The Eleventh Circuit Court of Appeals recently affirmed the dismissal of a lawsuit filed by Emerald Multispecialty, P.A. against UnitedHealthcare, Inc. The case, docketed as 26-11157, centered around claims for payment related to COVID-19 testing and treatment services provided to UnitedHealthcare's insured patients. The court's ruling has implications for healthcare providers seeking compensation from insurers, particularly in the context of pandemic-related services.

Emerald Multispecialty, a medical practice not part of UnitedHealthcare's provider network, treated patients during the COVID-19 pandemic. The practice administered COVID-19 tests and monoclonal-antibody treatments, later seeking payment from UnitedHealthcare. Emerald argued that federal regulations required health plans to cover these services regardless of whether the provider was in-network. However, the insurer did not pay for these claims, leading Emerald to file a lawsuit.

The dispute began when Emerald sued UnitedHealthcare in Florida state court for breach of an implied-in-fact contract and sought declaratory relief. UnitedHealthcare removed the case to federal court, where it moved to dismiss the claims. The district court granted the motion, dismissing both claims with prejudice, meaning Emerald could not amend its complaint to address the issues identified by the court.

Emerald's claims were based on the assertion that an implied contract existed between the two parties. The court found that Emerald had not presented sufficient facts to suggest that UnitedHealthcare had agreed to pay for the services provided. The court stated, "Emerald has not pleaded facts that establish United assented to pay for the COVID-19 tests and treatments." The judges emphasized that without mutual assent, an implied-in-fact contract could not be established.

The court also addressed Emerald's request for declaratory relief, which was dismissed as well. The judges noted that the request was retrospective, concerning completed actions rather than an ongoing controversy. The court ruled that the district court acted within its discretion in declining to entertain the request for declaratory relief.

The ruling has significant implications for healthcare providers who may find themselves in similar situations. It underscores the necessity for clear agreements between providers and insurers, particularly regarding payment for services rendered. The court's decision reinforces the idea that simply providing services does not guarantee payment, especially when the provider is out of network.

Emerald's case highlights the complexities surrounding healthcare billing and insurance coverage, particularly during the pandemic. As healthcare providers navigate these challenges, the ruling serves as a reminder of the importance of establishing clear contractual relationships with insurers to ensure compensation for services rendered.

Looking ahead, Emerald Multispecialty may consider appealing the decision, although the court filing did not provide details on any potential next steps. There is currently no related case pending that could impact this ruling.