Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Phi Air Medical, LLC v. New Mexico Office of Superintendent of Insurance

United States District Court, D. New Mexico

December 10, 2018

PHI AIR MEDICAL, LLC, Plaintiff,
v.
NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE, and JOHN G. FRANCHINI, Superintendent of Insurance in his official capacity, and JEREMY RODRIQUEZ-ORTEGA, Compliance Officer, New Mexico Officer of Superintendent of Insurance, Managed Health Care Bureau, in his official capacity, Defendants.

          MEMORANDUM OPINION AND ORDER DISMISSING COMPLAINT AND COUNTERCLAIM WITHOUT PREJUDICE FOR LACK OF SUBJECT MATTER JURISDICTION

         In DEFENDANT-COUNTERCLAIMANTS' MOTION FOR JUDGMENT ON THE PLEADINGS (Doc. No. 20) (Motion), Defendants the New Mexico Officer of Superintendent of Insurance (OSI) and John G. Franchini (Superintendent)[1] (together the OSI Defendants) ask the Court to dismiss Plaintiff PHI Air Medical, LLC's (PHI's) claims for declaratory judgment and injunction as set forth in the COMPLAINT (Doc. No. 1) (Complaint). The OSI Defendants ask the Court to grant declaratory judgment in their favor as requested in the ANSWER TO COMPLAINT [Doc. 1] AND COUNTERCLAIM FOR DECLARATORY JUDGMENT (Doc. No. 10) (Counterclaim). The Motion is fully briefed. See PHI's RESPONSE TO MOTION FOR JUDGMENT ON THE PLEADINGS (Doc. No. 28) (Response); and REPLY IN SUPPORT OF [20] DEFENDANTS-COUNTERCLAIMANTS' MOTION FOR JUDGMENT ON THE PLEADINGS (Doc. No. 29) (Reply).[2]

         In the Complaint, PHI asks the Court to enter declaratory judgment that under the Airline Deregulation Act (ADA), 49 U.S.C. § 41713(b)(1), the New Mexico insurance laws prohibiting the balance billing of air ambulance patients are preempted and unenforceable. PHI also asks the Court to enjoin the OSI Defendants from enforcing New Mexico insurance laws against PHI and other air ambulance providers. (Compl. at p.11.)

         In the Counterclaim, the OSI Defendants allege that under the McCarran-Ferguson Act, 15 U.S.C. § 1012(b) (MFA), New Mexico insurance laws prohibiting balance billing of patients covered by managed health care plans remain valid because the state laws were enacted for the purpose of regulating the “business of insurance.” Id.

         Because the Court lacks subject matter jurisdiction over the claims in the Complaint and the Counterclaim, the Court will dismiss the Complaint and the Counterclaim without prejudice.

         I. BACKGROUND

         PHI is an air ambulance company registered in Louisiana and headquartered in Phoenix, Arizona. (Compl. ¶ 14.) PHI is certified as a Part 135 Air Carrier by the Federal Aviation Administration. (Id. ¶ 1, Exs. A & B.) PHI is licensed by the New Mexico Department of Health to provide air ambulance services to New Mexico residents from bases in Albuquerque, Socorro, and Grants, New Mexico. (Id.)

         A. R.W. transported from Grants, N.M. to Albuquerque, N.M.

         On April 11, 2016, PHI provided emergency air transportation to R.W., a stroke patient, from Grants, New Mexico to Presbyterian Hospital in Albuquerque, New Mexico. (Id. ¶ 27.) R.W. was covered by a Group Care Connect Gold HMO plan (R.W.'s Plan) issued by New Mexico Health Connections (NMHC). (Id. ¶ 28.) On May 3, 2016, PHI submitted an invoice in the amount of $46, 620.00 to NMHC for the transportation services. (Id.) The invoiced amount consisted of a base rate of $25, 678.00 plus $283.00 per loaded mile for the 74-mile trip. (Id. ¶ 29.) PHI was an out-of-network provider under R.W.'s Plan. (Id. Ex. C.) R.W.'s Plan provided that if a member requires emergency services from an out-of-network provider, NMHC will cover those services at the in-network benefit level. (Id.) Hence, R.W.'s Plan covered out-of-network services up to the “usual, customary, and reasonable amount” as determined by NMHC. (Id.; Compl. Ex. C at 2.) Under R.W.'s Plan, R.W. is required to pay a $100 co-pay to NMHC for PHI's services, and R.W. made that co-payment. (Id.) NMHC paid PHI $15, 658.86, using a base rate of $13, 808.86 plus $25.00 per loaded mile, which is its usual, customary, and reasonable rate for helicopter transport. (Id. ¶ 30; Ex. C.)[3] The unpaid balance of PHI's invoice is $30, 961.14. (Id. Ex. C.)

         1. Internal Review with NMHC.

         PHI, using NMHC's internal review process, appealed the deficient reimbursement. (Id. ¶ 31.) NMHC denied PHI's request for additional reimbursement. (Id.) PHI then billed R.W. for the unpaid balance. (Id.)

         2. External Review with the OSI.

         On January 25, 2017, R.W. filed an external review request with the OSI under 13.10.17.23 NMAC. [R.W.] v. NMHC, OSI File No. 17-0086-EXTR-ADMIN. (Id. ¶ 32.) R.W. disputed the decision by NMHC to partially deny coverage for “emergency air transport services supplied by [PHI].” (Compl. Ex. C.) PHI was not a party to the external review proceeding. The OSI issued an ORDER GRANTING REQUEST FOR EXTERNAL REVIEW (Compl. Ex. C) (R.W.'s Order). In R.W.'s Order, the OSI determined that “[t]he New Mexico Patient Protection Act requires that managed health care plans shall provide reasonable access to health care services including access to emergency care that is immediately available without prior authorization at no additional cost to the patient. (Id. ¶ 17, citing NMSA 1978 § 59A-57-4(B)(3)(d)). Section 59A-57-4(B)(3)(d) states:

B. The regulations adopted by the department [OSI] to protect patient rights shall provide at a minimum that
(3) in providing reasonable accessible health care services that are available in a timely manner, a managed health care plan shall ensure that …
(d) emergency care is immediately available without prior authorization requirements, and appropriate out-of-network care is ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.