Centene V. Murphy Medical

Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 1 of 30
UNITED STATES DISTRICT COURT

DISTRICT OF CONNECTICUT
---------------------------------- x Docket No.: 3:22-cv-504
MURPHY MEDICAL ASSOCIATES, LLC; :
DIAGNOSTIC AND MEDICAL SPECIALISTS : COMPLAINT
OF GREENWICH, LLC; and STEVEN A.R. :
MURPHY, M.D., : JURY TRIAL DEMANDED
:
Plaintiffs, :
vs. :
:
CENTENE CORPORATION, FIDELIS CARE and :
WELLCARE HEALTH PLANS, INC. :
:
Defendant.
- -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X
Plaintiffs Murphy Medical Associates LLC, Diagnostic and Medical Specialists of
Greenwich, LLC (collectively, “Murphy Practice”) and Steven A.R. Murphy, M.D. (“Dr.
Murphy”), by their attorneys, Harris Beach, PLLC, for their Complaint against the Defendant,
Centene Corporation ( “Centene”), Fidelis Care (“Fidelis”) and WellCare Health Plans, Inc.
(“WellCare”)(collectively, “Defendants”), allege as follows.
INTRODUCTION
1. Plaintiffs bring this case because Centene, one of the largest publicly traded health
plan issuers in the United States and two of its wholly owned managed care health insurance
subsidiaries, Fidelis and WellCare, are blatantly defying federal and state law, as well as principles
of equity, by refusing to reimburse Plaintiffs for COVID-19 testing that Plaintiffs provided to
members and/or beneficiaries of Defendants’ health plans in the midst of a public health crisis.
2. In 2020, and in response to the COVID-19 pandemic and public health emergency,
Congress twice passed statutes – the Families First Coronavirus Response Act (FFCRA) and the
Coronavirus Aid, Relief, and Economic Security Act (CARES Act) – requiring all fully-insured,
1
level-funded, and self-insured health plans, including those plans that Fidelis and WellCare
administer, to cover such COVID-19 tests and related services, regardless of whether they are
provided by in-network or out-of-network providers. Such coverage must be complete:
copayments, deductibles, coinsurance and limits on coverage are not permitted.
3. The recent emergence of the highly transmissible BA.2 Omicron variant ensures
that the need for continued, efficient COVID-19 testing persists. The Murphy Practice will
continue to provide critical COVID-19 testing to uphold its Hippocratic Oath during this public
health crisis.
4. Defendants, however, have refused to honor federal law and, instead, have issued
outright denials or infinitesimal “reimbursement” of claims submitted by the Murphy Practice. The
Murphy Practice has appealed every claim submitted to Fidelis and WellCare, which were
summarily denied and later advised to the Murphy Practice that it has exhausted all appeal rights.
5. Plaintiffs, therefore, are left with no recourse against Defendants other than through
this Court to hold Defendants accountable for their wrongful conduct during the current public
health crisis.
PARTIES
6. At all times relevant to this matter, Plaintiff Murphy Medical Associates LLC is a
limited liability company organized under Connecticut law. Its principal place of business is
located at 30 Buxton Farms Road, Stamford, Connecticut 06905.
7. At all times relevant to this matter, Plaintiff Diagnostic and Medical Specialists of
Greenwich, LLC is a limited liability company organized under Connecticut law. Its principal
place of business is located at 30 Buxton Farms Road, Stamford, Connecticut 06905.
2
8. At all times relevant to this matter, Plaintiff Steven A.R. Murphy, M.D. (“Dr.
Murphy”) is a physician licensed to practice medicine in Connecticut and New York. His principal
place of practice is located at 30 Buxton Farms Road, Stamford, Connecticut 06905.
9. Dr. Murphy, a board-certified internist, is the principal of the Murphy Practice.
10. Dr. Murphy completed his internship in medical genetics and pediatrics at Mount
Sinai Hospital in New York. He subsequently served as the Chief Resident for Internal Medicine
at Greenwich Hospital-Yale New Haven Health in Greenwich, Connecticut from July 2007
through May 2008. Prior to entering private practice, Dr. Murphy also served as a clinical fellow
in medical genetics at Yale Medical School in New Haven, Connecticut from June 2008 until
November 2008.
11. As a physician, Dr. Murphy specializes in general medical care, personalized
medicine and genetics, weight loss medicine, adolescent care, and hereditary cancers. In addition,
Dr. Murphy is an FAA Senior Aviation Medical Examiner, a United States Civil Surgeon, and an
obesity medicine specialist.
12. Dr. Murphy also serves as an assistant professor of medicine, cell biology, and
anatomy at New York Medical College in Valhalla, New York.
13. Dr. Murphy is the certified laboratory director for Plaintiff Diagnostic and Medical
Specialists of Greenwich, LLC under the federal Clinical Laboratory Improvement Amendments
(“CLIA”) and Connecticut law.
14. Upon information and belief, Defendant Centene is a publicly traded managed care
company that issues and administrates various health plans with its principal place of business
located at 7700 Forsyth Boulevard St. Louis, MO 63105.
3
15. Defendant Centene is multi-billion-dollar company and one of the largest health
insurance providers in the United States with reported 2021 revenues of $126 billion.
16. Upon information and belief, Fidelis is a corporation organized under New York
law with its principal place of business located at 100 Willowbrook Office Park #100, Fairport,
NY 14450. Fidelis is a wholly owned subsidiary of Defendant Centene.
17. Upon information and belief, WellCare is corporation organized under Florida law
with its principal place of business located at 7700 Forsyth Boulevard St. Louis, MO 63105.
WellCare is a wholly owned subsidiary of Defendant Centene.
JURISDICTION AND VENUE
18. This Court has jurisdiction over this dispute under 28 U.S.C. § 1331 because the
Murphy Practice asserts federal claims against Defendants under the Families First Coronavirus
Relief Act, the CARES Act, the Affordable Care Act, and ERISA.
19. This Court also has supplemental jurisdiction over the Murphy Practice state law
claims against Defendants because these claims are so related to the Murphy Practice’s federal
claims that the state law claims form a part of the same case or controversy. This Court accordingly
has supplemental jurisdiction over these claims pursuant to 28 U.S.C. § 1367(a).
20. This Court also has personal jurisdiction over Defendant Centene because Centene
carries on one or more businesses or business ventures in this judicial district; there is the requisite
nexus between the businesses and this action; and Centene engages in substantial, and not isolated,
activity within this judicial district.
21. This Court also has personal jurisdiction over Defendant Fidelis because Fidelis
carried on one or more businesses or business ventures in this judicial district; there is the requisite
nexus between the businesses and this action; and Fidelis engaged in substantial, and not isolated,
4
activity within this judicial district.
22. This Court also has personal jurisdiction over Defendant WellCare because
WellCare carries on one or more businesses or business ventures in this judicial district; there is
the requisite nexus between the businesses and this action; and WellCare engages in substantial,
and not isolated, activity within this judicial district.
23. Venue is proper in this District under 28 U.S.C. § 1391(b)(2), because a substantial
portion of the events giving rise to this action arose in this District.
FEDERAL LAW REQUIRES DEFENDANTS TO REIMBURSE PLAINTIFFS
24. In March 2020, Congress, in recognition of the COVID-19 public health emergency
and the desperate need to address it by making COVID-19 testing readily available to anyone who
needed or wanted it, enacted two statutes that addressed the issue of payment for testing: the
Families First Coronavirus Response Act (“FFCRA”) and the Coronavirus Aid, Relief, and
Economic Security Act (“CARES Act”).
25. Specifically, through the FFCRA, Congress mandated that health plans, including
large and small group plans, self-funded plans, managed care plans and individual market plans,
such as Defendants’, must cover and reimburse providers for conducting COVID-19 testing,
COVID antibody testing, and related testing and services.
26. In recognition of the public health crisis, Congress went much further than merely
requiring health plans to cover testing. To ensure that no patient would be deterred from getting a
COVID-19 test due to a concern for the cost, Congress required coverage for COVID-19 testing
and related services to be provided without cost sharing, deductibles, copayments or coinsurance,
or other medical management requirements, regardless of whether the COVID-19 testing and
related services were provided by “in-network” or “out of network” providers.
5
27. Indeed, guidance from the Departments of Labor (“DOL”), Health and Human
Services (“HHS”) and the Treasury has clarified that the FFCRA and the CARES Act apply to
COVID-19 testing, antibody testing, and related services rendered by both “in-network” and “out-
of-network providers.” 1
28. In essence, Congress sought to ensure that any patient with health coverage could
get a COVID-19 test without any out-of-pocket costs, and without having to get permission from
their health plan, heath plan administrator or employer under a self-funded plan.
29. After FFCRA and the CARES Act’s enactment, subsequent letters from Congress to
the HHS, DOL and the Secretary of Treasury emphasized the obligations of group health plans and
insurers to provide robust and comprehensive coverage of COVID-19 testing.2
PLAINTIFFS’ RESPONSE TO THE COVID-19 CRISIS
30. Formed by Dr. Murphy over a decade ago, the mission of the Murphy Practice is to
provide high-quality preventive and general health services, as well as acute primary care, to men,
women, and adolescents. Dr. Murphy, a board-certified internist, is the principal of the Murphy
Practice.
31. Among its other services, the Murphy Practice operates a state-licensed physician
office laboratory located at 30 Buxton Farms Road in Stamford, Connecticut. Dr. Murphy is the
certified laboratory director for this laboratory under the federal Clinical Laboratory Improvement
Amendments (“CLIA”) and Connecticut law.
1
FAQs dated April 11, 2020, at Q.7 and Q.4, available at https://www.cms.gov/files/document/FFCRA-Part-42-
FAQs.pdf
2
See Letter to HHS, DOL, and Secretary of Treasury dated July 8, 2022, available at
https://edlabor.house.gov/imo/media/doc/Democratic%20Health%20Leaders%20Demand%20Trump%20Administr
ation%20Immediately%20Revisit%20Guidance%20Limiting%20COVID-19%20Testing%20Coverage.pdf
6
32. On or about March 9, 2020 and in response to the COVID-19 pandemic, the Murphy
Practice, an internal medicine practice with offices throughout Connecticut, invested hundreds of
thousands of dollars to transform its traditional medical practice to set up COVID-19 testing sites
throughout Connecticut and New York.
33. These sites were erected virtually overnight and were designed to provide efficient
drive and/or walk-through COVID-19 testing to patients with symptoms or suspected exposure to
the novel coronavirus. These sites helped to fill the void for COVID-19 testing and were
unquestionably one of the first lines of defense against the pandemic.
34. In addition to creating the physical infrastructure for the sites, the Murphy Practice
had to assemble the clinical and administrative staff needed to operate the sites and to perform the
testing, including physicians, medical students, physician assistants, nurse practitioners, registered
nurses, medical assistants, registrars, coordinators, and IT staff. It also had to develop extensive
protocols and procedures to ensure the sites were effectively and efficiently operating, and all safety,
infection control, OSHA, and CDC guidance were observed.
35. Ultimately, the Murphy Practice operated drive and/or walk-through COVID-19
testing sites in, among other places, Greenwich, Stamford, New Canaan, Darien, Fairfield,
Bridgeport, New Haven, West Haven, Stratford, and Ridgefield, Connecticut, and Bedford,
Brooklyn, and Pound Ridge, New York.
36. Since March 9, 2020, the Murphy Practice has provided COVID-19 testing and/or
related services to over 35,000 patients and engaged in over 85,000 unique encounters with those
patients.
7
37. Generally, the Murphy Practice has utilized nasopharyngeal swabs to collect patient
samples to test for SARS-CoV-2, which was either sent to the Murphy Practice’s lab or to a third-
party laboratory for processing.
38. Through its fully licensed physician office laboratory located at 30 Buxton Farms
Road in Stamford, Connecticut, the Murphy Practice has been able to process internally many of
the patient samples that the Murphy Practice collects.
39. Each swab taken by the Murphy Practice was either sent to the Murphy Practice’s
lab or to a third-party laboratory for processing.
40. In May 2020 an advanced BioFire Film Array System, with COVID-19 testing
capability, was approved by the FDA for COVID-19 testing.3 The Murphy Practice was able to
purchase the new BioFire machine.
41. According to the makers of BioFire, “[t]he inclusion of SARS-CoV-2 in the
BIOFIRE® RP2.1 panel allows healthcare providers to quickly identify patients with common
respiratory pathogens, as well as those with COVID-19, using one simple test. The BIOFIRE®
RP2.1 panel takes approximately 45 minutes and tests nasopharyngeal swab samples in transport
media.”4
42. Beginning in or about June 1, 2020, and for the vast majority of swabs that the
Murphy Practice processed internally in its laboratory, the Murphy Practice utilized the BioFire
2.1 Respiratory Panel, a respiratory panel that tests for 22 respiratory pathogens, including SARS-
CoV-2.5
3
https://docs.biofiredx.com/wp-content/uploads/PRESS-RELEASE-BIOFIRE%C2%AE-Respiratory-Panel-2.1-
RP2.1-with-SARS-CoV-2.pdf
4
Id.
5
On March 17, 2021, the BioFire 2.1 became the first Covid-19 test to upgrade from an emergency use authorization
to fully approved FDA status. See https://www.biomerieux.com/en/biofirer-respiratory-21-rp21-panel-sars-cov-2-
obtains-de-novo-fda-authorization; https://www.news-medical.net/news/20210317/FDA-authorizes-marketing-of-
first-SARS-CoV-2-diagnostic-test-using-De-Novo-premarket-review-pathway.aspx. The myriad benefits of testing
8
43. The BioFire 2.1 Respiratory Panel allows the Murphy Practice to test for COVID-19
as well as other respiratory viruses and infections that could possibly cause the same or similar
symptoms as COVID-19, or could possibly co-exist with COVID-19. Information about other
potential respiratory viruses or infections is vitally important to ensure that patients who present with
symptoms or were possibly exposed to COVID-19 receive the most appropriate and effective course
of treatment.
44. In fact, medical studies have concluded that a significant percentage of patients
(20% in one study) who tested positive for COVID-19 also tested positive for one or more
respiratory pathogens.6
45. FAQs regarding the federal COVID-19 testing law that have been prepared jointly
by the Departments of Labor, Health and Human Services (HHS), and the Treasury (collectively,
“FAQs”), state that “the CDC strongly encourages clinicians to test for other causes of respiratory
illnesses.”7
46. The Murphy Practice’s use of its BioFire machines at its internal laboratory allowed
the Murphy Practice, generally, to analyze the samples being tested and produce results at a much
faster rate than commercial third-party labs.
47. In addition to the testing, the Murphy Practice, when medically appropriate, also
conducted a thorough medical history and basic examination on patients who seek COVID-19
testing. A baseline assessment of the patient’s current medical status is absolutely required to ensure
for other pathogens simultaneously with testing for SARS-CoV-2 are well stated in the literature and federal guidance.
6
Of the 116 specimens positive for SARS-CoV-2, 24 (20.7%) were positive for 1 or more additional pathogens,
compared with 294 of the 1101 specimens (26.7%) negative for SARS-CoV-2 (Table 1) (difference, 6.0% [95% CI,
–2.3% to 14.3%]). “Rates of Co-infection Between SARS-CoV-2 and Other Respiratory Pathogens,” JAMA.
2020;323(20):2085-2086.doi:10.1001/jama.2020.6266, Available at
https://jamanetwork.com/journals/jama/fullarticle/2764787
7
See FAQs About Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act
Implementation (hereinafter “FAQs”), Part 42 (April 11, 2020), available at
https://www.cms.gov/files/document/FFCRA-Part-42-FAQs.pdf at Q.5.
9
that the patient receives the most appropriate and effective treatment. Patients also need preventative
medicine counseling regarding the taking of universal precautions and other vitally necessary actions
or things to avoid. All of this was particularly important during the early days of the pandemic when
patients had little personal direct access to primary care physicians because of pandemic closures.
48. Further, during the time period between the day the sample was taken and the results
were available, the Murphy Practice’s clinical personnel conducted telemedicine visits with the
patients to check on their conditions and determine whether further medical intervention was needed.
The frequency and duration of these visits was dependent on each patient’s unique condition, with
an emphasis and priority on following up with patients suspected of being infected with the virus.
49. Beginning in or about May 2020, the Murphy Practice began providing COVID-19
testing and related services to members or beneficiaries of Centene, through the health plans it issues
and/or administers through its wholly owned subsidiaries, Fidelis and WellCare.
50. The Murphy Practice generally receives assignment of benefit forms from patients
who receive testing services at the Murphy Practice testing sites. Other patients that registered
electronically assigned their benefits to the Murphy Practice.
51. Exhibit 1 to this Complaint is a complete list of the claims against Defendant Fidelis
that are the subject of this Complaint. 8
52. Exhibit 2 to this Complaint is a complete list of the claims against Defendant
WellCare that are the subject of this Complaint. 9
8
In order to protect the patients’ identity, the Murphy Practice will only reference each patient’s identity by their
initials throughout the spreadsheet.
9
In order to protect the patients’ identity, the Murphy Practice will only reference each patient’s identity by their
initials throughout the spreadsheet.
10
53. As the operator of state- or locality-administered sites, drive-through sites, and/or
sites that do not require appointments, plans and issuers generally must assume that the receipt of
the test reflects an “individualized clinical assessment.”
54. As a result, the Murphy Practice was entitled to assume the diagnostic impetus
behind each test, consistent with the goals of both pieces of legislation: anyone who wanted a test
could get a test.
55. Upon information and belief, all swabs of Defendants members and/or beneficiaries
were processed in the Murphy Practice’s laboratory.
56. Based on the provisions of the FFCRA, the CARES Act, and the Affordable Care Act
discussed above, the Murphy Practice had every expectation that Defendants would honor their
obligations and reimburse the practice for COVID-19 testing and related services provided to their
members or beneficiaries. Indeed, large health plans and managed care companies similarly situated
to Centene, Fidelis and WellCare honored their obligations to the Murphy Practice.
57. To date, the Murphy Practice has billed Fidelis approximately $2,212,761.00 for over
1800 claims relating to COVID-19 testing and related services provided to the aforementioned
Fidelis members and/or beneficiaries, yet has only been reimbursed approximately $147,938.02.
58. As a result, Fidelis owes the Murphy Practice approximately $2,064,822.98 for
COVID-19 testing and related services provided to the aforementioned members and/or beneficiaries
of Fidelis’ health plans.
59. To date, the Murphy Practice has billed WellCare approximately $376,965.00 for
over 440 claims relating to COVID-19 testing and related services provided to the aforementioned
WellCare members and/or beneficiaries, yet has only been reimbursed approximately $39,091.79.
11
60. As a result, WellCare owes the Murphy Practice approximately $337,873.21 for
COVID-19 testing and related services provided to the aforementioned members and/or beneficiaries
of WellCare’s health plans.
61. In response to Defendants’ denials and infinitesimal “reimbursements”, the Murphy
Practice, and through counsel, sent numerous correspondence to Fidelis and WellCare requesting an
explanation for their behavior.
62. Defendants either ignored or failed to engage in a meaningful dialogue regarding the
claims and, instead, continued to send denials or send fractional reimbursement checks to the
Murphy Practice.
63. The Murphy Practice has attempted to appeal every claim which Defendants have
denied and, through that appeal process, sent Defendants hundreds of pages of responsive medical
and laboratory records.
64. The Murphy Practice’s efforts have largely fallen on deaf ears.
65. Defendants, notwithstanding the aforementioned FFCRA and CARES Act, have
summarily denied each attempted appeal without any investigation into the claims.
66. Each denial was made without sufficient investigation, lacked any reasonably
arguable basis and was in violation of federal and state law.
67. Defendants have since advised the Murphy Practice that the Murphy Practice has
exhausted its right of appeal on any of the denied claims.
68. Defendants have unlawfully denied or issued fractional reimbursements for each
claim submitted by the Murphy Practice in order to strangle and ultimately force the Murphy Practice
to accept dramatically reduced reimbursement rates for COVID-19 testing and related services.
12
69. Defendants are well aware that the Murphy Practice’s ability to continue to operate
these necessary COVID-19 testing sites is severely hampered by withholding payment for COVID-
19 testing and related services provided by the Murphy Practice to Defendants members and/or
beneficiaries.
70. This is precisely Defendants’ intent.
71. Despite not receiving reimbursement from Defendants, the Murphy Practice has not
and will not bill Defendants’ members or beneficiaries (or any patient for that matter) for any of
the testing services during this public health crisis.

72. Despite not receiving reimbursement from Defendants, the Murphy Practice will
continue running all of its existing testing sites and will establish new testing sites to care for all
patients, including Fidelis and WellCare members and/or beneficiaries, to help curb the spread of
the new Omicron BA.2 variant during this everlasting public health crisis.
FIRST CAUSE OF ACTION

(FFCRA and CARES Act)
73. Plaintiffs repeat, reiterate and re-allege each and every allegation contained above as
if more fully set forth at length herein.
74. Centene, through its wholly owned subsidiaries, Fidelis and WellCare, offer group
health plans and are health insurance issuers offering group or individual health insurance coverage
as those terms are defined in section 6001 of the Families First Coronavirus Response Act.
75. The COVID-19 testing and related services that the Murphy Practice provided to
Fidelis and WellCare members and beneficiaries constitute in vitro diagnostic products for the
detection of COVID-19 or the diagnosis of the virus that causes COVID–19 that are approved,
cleared, or authorized under Federal Food, Drug, and Cosmetic Act, and the administration of such
in vitro diagnostic products pursuant to 21 C.F.R. § 809.3(a), as provided by section 6001 of the
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FFCRA.
76. To the extent that any Defendants members and/or beneficiaries submitted to the
Murphy Practice for COVID-19 testing for non-diagnostic purposes (i.e. employer return to work
testing mandates or student return to school testing mandates), Defendants were still financially
responsible to reimburse the Murphy Practice for the costs of each test, since the Murphy Practice
was entitled to assume the diagnostic impetus behind each encounter. 10
77. Regardless, subsequent letters from Congress to HHS, DOL and the Secretary of
Treasury made clear that “widespread testing must be in place to detect and stop the spread of
COVID-19 and ensuring safety in the workplace is critical.”11 As a result, Defendants were
financially responsible to reimburse the Murphy Practice of the costs of each test, regardless of the
impetus behind each test.
78. The Murphy Practice did not have a negotiated rate with Defendants for the provision
of these services.
79. Under section 3202(a) of the CARES Act, if a health plan does not have a negotiated
rate with a provider such as the Murphy Practice for providing COVID-19 testing and/or related
services, the health plan is obligated to pay the provider its cash price for providing those services.
80. Defendants, despite numerous and persistent demands and requests, has failed and
refused to provide anything remotely close to the Murphy Practice’s cash price for providing the
COVID-19 testing related services.
10
FAQs Part 44 (February 26, 2021).
11
See Letter to HHS, DOL, and Secretary of Treasury dated July 8, 2022, available at
https://edlabor.house.gov/imo/media/doc/Democratic%20Health%20Leaders%20Demand%20Trump%20Administr
ation%20Immediately%20Revisit%20Guidance%20Limiting%20COVID-19%20Testing%20Coverage.pdf
14
81. By reason of the foregoing, Plaintiffs have been damaged and are entitled to a
judgment against Centene and/or Fidelis in the amount of at least $2,064,822.98, plus interest,
together with the costs and disbursements of this action, including reasonable attorneys’ fees.
judgment against Centene and/or WellCare in the amount of at least $337,873.21, plus interest,
SECOND CAUSE OF ACTION

(ACA)
83. Plaintiffs repeat, reiterate and reallege each and every allegation contained above as
84. The Patient Protection and Affordable Care Act added section 2719A to the Public
Health Services Act, 42 U.S.C. § 300gg-19a.
85. Section 2719A requires any group health plan, or health insurer that provides or
covers benefits with respect to services in an emergency department of a hospital, to cover any
emergency services, including, emergency services outside of the emergency department, without
the need for prior authorization, without regard to the provider’s status as an out-of-network provider,
and in a manner that ensures that the patient’s cost-sharing requirement is the same requirement that
would apply if such services were provided in-network. 42 U.S.C. § 300gg-19a. These requirements
are expressly incorporated into group health plans covered by ERISA. 29 U.S.C. § 1185d(a).
86. Defendants’ health plans at issue in this lawsuit are health plans that are subject to
the provisions of 42 U.S.C. § 300gg-19a or 29 U.S.C. § 1185d(a).
87. The COVID-19-related testing services provided by the Murphy Practice that are at
issue in this lawsuit meet the definition of emergency services under 42 U.S.C. § 300gg-19a.
15
88. Accordingly, Defendants were obligated to cover these COVID-19-related testing
services under 42 U.S.C. § 300gg-19a and 29 U.S.C. § 1185d(a).
89. Regulations provided pursuant to these sections require that, to satisfy their coverage
obligations for emergency services, health plans must reimburse out-of-network providers at the
greater of (a) the amount negotiated with in-network providers for the emergency service, accounting
for in-network co-payment and co-insurance obligations; (b) the amount for the emergency service
calculated suing the same method the plan generally uses to determine payments for out-of-network
services (such as usual, customary, or reasonable charges), but substituting in-network cost-sharing
provisions for out-of-network cost-sharing provisions; or (c) the amount that would be paid under
Medicare for the emergency service, accounting for in-network co-payment and co-insurance
obligations. 29 C.F.R. § 590.715-719A(b)(3)(i)(A)-(C).
90. Defendants, despite numerous and persistent demands and requests, have failed and
refused to provide to the Murphy Practice anything remotely close to the reimbursement required by
29 C.F.R. § 590.715-719A(b)(3)(i)(A)-(C).
THIRD CAUSE OF ACTION

(ERISA)
93. Plaintiffs repeat, reiterate and reallege each and every allegation contained above as
16
94. Even if the FFCRA and CARES Act did not, on their own, obligate Defendants to
reimburse the Murphy Practice for the medically necessary COVID-19-related testing and related
services that it performed – which they most certainly do – Defendants would still be obligated to
reimburse the Murphy Practice for these services. This is because the FFCRA and CARES Acts are
to be treated, for enforcement purposes, as if they were included in ERISA.
95. Even were this not the case, the FFCRA and the CARES Act broadly apply to all
health care plans governed by ERISA, meaning that ERISA plans are required to cover COVID-19
testing and related services as provided in the FFCRA and the CARES Act.
96. On information and belief, a significant number of claims the Murphy Practice has
submitted to Defendants relate to patients enrolled in Defendants’ health plans or health plans
Defendants’ administer subject to ERISA. ERISA, the FFCRA, the CARES Act and Affordable Care
Act all require Defendants to cover COVID-19 testing and related services regardless of the terms
of their plan.
97. Upon information and belief, Defendants’ health plans do not prohibit patients from
assigning their rights to benefits under the plans to the Murphy Practice, including direct payment of
benefits under the plans to the Murphy Practice.
98. As such, the Murphy Practice has standing to pursue claims under ERISA as the
assignee and authorized representative of its patients who are members or beneficiaries of
Defendants’ ERISA health plans.
99. As the assignee of its patients, the Murphy Practice is entitled to payment under
Defendants’ ERISA health plans for the medical services provided to Defendants’ patients by the
Murphy Practice.
17
100. Moreover, even if some of Defendants’ ERISA health plans prohibited the assignment
of benefits to the Murphy Practice, Defendants waived any purported anti-assignment provisions,
ratified the assignment of benefits to the Murphy Practice, and waived or is estopped from using any
purported anti-assignment provisions against the Murphy Practice due to Defendants’ course of
dealing with and statements to the Murphy Practice as an out-of-network provider.
101. Upon information and belief, Defendants’ ERISA health plans require payments of
emergent and elective medical expenses incurred by its members and beneficiaries up to the rate of
the Murphy Practice’s full incurred charges (less in-network patient responsibility amounts) for
emergency/urgent care and (less out-of-network patient responsibility amounts) for elective care.
102. The Murphy Practice’s incurred charges represent its usual and customary rates for
the treatment provided to Defendants’ plan members or beneficiaries.
103. Defendants’ breached the terms of its ERISA health plans by refusing to make out-
of-network payments for charges covered by the plans, in violation of ERISA § 502(a)(1)(B), 29
U.S.C. § 1132(a)(1)(B).
104. These breaches include, among other things, (a) refusing to reimburse the Murphy
Practice for the medically necessary testing it provided to Fidelis and WellCare’s plan members or
beneficiaries, as required by the FFCRA, the CARES Act, or the Affordable Care Act; (b) refusing
to reimburse the Murphy Practice for the medically necessary services that it provided to Fidelis and
WellCare’s plan members or beneficiaries, as required by 29 C.F.R. § 590.715-719A(b)(3)(i)(A)-
(C); or (c) otherwise refusing to reimburse Murphy Practice the legally required amounts due under
the plans for the medically necessary services provided by the Murphy Practice to Fidelis and
WellCare’s plan members or beneficiaries.
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105. On information and belief, Defendants’ blanket denials of the Murphy Practice’s
claims for COVID-19 testing and related services or attempted infinitesimal “reimbursements”, and
unjustifiable records requests, violate the provisions of these ERISA plans and wrongfully deny
benefits due under ERISA.
106. As a result of, among other acts, Defendants’ numerous procedural and substantive
violations of ERISA and other federal statutes, any appeals are deemed exhausted or excused, and
the Murphy Practice is entitled to have this Court undertake a de novo review of the issues raised in
this Complaint.
107. To the extent that any of Defendants’ ERISA plans have not followed the
requirements of the FFCRA and CARES Act, and do not provide full coverage of COVID-19 testing
and related services, they are in violation of the FFCRA, the CARES Act, the Affordable Care Act
and ERISA.
108. To the extent that any of Defendants’ ERISA plans do provide COVID-19 testing
benefits as required by the FFCRA and the CARES Act, Defendants have wrongfully failed to pay
the Murphy Practice as required by the plans, in violation of ERISA.
109. Based on the provisions of the FFCRA, the CARES Act and Affordable Care Act,
discussed above, the Murphy Practice had every expectation that Defendants would honor their
obligations and reimburse the practice for these COVID-19-related testing services provided to its
members or beneficiaries. Indeed, other health plans and health plan administrators similarly situated
to Defendants honored their obligations to the Murphy Practice.
110. It is hard to imagine a clearer violation of the FFCRA and the CARES Act, than an
insurer or health plan administrator who has been provided with proof that one of their beneficiaries
was determined by a physician to be in medical need of a COVID-19 test, and provided with proof
19
that the test was performed, yet refuses to pay anything.
113. The Murphy Practice is also entitled to declaratory relief to enforce the terms of
Defendants’ ERISA health plans and to clarify its right to future benefits under such plans.
FOURTH CAUSE OF ACTION

(ERISA)
114. Plaintiffs repeat, reiterate, and reallege each and every allegation contained above, as
115. As assignees and authorized representatives of its patients’ claims, the Murphy
Practice is entitled to receive protection under ERISA, including (a) a “full and fair review” of all
claims denied by Defendants; and (b) compliance by Defendants with applicable claims procedure
requirements.
116. Based on all of the foregoing, Defendants’ actions and inactions relating to the claims
at issue in this lawsuit are tantamount functionally to a denial of these claims.
117. For denied claims pursuant to 29 U.S.C. § 1133, an ERISA plan must (a) provide
adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan
has been denied, setting forth the specific reasons for such denial, written in a manner calculated to
be understood by the participant; and (b) afford a reasonable opportunity to any participant whose
20
claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of
the decision denying the claim. 29 U.S.C. § 1133(1) and (2).
118. ERISA regulations make clear that, in the case of post-service claims submitted
pursuant to group health plans, the required notification that the claim has been denied must be issued
within a reasonable period of time, but not later than 30 days after receipt of the claim, unless the
member or beneficiary is notified that, due to circumstances beyond the plan’s control, the plan
requires an additional 15 days to issue a required denial notification. 29 C.F.R. § 2560-
503.1(f)(2)(iii)(B).
119. Although Defendants is obligated to provide a “full and fair review” of denied and
underpaid claims pursuant to 29 U.S.C. § 1133, Defendants has failed to do so by, among other
things: (a) refusing to provide the specific reason or reasons for the denial or underpayment of claims;
(b) refusing to provide the specific plan provisions relied upon to support its denials or
underpayments; (c) refusing to provide the specific rule, guideline or protocol relied upon in making
the decisions to deny or underpay claims; (d) refusing to describe any additional material or
information necessary to perfect a claim, such as the appropriate diagnosis/treatment codes; (e)
refusing to notify the relevant parties that they are entitled to have, free of charge, all documents,
records and other information relevant to the claims for benefits; (f) refusing to provide a statement
describing any voluntary appeals procedure available, or a description of all required information to
be given in connection with that procedure; (g) refusing to provide the Murphy Practice with the
documents and information relevant to Defendants’ denial of the claims; and (h) refusing to timely
issue required notifications that the claims have been denied or underpaid.
120. By failing to comply with the ERISA claims procedure regulations, Defendants have
utterly failed to provide a reasonable claims procedure.
21
121. Because Defendants have failed to comply with the substantive and procedure
requirements of ERISA, any administrative remedies are deemed exhausted pursuant to 29 C.F.R. §
2560.503-1(I) and 29 C.F.R. § 590.715-2719(b)(2)(ii)(F)(1).
122. Exhaustion is also excused because it would be futile to pursue any administrative
remedies, because Defendants do not acknowledge any legitimate basis for their denials and thus
offers no meaningful administrative process for challenging their denials.
123. The Murphy Practice has been harmed by Defendants’ failure to provide a full and
fair review of appeals submitted and failure to comply with applicable claims procedure regulations
under ERISA. 29 U.S.C. § 1133.
124. The Murphy Practice is entitled to relief under 29 U.S.C. § 1132(a)(3), including
declaratory and injunctive relief, to remedy Defendants’ failures to provide a full and fair review, to
disclose information relevant to appeals, and to comply with applicable claim procedure regulations.
FIFTH CAUSE OF ACTION

(Unjust Enrichment)
if more fully set forth herein.
126. Plaintiffs have submitted numerous claims to Defendants for COVID-19-related
testing and services provided to members or beneficiaries of Defendants’ health plans and/or health
plans Defendants administer.
127. As discussed above, Defendants is obligated to reimburse Plaintiffs for the COVID-
19 testing Plaintiffs provided to members or beneficiaries of Defendants’ health plans.
128. Defendants have failed to reimburse Plaintiffs for the COVID-19 testing and related
services Plaintiffs provided to members or beneficiaries of Defendants’ health plans.
22
129. By providing medically necessary COVID-19 testing and related services to
Defendants’ members and beneficiaries, Plaintiffs conferred a benefit upon Defendants because
Plaintiffs’ provision of healthcare services facilitated Defendants’ obligations to arrange and pay for
COVID-19 testing and related services for its members.
130. Defendants benefited from the insurance premiums or funds it received from
members and beneficiaries in exchange for out-of-network healthcare coverage.
131. To satisfy its legal obligations, Defendants required the services of Plaintiffs to render
testing services to members or beneficiaries of Defendants’ health plans.
132. By virtue of the foregoing, Defendants have received a benefit, in that Plaintiffs have
provided COVID-19 testing and related services to members or beneficiaries of Defendants’ health
plans for which Defendants have not paid for.
133. Moreover, Plaintiffs’ COVID-19 testing and related services it provided to members
or beneficiaries of Defendants’ health plans conferred an additional benefit to Defendants by
decreasing the cost of long-term care as a result of early detection through COVID-19 testing.
134. Defendants knew that Plaintiffs provided the medically necessary testing services in
satisfaction of Defendants’ obligations to its members.
135. Defendants have unjustly failed to reimburse Plaintiffs for the benefit.
136. Defendants’ failure to reimburse Plaintiffs was and is to Plaintiffs’ detriment.
137. As a result, Plaintiffs are entitled to a judgment against Defendants Centene and/or
Fidelis in the amount of at least $2,064,822.98, plus interest.
138. As a result, Plaintiffs are entitled to a judgment against Defendants Centene and/or
WellCare in the amount of at least $337,873.21, plus interest.
23
SIXTH CAUSE OF ACTION

(Breach of Contract)
140. Upon information and belief, Defendants operate managed care health insurance
companies and issued policies to their beneficiaries pertaining to healthcare services.
141. Upon information and belief, these policies provided for the reimbursement of
medical care services rendered by providers, such as the Murphy Practice, who are commonly
referred to as non-participating providers, who do not have agreements with Defendants.
142. Based on the provisions of the FFCRA and the CARES Act, Defendants were required
to reimburse Plaintiffs as a non-participating provider for COVID-19 testing and related services to
members or beneficiaries of Defendants’ health plans.
143. As a result, an implied contract was created between Plaintiffs and Defendants.
144. At all times relevant herein, Plaintiffs were the intended beneficiaries of the policies,
which were issued or administered by Defendants.
145. At all times relevant herein, Defendants had knowledge that Plaintiffs treated its
members or beneficiaries of Defendants’ health plans and accepted the benefits conferred by
Plaintiffs.
146. The reasonable and customary charges for the services that were rendered to Fidelis’
members and beneficiaries is in an amount no less than $2,212,761.00, of which only $147,938.02
has been paid.
147. As a result, Centene and/or Fidelis owes Plaintiff an amount no less than
$2,064,822.98.
24
148. The reasonable and customary charges for the services that were rendered to
WellCare’s members and beneficiaries is in an amount no less than $376,965.00, of which only
$39,091.79 has been paid.
149. As a result, Centene and/or WellCare owes Plaintiff an amount no less than
$337,873.21.
150. Plaintiffs and members of Defendants’ health plans have fully performed their
obligations and conditions precedent under the policies.
151. Plaintiffs have made a demand upon Defendant Fidelis for payment of at least
$2,064,822.98.
152. Defendants’ refusal to make a single payment on the balance is in contravention and
in breach of its agreement with the Plaintiffs.
153. Plaintiffs have made a demand upon Defendant WellCare for payment of at least
$337,873.21.
154. Defendants’ refusal to make a single payment on the balance is in contravention and
in breach of its agreement with the Plaintiffs.
155. As a result of the aforesaid breach, Plaintiffs have been damaged by Centene and/or
Fidelis in an amount no less than $2,064,822.98.
156. As a result of the aforesaid breach, Plaintiffs have been damaged by Centene and/or
Fidelis in an amount no less than $337,873.21.
SEVENTH CAUSE OF ACTION

(Violations of CUIPA)
25
158. Defendants’sactions constitute unfair claims settlement practices in violation of the
Connecticut Unfair Insurance Practices Act, Conn. Gen. Stat. § 38a-816.
159. Defendants’ acts and omissions offend public policy as established by the
Connecticut Unfair Insurance Practices Act.
160. Defendants’ acts are immoral, unethical, oppressive, and unscrupulous, with respect
to their affects upon patients and providers, including Plaintiffs.
161. Defendants’ acts are causing substantial injury to patients and providers, including
Plaintiffs who continue to provide critical COVID-19 testing and related services.
162. Defendants’ acts are causing substantial injury to Plaintiffs.
163. Defendants’ acts have caused Plaintiffs to suffer an ascertainable loss of money
and/or property.
164. Plaintiffs are entitled to compensation for the ascertainable loss they suffered as a
result of Defendants’ acts.
EIGHTH CAUSE OF ACTION

(Violations of CUTPA)
166. Defendants’ acts represent a uniform practice of Defendants’ administration of the
health plans they administer.
167. Defendants’ acts constitute an unfair trade practice.
168. Defendants has engaged in the aforementioned unfair trade practices with such
frequency as to indicate a general business practice.
26
169. Despite Plaintiffs repeated efforts to obtain proper payment on the claims,
Defendants have refused to enter into a meaningful dialogue with Plaintiffs regarding the services
rendered to members of Defendants’ health plans.
170. Instead, Defendants have flatly denied the claims itself or attempted to make
fractional reimbursements, without sufficient investigation and/or lacking in any reasonably
arguable basis.
171. Defendants have denied each claim submitted by the Murphy Practice in order to
strangle and ultimately force the Murphy Practice to accept dramatically reduced reimbursement
rates for the claims.
172. Defendants are well aware that the Murphy Practice’s ability to continue to operate
these necessary COVID-19 testing sites is severely hampered by withholding payment for COVID-
19 testing and related services provided by the Murphy Practice to Defendants members and/or
beneficiaries.
173. This is precisely Defendants’ intent.
174. Plaintiffs have exhausted all attempts to appeal causing this litigation to ensue.
175. Defendants’ acts are a violation of the Connecticut Unfair Trade Practices Act,
Conn. Gen. Stat. § 42-110b.
176. Defendants’ acts are wanton and reckless given the harm they have caused and will
continue to cause Plaintiffs, and Defendants knew or should have known of the wrongfulness of
its acts and that such severe harm would have resulted from such acts.
177. Defendants acted with reckless indifference to the rights of others, including
Plaintiffs.
27
178. By reason of the foregoing, Plaintiffs are entitled to compensatory damages,
punitive damages, and attorney’s fees against Defendants pursuant to the Connecticut Unfair Trade
Practices Act, Conn. Gen. Stat. § 42-110g.
WHEREFORE, Plaintiffs demand judgment as follows:

a) On the First Count, a judgment against Centene and/or Fidelis,
awarding the Murphy Practice compensatory damages in an
amount to be determined at trial, such amount being no less than
$2,064,822.98, plus pre-judgment and post-judgment interest;
b) On the First Count, a judgment against Centene and/or WellCare,
$337,873.21, plus pre-judgment and post-judgment interest;
c) On the Second Count, a judgment against Centene and/or Fidelis,
d) On the Second Count, a judgment against Centene and/or
WellCare, awarding the Murphy Practice compensatory damages
in an amount to be determined at trial, such amount being no less
than $337,873.21, plus pre-judgment and post-judgment interest;
e) On the Third Count, a judgment against Centene and/or Fidelis,
f) On the Third Count, a judgment against Centene and/or WellCare,
g) On the Fourth Count, awarding the Murphy Practice relief under

29 U.S.C. § 1132(a)(3), including declaratory and injunctive relief,
to remedy Defendants’ failures to provide a full and fair review, to
disclose information relevant to appeals, and to comply with
applicable claim procedure regulations;
h) On the Fifth Count, a judgment against Centene and/or Fidelis,

28
i) On the Fifth Count, a judgment against Centene and/or WellCare,

j) On the Sixth Count, a judgment against Centene and/or Fidelis,

k) On the Sixth Count, a judgment against Centene and/or WellCare,
l) On the Seventh Count, a judgment against Defendants Centene

and/or Fidelis, awarding the Murphy Practice compensatory
damages in an amount to be determined at trial, such amount being
no less than $2,064,822.98, plus pre-judgment and post-judgment
interest;
m) On the Seventh Count, a judgment against Centene and/or
WellCare, awarding the Murphy Practice compensatory damages
in an amount to be determined at trial, such amount being no less
than $337,873.21, plus pre-judgment and post-judgment interest;
n) On the Eighth Count, awarding the Murphy Practice compensatory

no less than $2,064,822.98, punitive damages, and attorney’s fees
against Defendants Centene and/or Fidelis pursuant to the
Connecticut Unfair Trade Practices Act, Conn. Gen. Stat. § 42-
110g;
o) On the Eighth Count, awarding the Murphy Practice compensatory

no less than $337,873.21, punitive damages, and attorney’s fees
against Defendants Centene and/or WellCare pursuant to the
Connecticut Unfair Trade Practices Act, Conn. Gen. Stat. § 42-
110g;
p) On all Counts, punitive damages, in an amount to be determined at

trial, pursuant to C.G.S. § 42-110g(a);
i) On all Counts, Plaintiffs’ costs and reasonable attorney's fees in

bringing this action, pursuant to C.G.S. § 42-110g(d); and
j) Such other and further relief as the Court may deem equitable, just
and proper.
29
Dated: New Haven, Connecticut

April 4, 2022
HARRIS BEACH PLLC

Attorneys for Plaintiffs
By: /s/ Roy W. Breitenbach

Roy W. Breitenbach
Daniel S. Hallak
The Omni
333 Earle Ovington Boulevard, Suite 901
Uniondale, New York 11553
(516) 880-8484
195 Church Street, #18

New Haven, Connecticut 06510
(203) 784-3159
TO: Centene Corporation
7700 Forsyth Boulevard
St. Louis, MO 63105
Fidelis Care
100 Willowbrook Office Park #100
Fairport, NY 14450
WellCare Health Plans, Inc.

7700 Forsyth Boulevard
St. Louis, MO 63105
30

Centene V. Murphy Medical

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Centene V. Murphy Medical

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Case 3:22-cv-00504-VLB Document 1 Filed 04/06/22 Page 1 of 30

UNITED STATES DISTRICT COURT

Plaintiffs Murphy Medical Associates LLC, Diagnostic and Medical Specialists of

(“WellCare”)(collectively, “Defendants”), allege as follows.

provided by in-network or out-of-network providers. Such coverage must be complete:

copayments, deductibles, coinsurance and limits on coverage are not permitted.

located at 30 Buxton Farms Road, Stamford, Connecticut 06905.

place of business is located at 30 Buxton Farms Road, Stamford, Connecticut 06905.

place of practice is located at 30 Buxton Farms Road, Stamford, Connecticut 06905.

9. Dr. Murphy, a board-certified internist, is the principal of the Murphy Practice.

11. As a physician, Dr. Murphy specializes in general medical care, personalized

obesity medicine specialist.

anatomy at New York Medical College in Valhalla, New York.

(“CLIA”) and Connecticut law.

located at 7700 Forsyth Boulevard St. Louis, MO 63105.

NY 14450. Fidelis is a wholly owned subsidiary of Defendant Centene.

WellCare is a wholly owned subsidiary of Defendant Centene.

JURISDICTION AND VENUE

has supplemental jurisdiction over these claims pursuant to 28 U.S.C. § 1367(a).

activity within this judicial district.

activity within this judicial district.

and not isolated, activity within this judicial district.

FEDERAL LAW REQUIRES DEFENDANTS TO REIMBURSE PLAINTIFFS

Economic Security Act (“CARES Act”).

COVID antibody testing, and related testing and services.

related services were provided by “in-network” or “out of network” providers.

insurers to provide robust and comprehensive coverage of COVID-19 testing.2

PLAINTIFFS’ RESPONSE TO THE COVID-19 CRISIS

Amendments (“CLIA”) and Connecticut law.

throughout Connecticut and New York.

unquestionably one of the first lines of defense against the pandemic.

infection control, OSHA, and CDC guidance were observed.

Brooklyn, and Pound Ridge, New York.

party laboratory for processing.

the patient samples that the Murphy Practice collects.

lab or to a third-party laboratory for processing.

purchase the new BioFire machine.

41. According to the makers of BioFire, “[t]he inclusion of SARS-CoV-2 in the

faster rate than commercial third-party labs.

electronically assigned their benefits to the Murphy Practice.

that are the subject of this Complaint. 8

WellCare that are the subject of this Complaint. 9

53. As the operator of state- or locality-administered sites, drive-through sites, and/or

the test reflects an “individualized clinical assessment.”

could get a test.

were processed in the Murphy Practice’s laboratory.

of Fidelis’ health plans.

of WellCare’s health plans.

61. In response to Defendants’ denials and infinitesimal “reimbursements”, the Murphy

explanation for their behavior.

and laboratory records.

arguable basis and was in violation of federal and state law.

exhausted its right of appeal on any of the denied claims.

70. This is precisely Defendants’ intent.

the testing services during this public health crisis.

FIRST CAUSE OF ACTION

if more fully set forth at length herein.

was entitled to assume the diagnostic impetus behind each encounter. 10

impetus behind each test.

COVID-19 testing related services.

SECOND CAUSE OF ACTION

if more fully set forth at length herein.

Health Services Act, 42 U.S.C. § 300gg-19a.