac alleges it had, at most, an implied-in-fact contract with KMHP, and does not allege any agreement regarding attorneys' fees as part of the Parties' understanding regarding payment rates or that any statutory exception exists.
Medevac asserts that because it has alleged conduct by KMHP that demonstrates bad faith, it may seek attorneys' fees. Setting aside the question whether Medevac has alleged bad faith, fee awards for bad faith can be awarded in two situations: (1) bad faith during the pendency of litigation, available under the Court's equitable powers and Pennsylvania statute; *fn129 and (2) bad faith underlying the conduct that forms the basis for the claim. *fn130 Medevac does not seek fees for bad faith conduct during litigation, but rather for pre-litigation conduct. But fees awarded for conduct underlying the substantive claim are punitive in nature and thus cannot be awarded when punitive damages are not permitted. *fn131 And under Pennsylvania law, punitive damages are not permitted in breach of contract actions. *fn132
Medevac's claims for declaratory relief likewise do not permit recovery of attorneys' fees. Neither the federal nor state declaratory judgment statutes expressly provide for an award of attorneys' fees and costs to the prevailing party. *fn133 And Medevac points to no exception to the American rule for declaratory judgments, beyond bad faith. To date, Pennsylvania has recognized only one exception permitting attorneys' fees in actions under the state declaratory judgment statute: where fees are "implemented as supplemental relief to effectuate the declaratory judgment." *fn134 Medevac points to no other exception, and this Court's own research has revealed none.
Thus, an award of attorneys' fees would be permissible for only Medevac's Section 1983 claim *fn135 and, as discussed above, that claim is dismissed. Accordingly, the Court will grant KMHP's motion to strike Medevac's request for attorneys' fees and costs as such are not recoverable under the causes of action Plaintiff pleads.
IV. C ONCLUSION
For the foregoing reasons, the Court will grant KMHP's motion to dismiss Counts I and II, deny KMHP's Motion to Strike references to Medevac's billed charges, and grant KMHP's Motion to Strike Medevac's request for attorney's fees and costs in remaining Counts III, IV, V and VI.
An appropriate Order follows.