Athena Healthcare Sued by Claim Auditing Service for Breach of Contract

A suit was removed to federal court last Friday from Polk County, Iowa state court by defendants led by Innovative Health Health Plan, LLC. ClaimDOC, LLC’s initial complaint asserted civil claims for relief in the form of millions of dollars regarding fee payments required by a written agreement between the plaintiff and defendant Athena Healthcare Associates.

The removing defendants explain that the initial complaint does not conclusively establish diversity jurisdiction, and requested that the complaint proceed in the Southern District of Iowa.

According to the state court complaint, ClaimDOC “provides claim auditing and member advocacy services designed to achieve health benefits that are sustainable.” Defendant Athena is a “for-profit skilled nursing, short-term, and post-hospital care rehabilitation facility provider.” Athena employees and dependents are given a self-insured plan governed by the Employee Retirement and Income Security Act (ERISA). In 2018, the plaintiff accepted defendant Athena as a client to provide them with claim review services, per the state court document.

The agreement reached by the plaintiff and Athena specifies that ClaimDOC’s fees will be paid by either Athena or the plan, and in the event that the plan fails to make a payment, Athena will provide coverage.

Defendant Allen Jackson owns and operates defendants HP, IHIP, and HIS. The complaint alleges that Allen Jackson “teamed up with Athena-owner Lawrence Santilli in an effort to deny Athena beneficiaries over $9 million dollars in healthcare benefits and to avoid nearly $2 million dollars in contractual obligations to ClaimDOC.”

The plaintiff placed Athena on notice of termination after it failed to make timely payments and satisfy its contractual obligations. The complaint contends that those involved in the alleged conspiracy continued to represent that Athena was financially strong despite failing to make medical payments to the plaintiff.

Eventually, the two parties reached an amended agreement that allowed the plaintiff to continue servicing Athena, but they quickly fell behind on payments again and announced that they would be transitioning their services to defendant S&S Healthcare. Since the transition would be occurring before the end of the plan year, the plaintiff explains that it took extra steps to ensure the plan’s beneficiaries would be provided for and communicated with the defendants in regard to Athena’s lack of compliance and funding deficiencies.

After the agreement was terminated, Athena still owed millions of dollars in both medical claims and ClaimDOC fees. The plaintiff quickly realized that defendant Athena had involved itself in a scheme with the defendants where they would continually resubmit claims to avoid payment, which allowed Athena to “[prioritize] payment to the Defendants assisting it in avoiding the payment of medical claims, and those Defendants are accepting said funds at the expense of the Athena beneficiaries.”

The complaint cites breach of contract, interference with contract, fraud, unjust enrichment, and preliminary and permanent injunctive relief. Plaintiff ClaimDOC is seeking an injunction requiring defendant Athena to pay claims chronologically, litigation fees, court costs, and any other relief deemed just by the Court.

The plaintiff is represented by Nyemaster Goode, P.C.