Emergency Medical Care Facilities, PC v. BlueCross BlueShield of Tennessee, Inc. et al

Filing 119

ORDER REMANDING CASE TO STATE COURT. Signed by Chief Judge J. Daniel Breen on 1/19/17. (Breen, J.)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF TENNESSEE
EASTERN DIVISION
EMERGENCY MEDICAL CARE
FACILITIES, P.C.,
Plaintiff,
v.

No. 15-1014

BLUECROSS BLUESHIELD OF
TENNESSEE, INC. and VOLUNTEER
STATE HEALTH PLAN, INC.,
Defendants.
_____________________________________________________________________________
ORDER REMANDING CASE TO STATE COURT
_____________________________________________________________________________
I. BACKGROUND AND PROCEDURAL HISTORY
On or about August 13, 2014, the Plaintiff, Emergency Medical Care Facilities, P.C.
("EMCF"), brought a putative class action in the Circuit Court for Madison County, Tennessee,
against the Defendant, BlueCross BlueShield of Tennessee, Inc. ("BCBST"), alleging breach of
contract and breach of implied covenant of good faith and fair dealing under Tennessee law;
violation of Tennessee’s prompt pay requirement under Tennessee Code Annotated §§ 56-32109 and 56-7-105, et seq.; and violation of the Tennessee Consumer Protection Act, Tennessee
Code Annotated § 47-18-101, et seq. (“TCPA”). EMCF also sought declaratory judgment
pursuant to Tennessee Code Annotated § 29-14-101, et seq.1 The complaint was amended on or
about January 6, 2015, naming BCBST subsidiary Volunteer State Health Plan, Inc. ("VSHP") as
an additional defendant, dropping the prompt pay claim, and citing to federal law and regulation
1

In this initial pleading, the Plaintiff sought declaratory judgment that, pursuant to Section
Q of the BlueCare Attachment described below, BCBST’s reduction of payment to providers
materially affected EMCF’s position under the parties’ agreements and that BCBST was
contractually bound to negotiate further contracts in light of the payment change.

in support of Plaintiff’s state law and declaratory judgment claims. The matter was removed to
this Court on January 29, 2015, on federal question grounds. (Docket Entry (“D.E.”) 1.) In an
order entered June 5, 2015, the Court dismissed Plaintiff’s TCPA and stand-alone breach of
implied covenant of good faith and fair dealing claims. (D.E. 35.) Before the Court is the
Defendants’ motion for summary judgment on the remaining claims for breach of contract and
for declaratory judgment. (D.E. 100.)
II. FACTS2
VSHP has served as a managed care organization (“MCO”) in Tennessee’s TennCare
program since prior to 2008. TennCare is the state’s managed care system for residents eligible
for Medicaid. Chattanooga-Hamilton Cty. Hosp. Auth. v. UnitedHealthcare Plan of the River
Valley Inc., 475 S.W.3d 746, 749 (Tenn. 2015). BCBST is financially at-risk for its MCO
product, known as BlueCare, and contractually obligated to follow state budget reductions,
payment reform initiatives and state law. Another program, TennCareSelect, is distinct from
TennCare and serves a population selected by the state. BCBST is an administrative services
organization (“ASO”) for TennCareSelect and is not financially at-risk therefor.
EMCF has been a participating emergency medical provider in the BlueCare and
TennCareSelect networks under contracts including Group Specialist (Practice) Agreement,
BlueCare Attachment, TennCareSelect Amendment and associated amendments. Section Q of
the BlueCare Attachment provides as follows:

2

In a footnote contained in its response to the Defendants’ statement of undisputed facts,
Plaintiff noted that it repeated those facts for the Court’s convenience. Counsel is advised,
however, that the Local Rules of this district require that the response to statements of facts “be
made on the document provided by the movant or on another document in which the non-movant
has reproduced the facts and citations verbatim as set forth by the movant. In either case, the
non-movant must make a response to each fact set forth by the movant immediately below each
fact set forth by the movant.” LR 56.1(b) (emphasis added).
2

Compliance with Laws. The parties agree to recognize and abide by all
applicable State and Federal laws, regulation, and guidelines.
In addition, all applicable Federal and State laws or regulations, and revisions of
such laws or regulations shall automatically be incorporated by reference herein
as they become effective. In the event that changes in the Group Practice
Agreement, or this BlueCare Attachment, as a result of revisions in applicable
Federal or State law materially affect the position of one or more parties, the
parties agree to negotiate such further Attachments as may be necessary to correct
any inequities.
(D.E. 1-3 at PageID 173, D.E. 1-4 at PageID 463.) Section 10 of the 2009 BlueCare Compliance
Amendment states that
This Amendment incorporates by reference all applicable federal and state laws,
TennCare rules and regulations, consent decrees or court orders and revisions of
such laws, regulations, consent decrees or court orders shall automatically be
incorporated into this Amendment, as they become effective. In the event that
changes in this Amendment are a result of revisions and applicable federal or state
law materially affects the position of either party, Contractor and Participating
Provider agree to negotiate such further amendments as may be necessary to
correct any inequities.
(D.E. 1-3 at PageID 226-27.)

The parties’ agreements incorporate the BlueCare Provider

Administration Manual (the “Manual”) as part of the contracts and provide that the Manual may
be revised from time to time.
On or about April 8, 2011, the Bureau of TennCare issued to BCBST and other MCOs
official notice of program changes resulting from the proposed Tennessee fiscal year 2012
budget. All state departments were required to submit proposed budgets that included spending
reductions. This action was due to the expiration of one-time federal funding and the continued
impact of a national economic downturn on Tennessee revenues. Three categories of budget
reduction items were to be implemented by MCOs, including changes to reimbursement for nonemergency professional services performed in hospital emergency departments. Specifically, the
correspondence stated that “Most of you have implemented a reimbursement policy for facilities

3

whereby they are only paid a[n Emergency Medical Treatment and Active Labor Act, 42 U.S.C.
§ 1395dd (“EMTALA”)]3 screening fee for non-emergency [emergency department] visits. The
budget directs MCOs to pay [emergency department] physicians their average reimbursement
amount associated with CPT 99281 for non-emergency visits.” (D.E. 104-11 at PageID 2521.)
The changes were to go into effect on July 1, 2011.
BCBST notified its network providers of the anticipated July 1, 2011, reimbursement
changes in a letter dated May 6, 2011. Twenty days later, TennCare sent an email to MCOs
clarifying that reimbursement for non-emergency emergency department visits was capped at
$50. A letter dated June 14, 2011, from BCBST advised providers as follows:
VSHP has been directed to pay [emergency department] physicians VSHP’s
average reimbursement amount based on CPT 99281 for non-emergency visits.
Update: [Emergency department] physicians will continue to get their
contracted rate for non-emergency visits not to exceed $50.00. Whether or
not the visit is deemed emergent will be determined by looking at diagnosis
codes 1 and 2 on the claim and cross referencing with the Medical
Emergency Code List which can be found on our website at
www.vshptn.com/providers.
(D.E. 104-15 at PageID 2639.)
Additional rate reductions for other providers, to go into effect on January 1, 2012, were
communicated to MCOs by TennCare in a letter dated November 17, 2011. This missive
reiterated the $50 cap on reimbursement for non-emergency emergency department visits. A
third letter from BCBST to providers dated December 6, 2011, advised that the cap would
remain in place. These reductions in reimbursement continued to be in effect. It is the position
of the Defendants that this change was a “directive” by the state which caused the capped fee
3

The EMTALA, part of the Social Security Act, is designed to prevent "patient dumping,"
that is, refusal by hospital emergency departments to accept or treat patients with emergency
conditions if they do not have medical insurance. Alvarez-Torres v. Ryder Mem'l Hosp., Inc.,
582 F.3d 47, 51 (1st Cir. 2009); Johnson v. Va., No. 3:06cv00061, 2007 WL 1556555, at *4
(W.D. Va. May 24, 2007); Burton v. William Beaumont Hosp., 373 F. Supp. 2d 707, 713 (E.D.
Mich. 2005).
4

policy to be enacted into law. Thus, the policy was, pursuant to the terms of the parties’
contracts, automatically incorporated into their agreement.
The Plaintiff has alleged in this action that the cap on reimbursements constituted a
breach of the contractual agreements between it and the Defendants. Specifically, EMCF claims
that the Defendants reclassified emergency services performed by emergency room doctors as
non-emergency in order to justify paying a reduced reimbursement rate. It is averred that
Defendants took the position that payment of the $50 flat rate was authorized where the final
diagnosis indicated the services were non-emergent, despite the fact that the determination of
whether services are emergent or non-emergent must be made at the time of the patient’s arrival
in the emergency department. In its amended pleading, the Plaintiff contended as follows:
The provision of emergency medical services is of the utmost importance in
ensuring that individuals presenting at an emergency department are given the
immediate medical attention that they need to reduce the likelihood that the
person’s health is put in serious jeopardy or that there is a serious impairment to
the person’s bodily functions or organs.
Pursuant to [the EMTALA], physicians and other health care professionals
working in a Medicare-participating hospital emergency department are required
to provide to any individual who comes to the emergency department and makes a
request, or on whose behalf a request for medical treatment is made: (1) “an
appropriate medical screening examination . . . including ancillary services
routinely available to the emergency department, to determine whether or not an
emergency medical condition” exists.
Tenn[essee] Code[] Ann[otated] § 56-7-2355, Emergency Services, defines
“Emergency Medical Condition” as:
A medical condition that manifests itself by symptoms of sufficient
severity, including severe pain, that a prudent layperson, who
possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to
potentially result in:
(A)

Placing the person’s health in serious jeopardy;

(B)

Serious impairment to bodily functions; or
5

(C)

Serious dysfunction of any bodily organ or part.

Accordingly, under Tenn[essee] Code[] Ann[otated] § 56-7-2355, whether a
condition is an “emergency medical condition” is determined at the time when the
patient first arrives at the emergency department, not on the diagnosis reached
after the physician or other medical professional has obtained medical history,
examined the patient, and run such tests as the treating physician deems necessary
and appropriate to diagnose the patient.
Moreover, 42 C.F.R. § 438.114(d)(1)(i) requires that Medicaid [MCOs] cover and
pay for emergency services and poststabilization care services, and expressly
prohibits an MCO from limiting what constitutes an emergency medical condition
on the “basis of lists of diagnoses or symptoms.”
(D.E. 1-4 ¶¶ 6-10 at PageID 414-15.) The Group Practice Agreement among the parties defined
“emergency” as including any “emergency medical condition” as defined by the EMTALA and §
56-7-2355.
The declaratory judgment section of the amended complaint stated as follows:
. . . [S]hould the Court find that state law required that BCBST[] reduce the
payment made to the [Plaintiff] for the emergency medical services rendered by
the [Plaintiff] to BlueCare and TennCare enrollees, then the [Plaintiff] seeks a
declaratory judgment that the state law is inconsistent with Tennessee state law
and is in conflict with and preempted by federal law. In the alternative, the
[Plaintiff] seeks a declaratory judgment that, pursuant to Section Q of the
BLUECARE Attachment, as amended by Section 10 of the 2009 BLUECARE
Compliance Amendment: (i) such change has materially affected the [Plaintiff’s]
position; and (ii) BCBST[] is contractually bound to “agree to negotiate such
further amendments as may be necessary to correct any inequities” that have
resulted from such change.
(Id. ¶ 55 at PageID 423.)
In their notice of removal, the Defendants stated that EMCF’s assertions in its amended
complaint that the EMTALA and its regulations required additional reimbursement and its action
for declaratory judgment presented federal questions which formed the basis for this Court’s
jurisdiction. Plaintiff has not sought remand back to state court.

6

III. ANALYSIS
Title 28 U.S.C. § 1441(a) permits a defendant to remove a civil action from state court to
federal court if the plaintiff could have brought the matter in the federal district court. A Forever
Recovery, Inc. v. Twp. of Pennfield, 606 F. App’x 279, 280 (6th Cir. 2015). “It is a federal
court’s unflagging duty to verify that it has jurisdiction over the case before it, lest it pronounce
its opinion in contravention of Article III or the bounds imposed by Congress.” Naji v. Lincoln,
___ F. App’x ___, 2016 WL 6636762, at *2 (6th Cir. Nov. 9, 2016); see also United States v.
Ruiz, 536 U.S. 622, 628 (2002) (“a federal court always has jurisdiction to determine its own
jurisdiction”). “If at any time before final judgment it appears that the district court lacks subject
matter jurisdiction, the case shall be remanded.” 28 U.S.C. § 1447(c); see also Fed. R. Civ. P.
12(h)(3) (“If the court determines at any time that it lacks subject matter jurisdiction, the court
must dismiss the action.”). Where no challenge to jurisdiction has been made by a litigant, the
question should be raised by the Court sua sponte. Rote v. Zel Custom Mfg. LLC, 816 F.3d 383,
392 (6th Cir.), cert. denied sub nom. Direccion General de Fabricaciones Militares v. Rote, 137
S. Ct. 199 (2016). The removal statutes “are strictly construed against removal, such that doubt
should be resolved in favor of remand.”

Lexington-Fayette Urban Cty. Gov’t Civil Serv.

Comm’n v. Overstreet, 115 F. App’x 813, 816 (6th Cir. 2004).
As noted above, removal in this case was based on federal question jurisdiction.4 Such
jurisdiction “exists if federal law creates the cause of action or the plaintiff’s right to relief
necessarily depends upon a resolution of a substantial question of federal law.” A Forever
Recovery, Inc., 606 F. App’x at 281 (quoting Franchise Tax Bd. v. Constr. Laborers Vacation
Trust for S. Cal., 463 U.S. 1, 27-28 (1983)) (internal quotation marks omitted). It is well-settled
that “the mere presence of a federal issue in a state cause of action does not automatically confer
`

4

It appears from the face of the amended complaint that the parties are not diverse.
7

federal[]question jurisdiction.” Merrell Dow Pharm. Inc. v. Thompson, 478 U.S. 804, 813
(1986); see also Auto-Owners Ins. Co. v. Ergonomics Plus, Inc., 63 F. Supp. 3d 754, 758-59
(E.D. Mich. 2014) (same). There is a presumption that a cause of action lies outside a federal
court’s limited jurisdiction. Kokkonen v. Guardian Life Ins. Co. of Am., 511 U.S. 375, 377
(1994).
The first path to federal question jurisdiction describes “the vast majority of cases that
come within the district court’s original jurisdiction.” Franchise Tax Bd., 463 U.S. at 9. The
EMTALA creates a cause of action against participating hospitals by individuals and medical
facilities who have suffered personal harm or financial loss as a direct result of the participating
hospital’s violation of the statute. 42 U.S.C. § 1395dd(d)(2)(A)-(B). Courts have held that suits
against MCOs under the statute, however, cannot stand. See Moses v. Providence Hosp. & Med.
Ctrs., Inc., 561 F.3d 573, 587 (6th Cir. 2009) (the EMTALA authorizes private suits expressly
against hospitals); Bourbon Cmty. Hosp., LLC v. Coventry Health & Life Ins. Co., Civil Action
No. 3:15-cv-00455-JHM, 2016 WL 51269, at *6 (W.D. Ky. Jan. 4, 2016) (“Therefore, it appears
that EMTALA does not apply to MCOs since the [d]efendants are not hospitals and because
[p]laintiffs [(hospitals)] were not directly injured from any violation of EMTALA.”); ColonRamos v. Clinica Santa Rosa, Inc., 938 F. Supp. 2d 222, 226 (D.P.R. 2013) (“Based on
legislative intent and the plain wording of § 1395dd, we conclude that no cause of action exists
against [insurance companies or similar health care plan providers].”).
Indeed, the court in Bourbon Community Hospital, LLC faced an issue nearly identical to
that presented here. In that case, contracts between the plaintiff hospitals and the defendant
MCOs required all parties to comply with federal and state laws, regulations and standards.
Bourbon Cmty. Hosp., LLC, 2016 WL 51269, at *1. Federal law mandated that the defendant

8

MCOs provide coverage for members who presented with emergency medical conditions, based
on the prudent layperson standard, to emergency departments, while the hospital plaintiffs were
required to comply with the EMTALA. Id. A year after the contracts were entered into,
Kentucky MCOs sent letters to hospitals advising they would begin making $50 “triage”
payments for certain emergency department services. Id. at *1-2. The hospitals considered this
change in reimbursement a breach of their contracts and brought suit in federal court, claiming
they were entitled to the full, that is, higher, contractual rate for all healthcare, including
emergency services. Id. at *2. The court articulated as follows:
Plaintiffs merely allege that their contracts with Defendants require them to abide
by all federal and state laws, including EMTALA. Simply because Plaintiffs are
required to abide by EMTALA does not mean that this suit “arises” under federal
law. . . . Here, EMTALA is only relevant in the sense that it requires hospitals to
provide stabilizing treatment or appropriate transfer of an individual once that
patient has been deemed to have an emergency medical condition under the
prudent layperson standard[, citing 42 U.S.C. § 1395dd and 42 C.F.R. § 438.114].
The action at hand deals with the payment of claims that Defendants, after
patients have been screened and treated as having an emergency condition under
the prudent layperson standard, determine actually dealt with non-emergent
conditions. This payment structure in no way requires the interpretation of
Defendant MCOs’ responsibilities under EMTALA because it does not apply to
them. Additionally, this action in no way requires an interpretation of Plaintiff
hospitals’ responsibilities under EMTALA because, regardless of the fee
structure, Plaintiffs allege they are still fully performing their duties under the
statute.
Id. at *7. Consequently, the court held there was no basis for federal question jurisdiction. Id.
Based on the decision in Bourbon Community Hospital, LLC and the other cases cited herein, the
Court finds that federal question jurisdiction in this matter may not rest upon the existence of a
cause of action against the Defendants arising from the EMTALA.
The second avenue to jurisdiction, the so-called “substantial federal question doctrine,”
constitutes a "special and small category” of cases. Empire Healthchoice Assurance, Inc. v.
McVeigh, 547 U.S. 677, 699 (2006); Mikulski v. Centerior Energy Corp., 501 F.3d 555, 565 (6th
9

Cir. 2007). Pursuant to this doctrine, “a state law cause of action may actually arise under
federal law, even though Congress has not created a private right of action, if the vindication of a
right under state law depends on the validity, construction, or effect of federal law.” Mikulski,
501 F.3d at 565; Funderwhite v. Joint Apprenticeship & Training Comm. of Cleveland
Journeymen Plumbers Local No. 55, ___ F. Supp. 3d ___, 2016 WL 3913678, at *3 (N.D. Ohio
July 20, 2016). The rationale is that it
captures the commonsense notion that a federal court ought to be able to hear
claims recognized under state law that nonetheless turn on substantial questions of
federal law, and thus justify resort to the experience, solicitude, and hope of
uniformity that a federal forum offers on federal issues.
Grable & Sons Metal Prods, Inc. v. Darue Eng’g & Mfg., 545 U.S. 308, 312 (2005).
In Gunn v. Minton, 133 S. Ct. 1059 (2013), the United States Supreme Court, upon
observing that “[i]n outlining the contours of this slim category, we do not paint on a blank
canvas[; u]nfortunately, the canvas looks like one that Jackson Pollock got to first,” clarified that
jurisdiction under this category is conferred where a federal issue is (1) “necessarily raised,” (2)
“actually disputed,” (3) “substantial” and (4) “capable of resolution in federal court without
disrupting the federal-state balance approved by Congress.” Gunn, 133 S. Ct. at 1065; see also
Merrill Lynch, Pierce, Fenner & Smith Inc. v. Manning, 136 S. Ct. 1562, 1569-70 (2016) (same).
“Where all four of these requirements are met, . . . jurisdiction is proper because there is a
serious federal interest in claiming the advantages thought to be inherent in a federal forum,
which can be vindicated without disrupting Congress’s intended division of labor between state
and federal courts.” Gunn, 133 S. Ct. at 1065 (internal quotation marks omitted).
The federal question before this Court is not substantial. Courts have identified certain
factors that affect the substantiality of the federal interest:

10

(1) whether the case includes a federal agency, and particularly, whether that
agency’s compliance with the federal statute is in dispute; (2) whether the federal
question is important (i.e., not trivial); (3) whether a decision on the federal
question will resolve the case (i.e., the federal question is not merely incidental to
the outcome); and (4) whether a decision as to the federal question will control
numerous other cases (i.e., the issue is not anomalous or isolated).
Mikulski, 501 F.3d at 570; Funderwhite, 2016 WL 3913678, at *5. “While certain of these
factors may be more applicable than others in any given set of circumstances, no single factor is
dispositive and these factors must be considered collectively, along with any other factors that
may be applicable in a given case.” Mikulski, 501 F.3d at 570; Funderwhite, 2016 WL 3913678,
at *5. In Gunn, the Court pointed to examples of sufficient substantiality as the government’s
“direct interest in the availability of a federal forum to vindicate its own administrative action”
and where the “decision depends upon the determination of the constitutional validity of an act
of Congress which is directly drawn in question.” Gunn, 133 S. Ct. at 1066 (citing Grable, 545
U.S. at 315 & Smith v. Kansas City Title & Trust Co., 255 U.S. 180, 201 (1921)) (internal
quotation marks omitted). The Court will address each factor in turn.
There is no federal agency involved in this matter and there has been no allegation that
federal agency action violated the law. Rather, the dispute at bar features non-governmental
entities and their alleged breach of a state law contract. Thus, the first factor weighs against
substantiality. See Funderwhite, 2016 WL 3913678, at *5 (where no federal agency was a party
to the contract which was the subject of a state breach of contract action and no federal agency
played a part in the alleged breach, federal interest was not substantial).
In considering the “importance” of a federal question, courts are to determine whether it
“implicates any broader or more substantial issue.” Funderwhite, 2016 WL 3913678, at *6; see
Gunn, 133 S. Ct. at 1066 (“The substantiality inquiry . . . looks . . . to the importance of the issue

11

to the federal system as a whole.”). Here, there is no broader national policy at risk. Thus, the
second factor also militates against the exercise of jurisdiction.
The resolution of any federal question will not resolve this matter. According to the
pleadings, the Court must first determine whether Tennessee state law required BCBST to reduce
payments for emergency medical services. The only federal issue would arise if, upon answering
that question in the affirmative, the Court ruled on whether such law was inconsistent with or
preempted by the EMTALA. This issue need not be addressed at all, however, if the Court were
to conclude that the state law requiring the reduction was inconsistent with other state law or
that, pursuant to the BlueCare Attachment, the change materially affected the Plaintiff’s position
and BCBST was contractually bound to “agree to negotiate such further amendments as may be
necessary to correct any inequities” resulting from the change. Accordingly, the third factor does
not favor a finding that the federal question here is substantial.5 See Dominion Pathology Labs,
P.C. v. Anthem Health Plans of Va., Inc., 111 F. Supp. 3d 731, 737 (E.D. Va. 2015) (Gunn not
satisfied where the plaintiff’s breach of contract claim was predicated in part on conduct not
related to federal law and the court could resolve the dispute without referencing federal law).
As for the fourth factor, the issue is not necessarily “anomalous” or “isolated” and a
decision by this Court could potentially provide meaningful precedent in Tennessee with respect
to similar provider contracts if a ruling was made on the federal preemption issue. However, as
noted above, it is uncertain whether the federal law question would in fact be answered by this
Court and, in any case, this factor is insufficient to tip the scale in favor of substantiality in light
of the Court’s conclusions as to the other substantiality factors.
5

The fact that it may not be necessary to rule on any federal issue in this case also
supports remand under the preceding importance factor, as where the court has decided that it is
unnecessary to interpret federal law in order to rule on plaintiff’s case, the importance factor has
not been met. Funderwhite, 2016 WL 3913678, at *6.
12

In addition to a lack of substantiality, the federal question posited here is not “capable of
resolution in federal court without disrupting the federal-state balance approved by Congress,”
Gunn, 133 S. Ct. at 1065. Although the absence of a cause of action is not determinative in
deciding whether an exercise of jurisdiction will disturb the balance of federal and state
responsibilities, it is a factor that weighs against such exercise. Funderwhite, 2016 WL 3913678,
at *6. Moreover, courts have recognized, for purposes of finding this factor was not satisfied,
that “[m]ost insurance disputes arise under state law and are resolved in state court.” Hartland
Lakeside Joint No. 3 Sch. Dist. v. WEA Ins. Corp., 756 F.3d 1032, 1035 (7th Cir. 2014);
Dominion Pathology Labs, 111 F. Supp. 3d at 739.
Other courts have found that state law claims making reference specifically to the
EMTALA without asserting a cause of action do not satisfy the parameters of the substantial
federal question doctrine. In Alade v. Barnes-Jewish Hospital, Inc., No. 4:12-CV-497 CAS,
2012 WL 2598091 (E.D. Mo. 2012), the plaintiff, a psychiatry resident at Barnes-Jewish
Hospital, brought various state law claims against the facility because of mistreatment he
allegedly received as a result of his military service. Alade, 2012 WL 2598091, at *1. The suit
was removed to federal court in part on grounds that the complaint raised significant federal
questions with respect to the EMTALA. Id. at *3. The district court found federal question
jurisdiction did not exist based on the EMTALA, noting that, while Alade alleged the defendant
violated the statute, he did not assert a cause of action thereunder, none of his state law claims
were based on alleged violations of the EMTALA and his claims involved only private
defendants rather than federal agencies. Id. at *5.
In Williams v. EDCare Management, Inc., Civ. Action No. 1:08-CV-278, 2008 WL
4755744 (E.D. Tex. Oct. 28, 2008), the plaintiffs were a professional association that contracted

13

with emergency room doctors to provide emergency services to local hospitals. Williams, 2008
WL 4755744, at *1. After the owner of two of the hospitals terminated the contract and entered
into an agreement with one of the defendants, another emergency care physicians group,
plaintiffs filed suit in state court for tortious interference, breach of contract, civil conspiracy and
business disparagement. Id. Following the plaintiffs’ assertion that the defendants engaged in
illegal acts constituting violations of the EMTALA, the matter was removed to federal court on
federal question grounds. Id. at *1-2.
In support of their tortious interference claims, the plaintiffs alleged the defendants
“attempt[ed] to force plaintiffs to medically screen out an arbitrarily chosen percentage of
patients who were uninsured to increase the hospitals’ profits”; “requir[ed] and agree[d] that
physicians screen out indigent and/or uninsured patients and admit insured and Medicare patients
who would not otherwise be admitted”; violated laws regulating hospitals and had as a goal “a
reduction . . . in service to uninsured patients, specifically in contravention of the EMTALA. Id.
at *6. Rejecting the defendants’ argument against remand, the court noted that, “[e]ven if
[p]laintiffs’ causes of action require the court to interpret EMTALA and federal Medicare laws,
it does not necessarily follow that federal question jurisdiction exists” where the bulk of the
claims were based on state law theories of recovery. Id. at *7. Nor did such jurisdiction exist
merely because the state causes of action required interpretation of federal statutes. Id. at *6.
The plaintiff in Vance v. McCurtain Memorial Hospital, No CIV 10-282-FHS, 2010 WL
3910175 (E.D. Okla. Oct. 4, 2010), filed a suit in state court alleging medical negligence. Vance,
2010 WL 3910175, at *1. She supported her state law claims with assertions of purported
EMTALA violations by the defendant but did not assert a cause of action under the statute. Id. at
*2. The court found no federal question jurisdiction, stating that

14

[t]o the extent issues of interpretation and relevance need to be resolved in the
context of EMTALA regulations, however, the state court is quite competent to
resolve those issues. The mere mention of EMTALA regulations in the state
court proceedings, or the fact that such regulations may need to be interpreted by
the state court, does not necessarily equate with the existence of a substantial
question of federal law. To hold otherwise would result in the balance between
federal and state court responsibilities being disturbed by the opening of federal
courts to any state court action touching upon or mentioning federal law.
Id. at *3 (internal citations omitted). The court also noted that the plaintiff could ultimately
prevail on her claims without reliance on the EMTALA. Id.
Because not all of the Gunn requirements have been met in this case, this Court has no
basis for subject matter jurisdiction over EMCF’s claims.
The fact that the Plaintiff sought relief with respect to the EMTALA by way of a request
for a state declaratory judgment does not expand the Court’s jurisdiction. A federal court does
not have original jurisdiction, or acquire jurisdiction upon removal, when a federal question is
raised in a complaint seeking a state declaratory judgment if the district court would not have
jurisdiction over the same action if brought under the federal Declaratory Judgment Act, 28
U.S.C. § 2201 (the “Act”). See Franchise Tax Bd., 463 U.S. at 18-19; Ohio v. Nobile &
Thompson Co., L.P.A., No. 2:12-cv-01053, 2013 WL 753837, at *2 (S.D. Ohio Feb. 27, 2013).
The Act authorizes the federal courts to “declare the rights and other legal relations of any
interested party seeking such declaration,” without granting further relief. 28 U.S.C. § 2201.
“The point of the statute is to create a remedy for a preexisting right enforceable in federal court.
It does not provide an independent basis for federal subject matter jurisdiction.” Mich. Corr.
Org. v. Mich. Dep’t of Corr., 774 F.3d 895, 902 (6th Cir. 2014) (emphasis added) (internal
quotation marks omitted); see also Medtronic, Inc. v. Mirowski Family Ventures, LLC, 134 S. Ct.
843, 848 (2014) (“the Declaratory Judgment Act does not ‘extend’ the ‘jurisdiction’ of the
federal courts.”). Thus, “[a] federal court accordingly must have jurisdiction already” before a
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plaintiff may bring a declaratory judgment action. Davis v. United States, 499 F.3d 590, 594
(6th Cir. 2007) (internal quotation marks omitted). As the Court has found no grounds for
subject matter jurisdiction, Plaintiff’s declaratory judgment action provides no independent basis
therefor. See Bourbon Cmty. Hosp., LLC, 2016 WL 51269, at *6-7.
IV. CONCLUSION
For the reasons set forth herein, this case is hereby REMANDED to the Circuit Court of
Madison County, Tennessee. The Clerk is DIRECTED to mail a certified copy of this order to
the clerk of said court.
IT IS SO ORDERED this 19th day of January 2017.
s/ J. DANIEL BREEN
CHIEF UNITED STATES DISTRICT JUDGE

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