Court Opinion

ID: 9411766
Source: CourtListenerOpinion
Date Created: 2023-07-27 20:04:40.572892+00
Date Added: 2024-06-11T16:41:11.857717
License: Public Domain

Filed 7/27/23

                        CERTIFIED FOR PUBLICATION

                COURT OF APPEAL, FOURTH APPELLATE DISTRICT

                                  DIVISION ONE

                           STATE OF CALIFORNIA

ATON CENTER, INC.,                         D080122

       Plaintiff and Appellant,

       v.                                  (Super. Ct. No. 37-2019-
                                           00054459-CU-BC-NC)
UNITED HEALTHCARE INSURANCE
COMPANY et al.,

       Defendants and Respondents.

       APPEAL from a judgment of the Superior Court of San Diego County,
Cynthia A. Freeland, Judge. Affirmed.
       Law Office of John W. Tower and John W. Tower for Plaintiff and
Appellant.
       Dorsey & Whitney, Kent J. Schmidt, Michelle S. Grant and Alan J.
Iverson (pro hac vice) for Defendants and Respondents.

                                  INTRODUCTION
       This lawsuit arises from a payment dispute between a healthcare
provider and an insurance company. The provider contends it was underpaid
for substance abuse treatment that it rendered to 29 patients. Seeking to
recover the difference directly from the insurance company, the provider filed
suit in superior court, alleging the insurer entered into binding payment
agreements during verification of benefits and authorization calls with the
provider and otherwise misrepresented or concealed the amounts it would
pay for treatment. The trial court entered summary judgment against the
provider, from which the provider now appeals. We conclude the court did
not err in determining one or more elements of the provider’s causes of action
could not be established. Accordingly, we affirm the judgment.
              FACTUAL AND PROCEDURAL BACKGROUND
                                       I.

                             Factual Background1
      United Healthcare Insurance Company, United Behavioral Health
operating under the brand Optum (“UBH”), and United Healthcare Services,
Inc. (collectively, “United”) are insurers and third-party claims
administrators for group health plans sponsored by employers that provide
health benefits to their covered employees and dependents. United provides
covered individuals with access to a network of providers who have
contracted to accept established fees in exchange for being included in
United’s provider network. United does not have rate agreements with
providers that are not part of its network. Before admitting or providing
treatment to an individual covered by a policy issued or administered by
United, out-of-network providers often contact United by phone to confirm
the individual has out-of-network benefits. After verifying the individual’s

1     “Following the usual standard of review from the granting of a
summary judgment, we view all conflicting facts in favor of [plaintiff], the
party who opposed the motion for summary judgment.” (Davis v. Nadrich
(2009) 174 Cal.App.4th 1, 3, fn. 1.)

                                       2
consent, United provides the out-of-network provider with the requested
information, including whether the individual has out-of-network insurance
benefits, and individual member responsibility amounts, such as co-
payments, co-insurance, and deductible. This is known as a verification of
benefits (VOB) call.
      AToN Center, Inc. (Aton) is an inpatient substance abuse treatment
facility. Described by its chief executive officer, James Brady, as a “luxury”
treatment center, it has offered residential substance abuse and subacute
detoxification services since 2009.
      At all relevant times, Aton was not part of United’s provider network
and had no in-network contract with United. Before admitting prospective
patients covered by healthcare plans issued or underwritten by United, three
Aton employees who were members of Aton’s “intake team” (James Reed,
Lauren Mann, and Greg Liggett) placed VOB calls to United to confirm the
prospective patient’s policy provided out-of-network benefits. Information
obtained during the VOB calls was memorialized by Aton’s intake team on a
standardized “ ‘Insurance Quote of Benefits’ ” form (VOB form). The VOB
form asked for, among other information, a “ ‘rate of reimbursement.’ ” The
Aton intake team member filling out the form would respond to this question
by selecting one of the following four options: the usual, customary, and
reasonable (UCR) rate; the maximum non-network reimbursement (MNRP)
rate; the Medicare (MCR) rate; or the allowed amount (AA).
      During VOB calls, Aton’s employees asked only whether the rate of
reimbursement was “based on UCR, MCR, MNRP, or AA.” They did not ask
how much Aton could expect to be paid. Brady preauthorized Aton’s intake
team to admit prospective patients whose policies provided out-of-network
coverage using the UCR reimbursement rate. For patients whose policies

                                       3
provided out-of-network coverage at a reimbursement rate other than UCR,
the admission decision was made by Brady.
      This action arises out of United’s alleged underpayment of claims
pertaining to 29 individuals who sought and received treatment from Aton
between November 2016 and May 2019. During VOB calls, United’s
representatives advised members of Aton’s intake team that the
reimbursement rate for 20 of the 29 individuals was based on the MNRP or
Medicare rates, and that the MNRP reimbursement methodology relied on
rates published by Medicare. Brady personally approved the admission of
these 20 individuals. For the remaining nine individuals, United’s
representatives informed Aton’s intake team during VOB calls that the rate
of reimbursement was UCR. Aton contends that United should have
reimbursed 50 percent of Aton’s billed charges for those plans with
reimbursement rates based upon the MNRP or Medicare rates, and 100
percent of Aton’s billed charges for those plans whose reimbursement rate
was based upon the UCR rate. Instead, United allegedly paid Aton a
substantially lesser amount.
                                        II.
                            Procedural Background
A.    Pleadings
      In a complaint filed in superior court in October 2019, Aton asserted
causes of action for (1) breach of oral contract, (2) intentional
misrepresentation, (3) negligent misrepresentation, (4) fraudulent
concealment, (5) promissory estoppel, (6) quantum meruit, (7) violation of
Business and Professions Code section 17200 (the Unfair Competition Law
(UCL)), and (8) breach of implied contract.

                                         4
      United demurred, arguing in part that Aton’s causes of action were
preempted by section 514 of the Employee Retirement Income Security Act of

1974 (ERISA).2 United also demurred on the ground certain causes of action
failed to state facts sufficient to constitute a cause of action.
      In opposition, Aton argued its causes of action were not preempted by
section 514 of ERISA because it was “not alleging a breach of the ERISA
plan, nor [wa]s it requesting plan benefits” or seeking to advance claims
“based on assignments of plan rights from its patients.” Rather, it was only
asserting state law causes of action “which are not based on an insurance
policy or plan, but rather on the course of dealing between [Aton] and
[United] and the verbal representations and agreements that were made
during . . . verification of benefit and authorization communications.”
      The trial court sustained United’s demurrer as to Aton’s cause of action
for quantum meruit based on deficiencies in its supporting allegations. The
court overruled the demurrer on all other grounds, including ERISA
preemption, explaining that “[a]t this stage of the case, the Court is unable to
conclude that the complaint’s causes of action are preempted by ERISA
Section 514.”

2     Section 514 of ERISA provides, in relevant part, that ERISA
“supersede[s] any and all State laws insofar as they . . . relate to any
employee benefit plan.” (29 U.S.C. § 1144(a); see Pilot Life Ins. Co. v.
Dedeaux (1987) 481 U.S. 41, 48 [holding that § 514(a) preempts “common law
causes of action . . . based on alleged improper processing of a claim for
benefits under an employee benefit plan”]; Fast Access Specialty
Therapeutics, LLC v. UnitedHealth Group, Inc. (S.D.Cal. 2021) 532 F.Supp.3d
956, 963–972 [concluding out-of-network pharmacy’s state common law
claims against insurer for inadequate payment of claims were preempted by
ERISA where they were premised on preapproval letters and terms of the
patient’s insurance plan].)

                                         5
B.    United’s Motion for Summary Judgment or Alternatively, Summary
      Adjudication
      After conducting discovery, United moved for summary judgment or
alternatively, summary adjudication of the remaining causes of action in the
complaint. It submitted the following evidence in support of its motion.
      1.    United’s Moving Evidence
            a.    Declaration of Lisa Schmidt
      Lisa Schmidt, UBH’s director of customer service, oversaw call agents
taking inbound VOB calls from providers.
      Schmidt averred that United representatives conducting VOB calls are
not authorized to enter into commitments or contracts to pay or to guarantee
coverage. The representatives merely give the provider “preliminary
information” about a particular member’s insurance benefits; they do not
determine how claims associated with the member’s treatment will be paid.
At the verification stage, UBH does not know what services will ultimately be
provided, what codes will be used to bill for those services, what rates will be
charged by the provider, or whether the services will be provided and billed
in accordance with billing guidelines, among other conditions in the member’s
benefit plan. For an out-of-network provider, the amount that will be paid on
a particular claim is only determined after receiving the claim, reviewing it,
and applying the plan’s terms and limitations to the provider’s charge. To
the extent the terms of the member’s out-of-network benefit plan result in
United paying an out-of-network provider less than the amount billed, the
provider may bill the member for any difference between the amount
reimbursed and the billed charge.
            b.    Aton’s VOB Forms
      United also submitted Aton’s VOB forms memorializing VOB calls
relating to the terms of insurance plans covering the subject 29 patients.

                                        6
These forms showed that in the VOB calls, United representatives had
informed Aton the rate of reimbursement provided by plans covering 20
patients was based on MNRP or Medicare rates; for plans covering the
remaining nine patients, United representatives had informed Aton’s intake
team the rate of reimbursement was “based on UCR.”
            c.    Deposition Testimony of Aton’s Intake Team
      Aton employees Reed, Mann, and Liggett were responsible for placing
VOB calls to insurers.
      Reed, Aton’s intake director, created the VOB form in addition to
conducting VOB calls. The VOB process “is to call and using that [VOB] form
to get the information that we need.” During VOB calls, Reed and his team
“try to get information about rates of reimbursement,” but their primary
concern “is whether or not the coverage is there and the patient is eligible for
services.” During the VOB process, the insurer does not “agree . . . to pay.”
The VOB calls were not “a promise to pay.” Reed testified that he views the
VOB form as information, not as a contract. Aton does not know at the VOB
stage how much an insurer will pay for a particular claim.
      Reed further testified that the verification of benefits process happens
prior to admission. Upon admission, Aton requires patients to sign an
“Insurance Agreement” form stating: “ ‘[I]t is essential to understand that no
guarantees are made in advance or at any time that insurance will cover
treatment and at what rate.’ ” When patients complete this form, Aton does
not know how much the insurer will pay. Aton could not guarantee “how [the
patient’s] insurance company is going to reimburse,” because as Reed
explained, “We can’t give those numbers, because we don’t have them.” At
the time of admission, Aton also requires patients to sign a “Financial
Agreement” form that says the patient is “ ‘wholly responsible’ ” for Aton’s

                                       7
daily rate, including any portion not reimbursed by the insurer. Neither
Reed nor Liggett could remember a single promise United made during a
VOB call. Mann testified that Aton does not inform United during VOB calls
that Aton expects to collect a percentage of its billed charges. She did not
know what monetary amounts were associated with the reimbursement rates
listed on the VOB form or whether they were the “ ‘same or different’ ” from
billed charges.
            d.     Deposition Testimony of Aton’s CEO
      Brady testified on behalf of Aton regarding the facts supporting each of
Aton’s claims, including breach of contract. He had not listened to nor read
transcriptions of VOB calls and was “not sure of what verbiage goes back and
forth.” He testified, “I get the meat and potatoes [from] the VOB forms . . . .
That’s all I have to look at. We don’t record [United’s] calls.”
      Brady described the oral contracts between Aton and United as follows:
“Us calling and asking for the benefit. The benefit being quoted. Us under
that benefit quoted having an acceptance by taking the patient into the
facility. [¶] Us then performing under the conditions noted in the
verification; be it . . . the prior authorization and having the proper licensure,
accreditation, and then providing the services that meet or exceed the level of
care . . . that were being billed to United or Optum . . . . [¶] And then the
final piece of the contract is I guess reimbursement or compensation, and
that’s the reason we’re here is we believe that wasn’t fully met on [United’s]
side.” “So again, there’s been an offer, it seems, the VOB. An acceptance; the
admission of the patient. Performance; which we’ve treated the patient. And
then compensation is somewhat lacking.”
      Brady specifically considered “the verification of benefits quotation” to
be an offer. It was his belief that “when Aton affirmatively calls United and

                                        8
asks questions and United responds to those questions, . . . that’s an offer[.]”
Brady did not know whether United representatives conducting VOB calls
have the authority to enter into contracts.
      Aton did not ask during VOB calls whether reimbursement rates
corresponded with billed charges. Brady testified that when Aton had asked
that question in the past, “the answer has been, ‘We don’t know. You’ll know
when the claim processes.’ ” When Aton is quoted the UCR or MNRP
reimbursement rates, Aton “believes” it knows what those rates should be.
      Brady testified that UCR means the “usual and customary rate.” He
understands UCR to correspond to 100 percent of Aton’s billed charges. He
explained: “[W]hat I bill is reasonable because I bill it, I bill it to everybody
the same way, and I know what my geographic area is and therefore that is
UCR.” He believed United understands UCR the same way based on how
Aton was typically paid on UCR policies.
      On the topic of the MNRP reimbursement rate, Brady testified his
understanding that MNRP means 50 percent of billed charges is derived in
part from a United plan document “[p]lus hundreds of payments at 50
[percent] of [the] billed charge.” When asked if he knows whether United
understands MNRP to be 50 percent of billed charges “in all cases,” Brady
stated, “I’m not United. I can’t figure out what United thinks.”
      Brady was unaware whether United representatives “intentionally
concealed anything[.]” He testified, “I’m unaware of what their intention
was. I do know that we have been misquoted benefits if we’re paid contrary
to what our historical reimbursement was, and [the] number of plans I’ve
looked at[.]”

                                         9
               e.   Evidence Relating to the Preauthorization Process
      Dr. Kevin Murphy is tasked by Aton with demonstrating to insurers
that a patient meets the criteria for “this level of care.” The purpose of the
authorization process is to demonstrate medical necessity. Murphy never
discusses rates of reimbursement during authorization. During the
authorization process, United makes no representations to Murphy regarding
payment.
      Between December 2016 and May 2019, United sent Aton over 50
letters authorizing “SA Detox Residential Adult” or “SA Residential Adult”
services. Each authorization letter contained the following language:
“ ‘Payment for services described in this letter is subject to the member’s
eligibility at the time services are provided, including employment or
Healthcare Exchange premium payment status, benefit plan limitations, and
availability of remaining coverage. An eligibility disclaimer was given at the
time of this benefit request. Please discuss this with the member.’ ” (Italics
added.) Brady acknowledged Aton had received these letters and that United
had repeatedly advised Aton that payment of claims would be subject to plan
limitations.
      2.       United’s Moving Arguments
      Based on the foregoing evidence, United argued that Aton could not
establish one or more elements of each of the complaint’s remaining causes of
action.
      More specifically, United argued summary adjudication of Aton’s
breach of oral and implied contract causes of action was appropriate because
Aton could not demonstrate the existence of mutual assent or consideration.
United had not agreed during VOB calls to reimburse 100 percent or 50
percent of the amounts Aton billed for treatment. United’s payment

                                       10
obligation was dependent on the terms of the operative benefit plans and was
determined only after claims were submitted.
      No evidence of actual, affirmative or knowing misrepresentations
existed to support Aton’s causes of action for intentional misrepresentation
and negligent misrepresentation. Aton could not show United
representatives conducting VOB calls intentionally concealed any facts, nor
could it prove United had a duty to disclose the amount it would pay,
defeating its fraudulent concealment cause of action. Nor could Aton
establish the unfair, unlawful, or fraudulent business practices needed to
support its cause of action for violation of the UCL.
C.    Aton’s Opposition to United’s Motion
      1.    Aton’s Evidence Filed in Support of Its Opposition
      In opposition to United’s motion, Aton submitted additional testimony
from Brady, Reed, Mann, Liggett, and Schmidt, as well as testimony of three
other individuals (Nikki Weidlund, an Aton employee who filled out one of
the VOB forms submitted in support of United’s motion; and Chi Mao and
Denise Strait, both representatives of United), and an expert witness (Luisa
Davis).
      Aton’s evidence did not include transcripts, recordings, or other like
evidence establishing what United’s representatives said during the VOB
calls at issue. Instead, its evidence generally concerned Aton’s understanding
that UCR and MNRP reimbursement rates equated to 100 percent and 50
percent, respectively, of the amount Aton billed for its services. Brady was
the chief source of this understanding.
      In the excerpts of Brady’s deposition testimony submitted by Aton,
Brady testified that during VOB calls, “they [i.e., United representatives] do
not give us anything other than it’s an MNRP, and they may throw in that it

                                       11
is tied to a percentage of Medicare, which we know doesn’t exist. So that’s
nebulous.” His understanding “is [that] there is not a Medicare rate[.]”
Referring to language in United’s MNRP plans that apparently gave a point-
by-point explanation of the manner in which MNRP reimbursement rates

were calculated,3 Brady testified: “we believe that the MNRP is pointing us
to they are going to reduce our billing by 50[ percent] typically, and that’s
what we see.” Aton also submitted the same deposition excerpts relied on by
United in which Brady testified to his belief that the UCR reimbursement
rate corresponded to 100 percent of Aton’s billed charges.
      Aton also submitted a declaration from Brady in which he averred that
at the time of the “claims at issue in this lawsuit,” his understanding was
that “United’s MNRP pricing method was based on Medicare rates for the
service provided.” Because there was no Medicare rate for residential
substance abuse treatment, Brady “understood based on payment history and
[his own] understanding of the [United] plans that United was to pay
50[ percent] of billed charges.”
      Aton’s excerpts of the Reed, Mann, and Liggett depositions largely
overlapped with the excerpts submitted by United and did not change the
substance of the testimony relied upon by United.
      In Aton’s excerpts of Schmidt’s deposition testimony, Schmidt agreed
United representatives gave providers accurate information about members’

3     It appears the plan language discussed by Brady gave United the
option of using a so-called “GAP methodology” to calculate the MNRP
reimbursement rate. Brady testified “the GAP methodology doesn’t apply, so
the ultimate end result is 50[ percent].” United’s use of this GAP
methodology when calculating reimbursement of certain claims covered by
MNRP plans appears to be one source of Aton’s claim that it was underpaid.

                                       12
insurance benefits. The representatives would only provide “the method, the
reimbursement program,” which would be either “UCR or MNRP.” To her
knowledge, United’s representatives did not ever inform providers “that one
of the methods of payment could be 50 percent of a bill [sic] charge[.]”
      Weidlund, the Aton employee who completed one VOB form, testified
she understood when she filled out the form that MNRP meant a rate of
reimbursement of 50 percent of the billed charge. However, the source of her
understanding of the meaning of MNRP was not established.
      The specific duties or position of Mao, the apparent United employee,
were not established. In the deposition excerpt submitted by Aton, Mao
responded to questions about United’s “plan language.” Mao agreed United
was required to pay claims in accordance with the terms of its plans. Strait,
another apparent United employee whose duties and role at United were not
established, answered questions about United’s pricing methodologies,
although it was not clear she had information about the specific claims at
issue in the litigation.
      Davis, an expert on medical and substance use disorder claim billing
and bill review, opined: “[F]or the VOB’s in which [Aton] was informed the
allowed amount was to be based on the UCR, [Aton] should be paid it’s [sic]
billed amount. In the VOB’s in which [Aton] was informed that the MNRP
CMS/Medicare rate pricing methodology would be used to determine allowed
amounts, the allowed amount should have been 50[ percent] of the billed
amount.”

                                       13
      Finally, Aton submitted one page of a 12-page explanation of benefits it
received from United. The page reflected payment for several days of

treatment of one of the 29 patients whose claims were at issue.4
      2.    Aton’s Opposition Arguments
      In opposition, Aton argued its VOB and authorization processes created
binding oral and/or implied contracts with United because Aton alleged that
it was told it “would be paid” based on the UCR or MNRP reimbursement
methods. Aton argued that United, “[b]y representing that it would pay the
UCR . . . [,] provided a recognized method by which the amount it would pay
would be objectively determined.” Aton also emphasized that Brady
“understood that [Aton] and [U]nited were entering into oral or implied
agreements.”
      As for its promissory estoppel cause of action, Aton asserted that
“[s]pecific representations/promises regarding payment rates” are “an
appropriate factual predicate for promissory estoppel,” but it cited no
evidence of the purported promises.
      Aton argued it possessed evidentiary support for its intentional
misrepresentation, negligent misrepresentation, and fraudulent concealment
causes of action based on the VOB forms United filed in support of summary
judgment, which Aton claimed showed United “misrepresented its payment
methodologies to [Aton].” Aton maintained its misrepresentation and

4     We do not summarize evidence excluded by the trial court in response
to United’s objections. Aton does not challenge the court’s rulings on United’s
evidentiary objections on appeal, and as a result, the rulings excluding the
evidence from consideration are binding on appeal. (See, e.g., RMR
Equipment Rental, Inc. v. Residential Fund 1347, LLC (2021) 65 Cal.App.5th
383, 392 (RMR Equipment Rental) [unchallenged trial court ruling is binding
on appeal].)

                                      14
fraudulent concealment causes of action were also adequately supported by
evidence that United’s MNRP payment methodology operated in a way that
was “contrary to its plans.” Finally, Aton argued its cause of action for
violation of the UCL had evidentiary support because it “alleges two
intentional fraud claims” which were supported by “allegations [that] clearly
state a claim for deceptive business practices.”
D.    United’s Reply
      In reply, United argued in part that Aton, having previously disavowed
reliance on the terms of the patients’ underlying ERISA plans when it
opposed United’s demurrer, was judicially estopped from relying on plan
terms to oppose summary judgment.
      United also argued Aton had failed to carry its burden of presenting
evidence that United representatives made payment promises or
commitments during VOB calls, much less promises or commitments to pay
100 percent or 50 percent of the amount Aton ultimately billed for those
claims, and that Aton also failed to introduce evidence showing United
fraudulently misrepresented or concealed facts during the calls.
E.    Trial Court’s Ruling
      The trial court granted United’s summary judgment motion in a
detailed minute order issued in November 2021.
      As an initial matter, the court ruled that Aton was foreclosed from
relying on the terms of United’s plans to support its claims. The court
explained that Aton had contended, and the court had accepted in partially
overruling United’s demurrer on ERISA preemption grounds, that Aton was
not “(1) attempting to assert an ERISA claim; (2) alleging a breach of an
ERISA plan; (3) requesting plan benefits; or (4) alleging claims based upon
what the policies and/or plans may set as the payment rate.” As a result,

                                       15
Aton was judicially estopped from taking a contrary position on summary
judgment.
      The trial court then analyzed the parties’ evidence and arguments
pertaining to each of Aton’s causes of action and concluded United had
succeeded in showing, as to each cause of action, that Aton could not
establish one or more necessary elements. The court granted United’s motion
in its entirety. Judgment in favor of United and against Aton was entered in
December 2021. Aton was served with notice of the judgment’s entry in
January 2022.
                                 DISCUSSION
      In challenging entry of summary judgment, Aton largely focuses on
establishing the trial court committed legal errors. To a lesser extent, it
attempts to demonstrate its evidentiary showing was sufficient to create a
factual dispute precluding entry of summary judgment. As we discuss, Aton
fails to establish that summary judgment was erroneously granted.
                                        I.
                              Standard of Review
      “Summary judgment is appropriate only ‘where no triable issue of
material fact exists and the moving party is entitled to judgment as a matter
of law.’ ” (Regents of University of California v. Superior Court (2018) 4
Cal.5th 607, 618.) A triable issue of material fact exists only if “the evidence
would allow a reasonable trier of fact to find the underlying fact in favor of
the party opposing the motion in accordance with the applicable standard of
proof.” (Aguilar v. Atlantic Richfield Co. (2001) 25 Cal.4th 826, 850
(Aguilar).)
      A defendant moving for summary judgment has the initial burden of
presenting evidence that a cause of action lacks merit because the plaintiff

                                       16
cannot establish an element of the cause of action or there is a complete
defense. (Code Civ. Proc., § 437c, subd. (p)(2); Aguilar, supra, 25 Cal.4th at
p. 853.) If the defendant does so, the burden then shifts to the plaintiff to
produce admissible evidence demonstrating a triable issue of material fact as
to the claim or defense. (Code Civ. Proc., § 437c, subd. (p)(2); Aguilar, at
p. 850.) Theories that are not supported by evidence will not raise a triable
issue. (Code Civ. Proc., § 437c, subd. (p)(2) [“[t]he plaintiff or cross-
complainant shall not rely upon the allegations or denials of its pleadings to
show that a triable issue of material fact exists”]; Sangster v. Paetkau (1998)
68 Cal.App.4th 151, 163, 166 [“bare assertion” that the moving parties
“ ‘fabricated’ ” evidence insufficient to avoid summary judgment].)
      Whether the trial court erred by granting United’s motion for summary
judgment is a question of law we review de novo. (See Samara v. Matar
(2018) 5 Cal.5th 322, 338.) “ ‘[W]e examine the facts presented to the trial
court and determine their effect as a matter of law.’ ” (Regents of University
of California v. Superior Court, supra, 4 Cal.5th at p. 618.) “We review the
entire record, ‘considering all the evidence set forth in the moving and
opposition papers except that to which objections have been made and
sustained.’ [Citation.] Evidence presented in opposition to summary
judgment is liberally construed, with any doubts about the evidence resolved
in favor of the party opposing the motion.” (Ibid.)
      “ ‘[A]lthough we use a de novo standard of review here, we do not
transform into a trial court.’ ” (Dinslage v. City and County of San Francisco
(2016) 5 Cal.App.5th 368, 379 (Dinslage).) We approach a summary
judgment appeal, as with any appeal, with the presumption the appealed
judgment is correct. (Denham v. Superior Court (1970) 2 Cal.3d 557, 564.)
Therefore, “ ‘ “[o]n review of a summary judgment, the appellant has the

                                        17
burden of showing error, even if he did not bear the burden in the trial
court.” ’ ” (Dinslage, at p. 379.)
                                       II.
                  Oral and Implied Contract Causes of Action
A.    Relevant Legal Principles
      The elements of a breach of oral contract cause are: “(1) existence of
the contract; (2) plaintiff’s performance or excuse for nonperformance;
(3) defendant’s breach; and (4) damages to plaintiff as a result of the breach.”
(CDF Firefighters v. Maldonado (2008) 158 Cal.App.4th 1226, 1239 [elements
of breach of contract]; Stockton Mortgage, Inc. v. Tope (2014) 233 Cal.App.4th
437, 453 [elements of breach of oral contract and breach of written contract
claims are the same].) “A cause of action for breach of implied contract has
the same elements as does a cause of action for breach of contract, except that
the promise is not expressed in words but is implied from the promisor’s
conduct.” (Yari v. Producers Guild of America, Inc. (2008) 161 Cal.App.4th
172, 182; Civ. Code, § 1621 [“An implied contract is one, the existence and
terms of which are manifested by conduct.”].) “ ‘[B]oth types of contract are
identical in that they require a meeting of minds or an agreement [citation].
Thus, it is evident that both the express contract and contract implied in fact
are founded upon an ascertained agreement or, in other words, are
consensual in nature, the substantial difference being in the mode of proof by
which they are established [citation].’ ” (Pacific Bay Recovery, Inc. v.
California Physicians’ Services, Inc. (2017) 12 Cal.App.5th 200, 215 (Pacific
Bay Recovery).)

                                       18
B.    The Trial Court’s Ruling
      The trial court granted summary adjudication of Aton’s breach of oral
contract cause of action on the ground United succeeded in showing Aton
could not establish the existence of an oral contract.
      The essential elements of a contract are: “1. Parties capable of
contracting; [¶] 2. Their consent; [¶] 3. A lawful object; and, [¶] 4. A
sufficient cause or consideration.” (Civ. Code, § 1550.) “ ‘[T]he vital elements
of a cause of action based on contract are mutual assent (usually
accomplished through the medium of an offer and acceptance) and
consideration.’ ” (Pacific Bay Recovery, supra, 12 Cal.App.5th at p. 215.) The
court found the evidence of both these elements to be lacking, although its
decision focused primarily on the absence of evidence of mutual consent.
      “Contract formation requires mutual consent, which cannot exist
unless the parties ‘agree upon the same thing in the same sense.’ ”
(Bustamante v. Intuit, Inc. (2006) 141 Cal.App.4th 199, 208 (Bustamante),
quoting Civ. Code, § 1580.) “ ‘Mutual assent is determined under an objective
standard applied to the outward manifestations or expressions of the parties,
i.e., the reasonable meaning of their words and acts, and not their
unexpressed intentions or understandings.’ ” (Bustamante, at p. 208.) “The
question is what the parties’ objective manifestations of agreement or
objective expressions of intent would lead a reasonable person to believe.”
(Winograd v. American Broadcasting Co. (1998) 68 Cal.App.4th 624, 632.)
      In determining that Aton could not show the mutual consent required
to form an oral contract, the trial court compared the asserted basis of Aton’s
oral contract cause of action (that the VOB calls constituted offers, and Aton’s
admission of patients constituted acceptances) with the evidence produced by
the parties. The court elaborated in detail on the facts and evidence that in

                                       19
its view tended to show there was “no mutual assent or meeting of the minds
between [Aton] and [United] during the VOB process as to the subject
claims.” These facts included the following:
      United representatives conducting VOB calls only verify benefits and
are not authorized to enter into commitments or contracts to pay or
guarantee coverage. They did not know at the verification stage what
services would ultimately be provided or the rates the provider would charge
for those services. During VOB calls, insurers do not agree to pay at a
specific reimbursement rate or promise to pay a certain amount, nor does
Aton learn how much it will be paid for a particular claim. Liggett could not
recall a single promise made by United or an occasion when he believed a
contract was formed during a VOB call.
      Brady admitted he did not know whether United representatives were
authorized to enter into contracts, nor did he know whether Aton informed
United of its belief that the VOB calls were contracts. He also did not know
whether United’s representatives possessed information about the correlation
between UCR, MNRP, and the percentage of billed charges. While Brady
believed UCR meant 100 percent of Aton’s billed charges, he was unable to
state based on anything other than United’s payment history whether United
held the same view. When asked whether he believed United understood the
MNRP rate to be 50 percent of billed charges, Brady responded that he did
not know what United “thinks.” He also admitted that Aton does not ask
during VOB calls what it will be paid; rather, when Aton is quoted UCR or
MNRP reimbursement rates, it “ ‘believes’ ” it knows what those rates
“should be.”
      The trial court concluded: “At best, [Aton] has established that it
believed oral contracts were formed during the VOB process. However, there

                                      20
is no evidence . . . [Aton] ever communicated that belief to [United], or [that
United] held the same view.”
      Turning to Aton’s implied contract cause of action, the trial court stated
it shared a common factual predicate with Aton’s oral contract cause of
action. The court ruled that for the same reasons Aton failed to demonstrate
mutual assent to enter an oral contract, it also failed to demonstrate mutual
assent to enter an implied-in-fact contract. To the extent Aton’s implied
contract claim was based on previous payments, historical knowledge, or the
parties’ history, Aton failed to establish that United “agreed to pay the
subject claims the same as it had paid previous claims.”
C.    Analysis of Aton’s Contentions on Appeal
      1.    Aton’s Reliance on Unpublished Federal Cases Upholding
            Contract Claims Fails to Persuade Us the Trial Court Erred
      Aton contends the trial court erred as a matter of law by concluding its
evidence fell short of establishing the mutual consent necessary to form oral
or implied agreements between itself and United. Its challenge is principally
derived from a line of cases in which courts have considered the viability of
breach of contract claims predicated on contracts allegedly formed during
VOB and/or authorization calls between a provider and insurer.
      In several of the cases cited by Aton, contract claims based on such
communications were rejected on the ground that “ ‘within the medical
insurance industry, an insurer’s verification is not the same as a promise to
pay.’ ” (TML Recovery, LLC v. Humana Inc. (C.D. Cal. Mar. 4, 2019)
No. SACV 18-00462 AG (JDEx), 2019 WL 3208807, *4 [dismissing oral and
implied contract claims pursuant to Federal Rule of Civil Procedure 12(b)(6)
(Rule 12(b)(6)) for failure to state a claim; “Plaintiffs allege that they verified
the patients’ benefits and obtained authorization as necessary. . . . But
‘within the medical insurance industry, an insurer’s verification is not the

                                        21
same as a promise to pay.’ ”]; TML Recovery LLC v. Cigna Corporation (C.D.
Cal. Mar. 29, 2021) No. SA CV 20-00269-DOC-(JDEx), 2021 WL 5238575, *5
[same]; Aton Center, Inc. v. Blue Cross and Blue Shield of South Carolina
(S.D. Cal. Aug. 17, 2020) No. 3:20-cv-00496-WQH-BGS, 2020 WL 4747752, *5
[dismissing oral contract claim based on VOB calls pursuant to Rule 12(b)(6)
for failure to state a claim].) As one of these courts explained, “VOB and
authorization phone calls alone are generally insufficient to form the basis for
an oral or implied contract because they lack a manifestation of intent to
enter into a contract.” (Aton Center, Inc. v. Blue Cross and Blue Shield of
South Carolina, supra, 2020 WL 4747752 at p. *3.)
      In Pacific Bay Recovery, supra, 12 Cal.App.5th 200, this court reached a
similar conclusion and affirmed a trial court’s ruling sustaining a demurrer
to a breach of implied contract cause of action. There, the provider alleged it
contacted the insurer to obtain prior authorization, was advised the
prospective patient was insured for the treatment to be rendered and that the
provider “would be paid” for the treatment, and “ ‘was led to believe that it
would be paid a portion or percentage of its total billed charges, which
charges correlated with usual, reasonable and customary charges.’ ” (Id. at
p. 216.) We held these allegations “lack[ed] the specific facts required for us
to determine there was any meeting of the minds between the parties,”
including because “it does not appear the parties reached any sort of
agreement as to the rate [the insurer] would pay [the provider].” (Ibid.) We
further held the provider failed to state a cause of action for estoppel because
it “has not alleged a promise clear and unambiguous in its terms.” (Id. at
p. 215, fn. 6.)
      Aton does not dispute the consensus reached by the above district
courts, namely, that “ ‘within the medical insurance industry, an insurer’s

                                       22
verification is not the same as a promise to pay.’ ” (TML Recovery, LLC v.
Humana Inc., supra, 2019 WL 3208807, at p. *4.) It argues the cases
rejecting contract claims premised on verification and/or authorization calls
are distinguishable because in each of them, “the insurers were only asked
and the providers were only informed that the subject patient was ‘insured,
covered, and eligible for coverage’ under [the insurers’] plan for the services
[the provider] provided.” It contends the viability of its contract claims
should instead be decided in accordance with the following cases where courts
have upheld such claims.
      In Summit Estate, Inc. v. Cigna Healthcare of California, Inc. (N.D.
Cal. Oct. 10, 2017) No. 17-CV-03871-LHK, 2017 WL 4517111, the district
court denied the defendant insurers’ motion pursuant to Rule 12(b)(6) to
dismiss the plaintiff provider’s breach of oral contract claim. The court
explained: “Plaintiff’s complaint does not allege that Defendants merely
verified coverage to Plaintiff. Instead, Plaintiff’s complaint alleges that, ‘in
all cases,’ Defendants told Plaintiff that ‘Defendants would pay for treatment
at the usual, reasonable and customary rate.’ [Citation.] Thus, Plaintiff has
alleged sufficient facts to plausibly suggest that Defendants exhibited
outward conduct indicating Defendants’ intent to contract with Plaintiff.”
(Summit Estate, Inc., at p. *3, italics added.)
      In Aton Center, Inc. v. Blue Cross and Blue Shield of Illinois (S.D. Cal.
Feb. 16, 2021) No. 3:20-cv-00500-WQH-BGS, 2021 WL 615051, the court
denied a Rule 12(b)(6) motion to dismiss an oral contract claim where the
provider alleged it “ ‘was advised in . . . VOB calls . . . [the insurer] would pay
for inpatient treatment, based on the usual, customary and reasonable rate
(UCR) and/or prior payment history’ ”; that for certain patients, the insurer
told the provider it “ ‘would pay 60[ percent] of [the provider’s] billed

                                        23
charges’ ” and for others it “ ‘would pay 80[ percent] of [the provider’s] billed
charges.’ ” (Id. at p. *5, italics added.) The complaint also affirmatively
alleged the provider and insurer “ ‘entered into agreements’ ” whereby the
provider would provide treatment to the insured patients. (Ibid.) The court
explained “[t]he factual allegations of oral contract go beyond VOB and
authorization calls describing the type of treatment and specific billing rates”
and there were “sufficient facts to infer mutual consent in which ‘the parties
all agree[d] upon the same thing in the same sense.’ ” (Ibid.)
      And in Aton Center, Inc. v. Carefirst of Maryland, Inc. (D. Md. Dec. 14,
2021) No. DKC 20-3170, 2021 WL 5909101, the district court granted the
provider leave to amend its complaint to assert a breach of express contract
claim where the proposed pleading alleged the defendant insurers stated
during VOB calls they “ ‘would pay for inpatient treatment’ ” at specified
percentages of the provider’s billed charges. (Id. at p. *3, italics added.) The
court concluded the complaint alleged “sufficiently definite promises”
including because it “specif[ied] the precise percent of the billed amount that
[the insurer] allegedly promised to pay during the VOB calls[.]” (Ibid.)
      Aton contends its oral and implied contract claims are like the contract
claims in these three cases because “[t]he evidence before the trial court here
went well beyond simply verifying coverage” and showed “United informed
[Aton] it would pay for either of its treatments (detox care or residential
treatment) under the UCR or MNRP pay rates.” (Italics added.) Aton
argues, “where (as here) facts go beyond mere verification of coverage and
into promises to pay for treatment . . . at a specific rate,” courts allow
contract claims to proceed. United responds that the cases Aton relies upon
are distinguishable because they were decided in procedural contexts other
than summary judgment.

                                        24
         In our view, the problem with Aton’s reliance on these cases is factual

rather than procedural.5 Although the cases involved pleadings challenges
rather than summary judgment, they nevertheless addressed the sufficiency
of contract claims based on verification calls, and each determined that
particular factual allegations supported an inference of mutual assent. They
are therefore at least potentially persuasive authority for the proposition that
the same conclusion should be reached in another case involving similar
facts.
         Instead, our difficulty with Aton’s challenge to the trial court’s ruling is
that it is built on two unfounded factual assertions: that its evidence showed
United’s representatives conducting VOB calls used words constituting an
offer or promise (e.g., that United “would pay” Aton); and that United and
Aton mutually understood the “UCR or MNRP pay rates” corresponded with
100 percent and 50 percent, respectively, of Aton’s billed charges. As we shall
discuss, Aton produced no evidence tending to show United’s representatives
made promises or offers during VOB calls. It also failed to introduce evidence
that both sides possessed the same understanding of the UCR and MNRP
reimbursement rates. For these reasons, Aton’s authorities are inapposite.
         As Aton implicitly concedes by repeatedly asserting that the evidence
before the trial court showed United representatives told Aton that United
“would pay” Aton for certain types of treatment at specific rates, the use of
such words during VOB calls is material to Aton’s claim that an oral contract
was formed during the calls. In the case of an express agreement, mutual

5     Unpublished federal court cases like those on which Aton relies are
citable only for their persuasive value. (Gray v. Quicken Loans, Inc. (2021) 61
Cal.App.5th 524, 528, fn. 2.)

                                          25
assent is manifested in words, usually “through the medium of an offer . . .
communicated to the offeree and an acceptance . . . communicated to the
offeror.” (1 Witkin, Summary of Cal. Law (11th ed. 2017) Contracts, § 117,
pp. 158–159 [citations omitted].) “ ‘ “An offer is the manifestation of
willingness to enter into a bargain, so made as to justify another person in
understanding that his assent to that bargain is invited and will conclude
it.” ’ ” (City of Moorpark v. Moorpark Unified Sch. Dist. (1991) 54 Cal.3d 921,
930.) Determining whether a particular communication reasonably
constitutes an express offer requires an examination of the words used by the
purported offeror as well as the circumstances surrounding the offer. (See
e.g., ibid.; 1 Witkin, Summary of Cal. Law, supra, Contracts, §§ 130–132,
pp. 170–173.)
      As Aton acknowledges and as courts like those in the cases referenced
above have held, when an insurer merely provides information about a
prospective patient’s healthcare plan in response to a provider’s inquiries,
this does not, on its own, amount to a promise to pay. (See, e.g., TML
Recovery, LLC v. Humana Inc., supra, 2019 WL 3208807, at p. *4 [“ ‘within
the medical insurance industry, an insurer’s verification is not the same as a
promise to pay’ ”].) But when (as in the cases relied on by Aton) the insurer
goes further and tells the provider it will pay the provider for a particular
patient’s treatment, the insurer may be found to have extended an offer or
promise because such words reasonably signal an intent to transact. (See
e.g., Aton Center, Inc. v. Blue Cross and Blue Shield of Illinois, supra, 2021
WL 615051, p. *5 [intent to contract could be inferred from allegations
insurer advised provider during VOB calls it “would pay for inpatient
treatment,” “ ‘would pay 60[ percent] of [the provider’s] billed charges’ ” and “
‘would pay 80[ percent] of [the provider’s] billed charges’ ” (italics added)];

                                        26
and see generally Richards v. Flower (1961) 193 Cal.App.2d 233, 235–236
(Richards) [rejecting argument that a defendant made a binding offer to sell
property “merely because he chose to answer certain inquiries” by the
plaintiffs]; Leo F. Piazza Paving Co. v. Bebek & Brkich (1956) 141 Cal.App.2d
226, 228–232 [subcontractors prepared detailed price quotations in response
to general contractor’s request, on which the general contractor relied; held,
not a firm offer].) We do not suggest that a contract is created whenever an
insurer’s representative uses the words “will pay” during a VOB call.
Instead, we merely hold that to the extent Aton relies on decisions allowing
contract claims to proceed on the basis of such facts, it fails to establish those
facts exist in this case.
      The difficulty with Aton’s challenge is that contrary to its contentions,
no evidence was introduced showing United representatives conducting VOB
calls used words objectively manifesting contractual offers or promises of
payment. United’s moving evidence established that its representatives who
conducted VOB calls were not authorized to enter into commitments or
contracts or guarantee payment, which supported a reasonable inference that
no express promises or offers to pay were made during the VOB calls at issue.
United further established through Reed’s testimony that during the VOB
process, insurers do not agree to pay at a specific reimbursement rate. Reed
also testified he regarded VOB forms as information rather than as contracts.
In the excerpts of Brady’s deposition testimony submitted by United, Brady
described the VOB calls as “[Aton] calling and asking for the benefit. The
benefit being quoted.” Brady’s description established only that United
provided plan information in response to Aton’s inquiries, the very sort of
communications that have been held to fall short of forming the basis of an
oral contract. United’s moving evidence thus supported the conclusion the

                                        27
VOB calls were devoid of communications objectively manifesting an intent to
contract.
      In opposition, Aton introduced no evidence at all of the actual words
used by United representatives during VOB calls, much less evidence tending
to show United’s representatives conducting VOB calls used words
reasonably constituting an offer or promise to pay. Instead, it relied on the
complaint’s allegations “that [Aton] was told it would be paid[.]” A party
cannot avoid summary judgment by relying on “the allegations or denials of
its pleadings.” (Code Civ. Proc., § 437c, subd. (p)(2).) Although Aton pointed
to testimony that Brady “understood” Aton and United were entering into
oral or implied agreements during the VOB calls, the evidence established
Brady did not participate in or listen to the calls. His unilateral, subjective
impression of their effect falls short of establishing mutual assent. (See
Bustamante, supra, 141 Cal.App.4th at p. 208 [“ ‘If there is no evidence
establishing a manifestation of assent to the “same thing” by both
parties, then there is no mutual consent to contract and no contract
formation.’ [Citation.] ‘Mutual assent is determined under an objective
standard applied to the outward manifestations or expressions of the parties,
i.e., the reasonable meaning of their words and acts, and not their
unexpressed intentions or understandings.’ ”].)
      On appeal, Aton again cites no evidence establishing that United
representatives said anything during VOB calls that, when reasonably
interpreted, conveyed an intent to enter into a contract. Instead, Aton
asserts, “United informed [Aton] it would pay for either of its treatments
(detox care or residential treatment) under the UCR or MNRP pay rates.”
(Italics added.) Aton cites two pages of VOB forms (one completed by Reed,
the other by Liggett) in support of this assertion. However, these forms only

                                       28
reflect that Reed and Liggett learned from a United representative that a
prospective patient’s policy used the UCR or MNRP reimbursement rate.
They do not indicate what the United representative’s actual words were or
otherwise reflect that the representative said United “would pay” for the
prospective patient’s treatment. Moreover, Reed, the creator of the VOB
forms, testified Aton’s VOB forms are merely informational. Aton’s citation
to the forms therefore fails to establish that its communications with United
went “beyond VOB . . . calls describing the type of treatment and specific

billing rates.”6 (Aton Center, Inc. v. Blue Cross and Blue Shield of Illinois,
supra, 2021 WL 615051, at p. *5.)
      Turning to Aton’s second argument—that both sides did or should have
understood that MNRP meant “50[ percent] of the provider’s billed charges”
and UCR meant “100[ percent] of [Aton’s] billed charges”—this contention
also does not withstand scrutiny. Although Aton cites evidence ostensibly
supporting its assertion, an examination of the evidence reveals it does not
provide factual support for Aton’s claim.

6      In reply, Aton, citing excerpts of Mann’s deposition testimony
submitted in opposition to summary judgment, argues for the first time on
appeal that Mann “believed the VOB calls represented promises to pay.”
This argument, and the testimony on which it relies, do not compel reversal
of summary judgment. Mann testified about two specific VOB forms and
calls, not VOB calls in general. Mann’s subjective belief the calls
“represented” a promise does not establish the same conclusion would be
reached under an objective standard. (Bustamante, supra, 141 Cal.App.4th
at p. 208.) Mann was interpreting the VOB forms and did not indicate she
had an independent recollection of the calls. And at the summary judgment
hearing, Aton’s counsel told the trial court none of the intake employees,
including Mann, “remember these calls.”

                                       29
      Aton relies in part on Brady’s declaration that United “historically
paid” 50 percent of Aton’s billed charges “under the MNRP method.”
However, this only establishes Brady’s unilateral expectation that United’s
future reimbursements would reflect its historical payment rates; it does not
establish that the parties mutually agreed during VOB calls that United’s
payment of the subject claims would comport with its payment of prior
claims. Aton also relies on Brady’s deposition testimony that UCR means

“[u]sual, customary, reasonable” and Aton “meet[s] all those criteria.”7
Again, however, this evidence shows only that Brady believed Aton’s rates
were usual, customary, and reasonable, not that United held the same belief.
      Aton also attempts to rely on “the language United uses in its own
plan.” We decline to consider this evidence. Aton has not challenged the trial
court’s ruling that Aton is judicially estopped from asserting claims “based
upon what the policies and/or plans may set as the payment rate.” As a
result, the ruling is binding on appeal (RMR Equipment Rental, supra 65
Cal.App.5th at p. 392) and Aton may not rely on the terms of United’s plan to
resurrect its claims.
      Aton also relies on the averment of its expert that for “ ‘the VOB[s] in
which [Aton] was informed that the allowed amount was to be based on the
UCR, [Aton] should be paid its billed amount.’ ” However, this statement
merely reflects the expert’s opinion of the operation of the UCR
reimbursement methodology in hindsight. It does not establish that United

7      Although Aton also cites three other parts of the record (one pertaining
to Brady’s declaration and two pertaining to Brady’s deposition testimony),
the citations are either not comprehensible or fail to address the UCR.

                                      30
held the same view or that it agreed during VOB calls to fully reimburse Aton
whatever it ultimately billed for a particular treatment.
      Finally, although Aton refers to United’s authorization of treatment in
the heading of the relevant section of its opening brief on appeal, it does not
go on to present a developed argument explaining how the authorizations
evidenced agreements to pay Aton at specified rates. Any such argument has
been forfeited. (Oak Valley Hospital Dist. v. State Dept. of Health Care
Services (2020) 53 Cal.App.5th 212, 228 [undeveloped arguments are forfeited
on appeal].) Even if we were to consider the authorizations, we would not
regard them as evidence of payment agreements independent of the terms of
United’s plans. United’s evidence pertaining to authorizations established
that payment was not addressed during the authorization process. Dr.
Murphy testified that rates of reimbursement or payment are not discussed
by him or United during authorization. United’s authorization letters were
devoid of information about the cost of anticipated treatment. To the
contrary, they cautioned that “[p]ayment for services described in this letter
is subject to,” among other things, “benefit plan limitations.” This evidence
tends to negate, rather than establish, that any rate agreement was formed
during the authorization process, much less an agreement that was
independent of existing plan terms. (See Pacific Bay Recovery, supra, 12
Cal.App.5th at p. 216 [no implied contract formed during prior authorization
process where “it does not appear the parties reached any sort of agreement
as to the rate [the insurer] would pay [the provider]”].)
      In short, Aton fails to cite record evidence supporting either of its
factual assertions. As a result, it fails to establish that the trial court erred
by concluding it lacked evidence to prove the mutual assent necessary to
establish the existence of an oral or implied contract with United.

                                        31
      Aton’s appellate reliance on Bristol SL Holdings, Inc. v. Cigna Health
and Life Ins. Co. (9th Cir. Jan. 14, 2022) 2022 WL 137547 (mem. dispo.)
(Bristol SL Holdings) does not persuade us to reach a different conclusion
about the viability of its contract claims. There, the district court granted
summary judgment in favor of Cigna after concluding there was “a lack of
discussion between the two parties over the ‘usual, customary, and
reasonable rate’ (UCR)” and because it determined that automatic
disclaimers played before verification and authorization calls prevented
formation of any contract. (Id. at p. *1.) The Ninth Circuit reversed in a
memorandum disposition, holding the first of these determinations was
simply incorrect—the provider did, in fact, “introduce evidence of discussions
over UCR, which the district court improperly ignored.” (Ibid.) As for the
disclaimers, the appellate court held they did not eliminate the possibility
contracts were formed during the calls. (Ibid.)
      Unlike Bristol SL Holdings, here we have been presented with no
evidence of “discussions over UCR” that the trial court improperly ignored.
Although the trial court did note the existence of disclaimers in United’s
authorization letters, it cited this as one of numerous factors supporting its
finding that Aton failed to establish mutual assent, unlike Bristol SL
Holdings in which the district court viewed such disclaimers as
independently precluding contract formation. Moreover, Bristol SL Holdings
did not address ERISA preemption, and the disclaimer language it
considered (that any information provided “ ‘does not guarantee coverage or
payment’ ”) was unlike the disclaimer language discussed above. (See Bristol
SL Holdings, supra, 2022 WL 137547 at p. *1.) The court therefore had no
occasion to consider the extent to which disclaimers like those at issue in this
case tend to dispel the implication the insurer’s authorizations created

                                       32
payment agreements independent of plan terms. In short, the reasoning of
Bristol SL Holdings does not persuade us that the trial court in this case
erred.
         2.    Aton’s Additional Arguments Lack Merit
         Aton separately advances seven additional arguments challenging the
trial court’s summary adjudication of its oral and implied contract causes of
action. We address each and conclude none justify reversal of summary
judgment.
         Aton’s first argument is addressed to the trial court’s finding that
United representatives responsible for conducting VOB calls were not
authorized to enter into contracts to pay or guarantee coverage on United’s
behalf. Aton asserts the authority of United’s representatives “could not be
adjudicated at the summary judgment stage because their agency in that
regard presented a question of fact.” It is well settled, however, that issues of
fact appropriately serve as the basis for entry of summary judgment when
they are not in dispute. (See Code Civ. Proc., § 437c, subd. (p)(2).) There is
nothing unique about an employee’s scope of agency that might exempt it
from this rule. (See, e.g., Universal Bank v. Lawyers Title Ins. Corp. (1997)
62 Cal.App.4th 1062, 1066 [summary judgment is appropriate where the
evidence of agency is undisputed and susceptible of only one inference].) No
material dispute was presented as to United VOB representatives’ lack of
authority to contract on behalf of United, and the trial court did not err by
relying on this undisputed fact in reaching its decision.
         Aton contends “a jury could find [United representatives’] actual or
ostensible authority was implied” based on evidence United’s representatives
provided “payment rates” to Aton. We are not persuaded. “Ostensible
authority is such as a principal, intentionally or by want of ordinary care,

                                         33
causes or allows a third person to believe the agent to possess.” (Civ. Code,
§ 2317.) “A corollary derived from this principle is that ostensible authority
of an agent cannot be based solely upon the agent’s conduct.” (Pierson v.
Helmerich & Payne Internat. Drilling Co. (2016) 4 Cal.App.5th 608, 635.)
Aton’s ostensible agency theory relies on the conduct of United’s
representatives. Because it cites no evidence of acts by United that caused it
to believe United’s VOB representatives possessed authority to contract,
Aton’s argument fails.
      Second, Aton maintains the parties did not have to inform each other of
their intent to enter into a contract for a contract to be formed. This point is
true enough. (See, e.g., Rest. 2d Contracts, § 21, com. a. [explaining that the
parties’ “accurate understanding of the applicable law” and “intention to
affect legal relations . . . may be important in interpreting their
manifestations of intention . . . but they are not essential to the formation of a
contract”].) However, Aton fails to explain how it establishes reversible error.
It leaps from this point to the following conclusion: “Therefore, the evidence
in this case satisfies all of the necessary elements of the existence of a
contract.” We are not required to address such an undeveloped argument
and instead pass on it without further consideration. (See Dinslage, supra, 5
Cal.App.5th at p. 379 [“ ‘ “On review of a summary judgment, . . . ‘it is the
appellant’s responsibility to affirmatively demonstrate error’ ” ’ ” which
requires it to both “ ‘direct the court to evidence that supports [its]
arguments’ ” and “ ‘explain how [its cited authority] applies in [its] case’ ”].)
      Aton’s third argument consists of a series of disconnected assertions
that again fail to establish reversible error. It argues (1) “it does not matter
that both sides may have differing views on the meaning of the VOB calls”
because mutual consent is determined under an objective standard;

                                        34
(2) mutual consent is ultimately an issue of fact; (3) to the extent Brady’s
understanding of VOB calls differed from that of Aton’s intake team, Brady’s
understanding “is the one that matters,” and any internal misunderstanding
raises a factual issue precluding summary judgment. The first and second
points are true, but do not establish reversible error given our conclusion the
summary judgment record was devoid of evidence of communications during
the VOB calls that objectively manifested mutual assent. The third point
lacks merit because Brady’s unilateral, undisclosed, subjective interpretation
of the VOB calls (which, we note, was not informed by actual knowledge of
what was said during the calls) is not evidence of mutual assent. (See
Founding Members of the Newport Beach Country Club v. Newport Beach
Country Club, Inc. (2003) 109 Cal.App.4th 944, 956 [“The parties’ undisclosed
intent or understanding is irrelevant to contract interpretation.”].)
      And to the extent Aton claims its own internal misunderstanding about
the VOB calls “raises . . . a factual dispute, precluding summary judgment,” it
confuses the issue. The mutual assent required for United and Aton to form
a contract is assent between United and Aton, not between Aton’s employees
and its CEO. (See Civ. Code, § 1565 [consent of the parties to a contract must
be “[f]ree,” “[m]utual,” and “[c]ommunicated by each to the other”]; Rest. 2d
Contracts, § 18 [“Manifestation of mutual assent to an exchange requires that
each party either make a promise or begin or render a performance” (italics
added)].)
      Aton’s fourth argument relies on California Lettuce Growers v. Union
Sugar Co. (1955) 45 Cal.2d 474, 482 and Civil Code section 1610. In
California Lettuce Growers, our high court applied the rule that “[t]he
absence of price provisions does not render an otherwise valid contract void”
in holding that an agreement to grow sugar beets was not void for want of a

                                       35
price provision. (See California Lettuce Growers, supra, 45 Cal.2d at pp. 481,
482, italics added.) And Civil Code section 1610 states: “When a
consideration is executory, it is not indispensable that the contract should
specify its amount or the means of ascertaining it. It may be left to the
decision of a third person, or regulated by any specified standard.” (Italics
added.) Both authorities presuppose the existence of a valid contract onto
which the element of consideration can be superimposed. Here, the essential
problem is that Aton failed to introduce evidence of the mutual assent
required to form contracts with United. Without mutual assent, there are no
extant contracts, and no basis for employing the foregoing authorities to fill
in the assertedly missing payment term.
      Fifth, Aton contends the trial court’s reliance on the “boilerplate
disclaimer” contained within “some authorization letters United issued after
the VOB calls” is misplaced because a meeting of the minds could objectively
be found “from the verification calls alone.” However, Aton identifies no
record evidence supporting its assertions. As we have already discussed,
Aton failed to introduce evidence of statements during verification calls from
which an objective manifestation of intent to enter a binding agreement
might be gleaned. We again pass on Aton’s unexplained, unsupported
assertion to the contrary. (Dinslage, supra, 5 Cal.App.5th at p. 379 [“An
appellant who fails to pinpoint the evidence in the record indicating the
existence of triable issues of fact will be deemed to have waived any claim the
trial court erred in granting summary judgment.”].)
      Aton’s sixth challenge to the trial court’s ruling is directed at the
contract element of consideration. As a separate ground for granting
summary adjudication, the trial court ruled that Aton’s oral contract cause of
action failed because “[d]uring the VOB process . . . [Aton] did not need to

                                       36
treat [United’s] members and [United] was under no obligation to pay [Aton]
for services”; as a result, there was no “bargained-for-exchange” between the
parties. We need not and do not address Aton’s challenge to this ruling,
which served as an independent basis for the court’s decision to grant
summary adjudication. Mutual consent and consideration are separate
elements of contract formation (see Civ. Code, § 1550), and summary
adjudication is properly granted where the moving party succeeds in
establishing that a single element of a cause of action cannot be proven (Code
Civ. Proc., § 437c, subd. (p)(2)). Because Aton has failed to establish error in
the court’s mutual consent ruling, we would not reverse the grant of
summary adjudication even if we were to agree with Aton’s appellate
challenge to the court’s ruling on consideration.
      Aton’s seventh argument is that the trial court erred in its resolution of
Aton’s breach of implied contract cause of action. According to Aton, the
court erroneously relied only on “the verbal promises alleged” and failed to
consider that “there was also a course of conduct, including treatment,
authorization calls, and a prior payment history at rates consistent with
[Aton’s] expectations.”
      We disagree that the court failed to comprehend the full scope of Aton’s
implied contract claim. The court expressly considered that Aton’s implied
contract claim, in addition to relying on VOB calls, also relied on “previous
payments, historical knowledge, [and] the parties’ history.” The court
concluded its reliance on these matters was unavailing as Aton “provides no
evidence that [United] agreed to pay the subject claims the same as it had
paid previous claims.” Aton, responding to the latter point about the paucity
of its evidence, points to evidence that the claims of one of the 29 subject
patients were paid at disparate rates. We disagree that this is evidence of an

                                       37
implied agreement to pay at any particular rate.8 (See Pacific Bay Recovery,
supra, 12 Cal.App.5th at p. 216 [no implied contract where plaintiff alleged
the insurer “did pay a portion of the billed charges, but [the provider]
argue[d] it was not enough”].)
      In sum, Aton fails to establish that the trial court erred by granting
summary adjudication of its oral and implied contract causes of action.
                                       III.
                     Promissory Estoppel Cause of Action
      “The elements of a promissory estoppel claim are ‘(1) a promise clear
and unambiguous in its terms; (2) reliance by the party to whom the promise
is made; (3) [the] reliance must be both reasonable and foreseeable; and
(4) the party asserting the estoppel must be injured by his reliance.’ ” (US
Ecology, Inc. v. State of California (2005) 129 Cal.App.4th 887, 901.)
      The trial court granted summary adjudication of Aton’s promissory
estoppel cause of action on the ground that “[Aton’s] evidence fails to
demonstrate that [United] made any promises to [Aton] during the VOB
process, much less promises to reimburse as a percentage of billed charges.

8      Similarly, to the extent Aton argues Brady’s testimony showed United
had a history of “consistently” paying Aton’s bills at 100 percent of the billed
amount “under the UCR” and 50 percent of the billed amount “on MNRP
quotations,” we disagree with this description of his testimony. In the cited
testimony, Brady discussed his understanding of MNRP and UCR, and he
stated Aton had received “numerous” prior payments of 50 percent of its
billed charges when the MNRP rate was quoted, but he did not specify how
frequently this had occurred. (Cf. Pacific Bay Recovery, supra, 12
Cal.App.5th at p. 216 [no implied contract where insurer only paid for six of
31 total days of treatment]; IV Sols., Inc. v. United Healthcare Servs. (C.D.
Cal. Sept. 27, 2017) 2017 WL 6372488, *14 [no implied contract based on
allegations of past payment where the referenced payments amounted to no
more than 51 percent of overall claims].)

                                       38
At best, [United] provided [Aton] with coverage information for its
insureds/[Aton’s] potential patients, which does not amount to a clear and
unambiguous promise to pay a certain dollar amount or a percentage of billed
charges.”
      Aton challenges this conclusion, arguing, “United did more than merely
provide coverage information in vague terms. It gave reimbursement
methods often supported by specific percentages, and then authorized specific
treatment for patients for a specific duration. That is enough for a trier of
fact to find a clear promise.” (Italics added.)
      We disagree. “ ‘ “[A] promise is an indispensable element of the
doctrine of promissory estoppel. The cases are uniform in holding that this
doctrine cannot be invoked and must be held inapplicable in the absence of a
showing that a promise had been made upon which the complaining party
relied to his prejudice . . . .” [Citation.] The promise must, in addition, be
“clear and unambiguous in its terms.” [Citation.] “Estoppel cannot be
established from . . . preliminary discussions and negotiations.” ’ ”
(Granadino v. Wells Fargo Bank, N.A. (2015) 236 Cal.App.4th 411, 417
(Granadino); see Pacific Bay Recovery, supra, 12 Cal.App.5th at p. 215, fn. 6
[provider failed to state a cause of action for estoppel because it did not allege
“a promise clear and unambiguous in its terms”].)
      Aton is confusing the requirement of specificity with the requirement of
the existence of a promise. “A ‘promise’ is an assurance that a person will or
will not do something.” (Granadino, supra, 236 Cal.App.4th at p. 417.) As
we have already discussed, United’s moving evidence tended to establish that
no commitments were made by United representatives during VOB calls. To
the contrary, United’s evidence established that VOB calls were not
“promises to pay.” In opposition, Aton identified no evidence supporting a

                                        39
reasonable inference that clear and unambiguous promises or assurances of
payment at rates corresponding to Aton’s billed charges were actually made
during the VOB calls at issue or the authorization process. Aton’s appellate
assertions, which are unsupported by citations to record evidence, that
United “gave” reimbursement methods and then authorized treatment fall
short of establishing that United promised to pay Aton in accordance with

Aton’s expectations.9
      The unpublished federal court cases on which Aton relies do not
demonstrate otherwise. For reasons we have already explained, Bristol SL
Holdings, supra, 2022 WL 137547, is inapposite. The other cases cited by
Aton are distinguishable because they were decided at the pleadings stage
and involved alleged facts distinct from the facts that were proven here. (See,
e.g., Aton Center, Inc. v. Blue Cross and Blue Shield of Illinois, supra, 2021
WL 615051, at p. *6 [where complaint alleged sufficient facts to state a claim
for breach of oral contract, it also alleged facts “to infer a clear and
unambiguous promise”]; California Spine and Neurosurgery Institute v.
Oxford Health Ins. Inc. (N.D. Cal. Nov. 20, 2019) No. 19-cv-03533-DMR, 2019
WL 6171040, *2–5 [denying motion to dismiss and permitting promissory

9      We disagree with Aton’s contention that the reimbursement methods
provided during VOB calls were “often supported by specific percentages,” to
the extent Aton implies the specific percentages pertained to its own charges.
The VOB forms, in addition to asking for a rate of reimbursement, asked for
the percentage “[r]eimbursed after the deductible is met[.]” Reed, the creator
of the VOB forms, testified this percentage corresponded to the rate of
reimbursement reflected in the form. He agreed, by way of example, that for
a VOB form indicating a rate of reimbursement of MNRP and a “percent
reimbursed” of 90 percent, this meant “the amount of reimbursement . . . is
90 percent of the MNRP[.]” The forms did not “say anything about
percentage of total charges.”

                                        40
estoppel claim to proceed where “the parties have not yet had the opportunity
to develop evidence of industry custom about whether Defendants’
authorization of services coupled with a verification call constitutes a promise
to pay”].)
                                       IV.
 Intentional Misrepresentation, Negligent Misrepresentation, and Fraudulent
                                  Concealment
      In a single section of its opening brief on appeal, Aton collectively
challenges the trial court’s summary adjudication of its second, third, and
fourth causes of action for intentional misrepresentation, negligent
misrepresentation, and fraudulent concealment. The trial court granted
summary adjudication of these causes of action after determining evidence
supporting several elements of each cause of action was lacking.
      The elements of intentional misrepresentation “are (1) a
misrepresentation, (2) knowledge of falsity, (3) intent to induce reliance,
(4) actual and justifiable reliance, and (5) resulting damage.” (Chapman v.
Skype Inc. (2013) 220 Cal.App.4th 217, 230–231.) The trial court granted
summary adjudication of Aton’s intentional misrepresentation upon
concluding that United succeeded in showing that Aton could not prove
United made misrepresentations, knew any alleged misrepresentations were
false, or intended to induce Aton’s reliance on the purported
misrepresentations.
      The elements of negligent misrepresentation are: “(1) the
misrepresentation of a past or existing material fact, (2) without reasonable
ground for believing it to be true, (3) with intent to induce another’s reliance
on the fact misrepresented, (4) justifiable reliance on the misrepresentation,
and (5) resulting damage.” (Apollo Capital Fund LLC v. Roth Capital

                                       41
Partners, LLC (2007) 158 Cal.App.4th 226, 243.) The trial court found that
United succeeded in showing Aton could not establish a misrepresentation of
a past or existing material fact (since misrepresentations about future
payment rates concerned future conduct), or United’s intent to induce Aton’s
reliance on the purported misrepresentation.
      The elements of fraudulent concealment are “(1) concealment or
suppression of a material fact; (2) by a defendant with a duty to disclose the
fact to the plaintiff; (3) the defendant intended to defraud the plaintiff by
intentionally concealing or suppressing the fact; (4) the plaintiff was unaware
of the fact and would not have acted as he or she did if he or she had known
of the concealed or suppressed fact; and (5) plaintiff sustained damage as a
result of the concealment or suppression of the fact.” (Graham v. Bank of
America, N.A. (2014) 226 Cal.App.4th 594, 606.) The trial court concluded
that Aton could not establish the elements of United’s concealment or
suppression of a material fact; United’s duty to disclose the purported
material fact; and United’s intent to defraud Aton.
      Aton asserts five collective challenges to these rulings. First, it asserts
that its “fraud claims . . . raise factual issues.” (Boldface and italics omitted.)
In part, Aton points to two unpublished federal district court orders.
(Summit Estate, Inc. v. Cigna Health and Life Insurance Co. (N.D. Cal. Mar.
30, 2022) No. 5:20-cv-04697-EJD, 2022 WL 958380, *3–4; Broad Street
Surgical Center, LLC v. UnitedHealth Group, Inc. (D.N.J. Mar. 6, 2012)
No. 11–2775 (JBS/JS), 2012 WL 762498, *12.) However, these decisions are
inapposite because they addressed the sufficiency with which the provider’s
complaint alleged fraud or negligent misrepresentation. Aton’s only attempt
to identify a factual dispute precluding summary adjudication of its “fraud
claims” is this assertion: “Given that United paid substantially less than

                                        42
what was promised and less than how it had even historically reimbursed
[Aton] provides the sort of circumstantial evidence needed to support the
fraud claims.” This argument runs afoul of the rule that “ ‘something more
than nonperformance is required to prove the defendant’s intent not to
perform his promise.’ ” (Tenzer v. Superscope (1985) 39 Cal.3d 18, 30.) “[I]f
plaintiff adduces no further evidence of fraudulent intent than proof of
nonperformance of an oral promise, he will never reach a jury.” (Id. at p. 31.)
Accordingly, we reject Aton’s first argument.
      Aton’s second and third arguments are perfunctory and undeveloped.
Its second argument is: “that United’s VOB team may have only innocently
passed on information United provided it does not get United off the hook for
fraud” because “ ‘a principal may be liable where he intentionally misinforms
or withholds information from the agent and the agent thereon innocently
misrepresents.’ ” However, Aton cites no record evidence establishing that
United intentionally misinformed or withheld information from its agents.
Its third argument is: “fraud usually presents a question of fact” and
“[c]ertainly, whether United intended to defraud or induce reliance raises
factual issues.” This argument is also unaccompanied by citation to evidence
purportedly showing United’s intent to defraud or induce Aton’s reliance.
Again, Aton’s obligation as the appealing party is to “ ‘direct the court to
evidence that supports [its] arguments’ ” and “explain how [its cited
authority] applies in [its] case.” (Dinslage, supra, 5 Cal.App.5th at p. 379.) It
is not our duty to “ ‘comb through the record for evidentiary items to create a
disputed issue of material fact.’ ” (Ibid.) Aton’s failure to properly support its
second and third arguments with citations to record evidence results in
forfeiture of both points.

                                       43
      Aton’s fourth argument is that United has a duty “to accurately provide
the payment reimbursement rate when it voluntarily agrees to do so.” Its
fifth argument makes the related point that “triable issues of fact remain
whether representations concerning the rate of percentage promised were
accurate” given that “at minimum, reimbursement at 50[ percent] was
promised.” In support of the latter argument, Aton cites testimony from a
United representative regarding the interpretation of language of a
particular insurance plan. Simply put, the cited testimony does not support
Aton’s factual assertion. We also agree with United’s contention that the
trial court’s unchallenged judicial estoppel ruling applies, and as a result,
Aton is foreclosed from attempting to revive its claims by relying on evidence
of “what the policies and/or plans may set as the payment rate.” We thus
reject Aton’s fourth and fifth arguments. In sum, we conclude Aton has failed
to establish that the trial court erred by summarily adjudicating its causes of
action for intentional misrepresentation, negligent misrepresentation, and
fraudulent inducement.
                                        V.
                              Violation of the UCL
      The last cause of action disposed of on summary judgment was Aton’s
cause of action for violation of the UCL. “Business and Professions Code
section 17200 et seq. prohibits unfair competition, including unlawful, unfair,
and fraudulent business acts. The UCL covers a wide range of conduct. It
embraces ‘ “ ‘ “anything that can properly be called a business practice and
that at the same time is forbidden by law.” ’ ” ’ ” (Korea Supply Co. v.
Lockheed Martin Corp. (2003) 29 Cal.4th 1134, 1143, fn. omitted.) Because
the UCL “ ‘is written in the disjunctive, it establishes three varieties of unfair
competition—acts or practices which are unlawful, or unfair, or fraudulent.’

                                       44
[Citation.] An act can be alleged to violate any or all of the three prongs of
the UCL—unlawful, unfair, or fraudulent.” (Berryman v. Merit Property
Management, Inc. (2007) 152 Cal.App.4th 1544, 1554.) However, the
remedies available for violation of the UCL are limited. Only equitable
remedies can be obtained; damages cannot be recovered. (Korea Supply Co.,
at p. 1144.)
      The trial court ruled that Aton’s cause of action for violation of the UCL
failed for a number of reasons. It found that Aton could not maintain its
UCL claims, which were equitable in nature, because it had an adequate
remedy at law—its other causes of action for which it sought money damages,
which the court ruled was “true even if the plaintiff’s non-UCL claims
ultimately fail.” It also found that United had succeeded in demonstrating
that Aton could not establish that United actually engaged in any unlawful,
unfair, or fraudulent business act or practice.
      On appeal, Aton challenges the trial court’s ruling only insofar as it
held Aton could not establish the fraud prong of its UCL claim. Aton asserts
that if this court reverses the summary adjudication of its intentional
misrepresentation or fraudulent concealment causes of action, we “must
likewise reverse judgment on the UCL claim.” We are not reversing the
court’s summary adjudication of Aton’s intentional misrepresentation or
fraudulent concealment causes of action, so Aton’s UCL claim cannot be
revived on the basis of the asserted merit of those causes of action.
      Next, Aton contends fraud was sufficiently established because it
“alleges a . . . continuing pattern of conduct by United in underpaying claims”
which creates a financial risk for patients as well as the potential for relapse.
This argument runs afoul of the summary judgment statute, which provides
that a party opposing summary judgment may not “rely upon the allegations

                                       45
or denials of its pleadings to show that a triable issue of material fact
exists[.]” (Code Civ. Proc., § 437c, subd. (p)(2).)
      Finally, Aton asserts that it “should be allowed to plead claims for both
monetary damages under the fraud claims and injunctive relief as alternative
remedies.” However, even if the opportunity to amend the complaint
remained available at this late juncture, the trial court ruled that Aton’s UCL
claim fails for reasons independent of concerns about Aton’s ability to seek
overlapping legal and equitable remedies. The proposed amendment would
not resolve these additional concerns, which are fatal to the viability of its
UCL claim. (See Vailette v. Fireman’s Fund Ins. Co. (1993) 18 Cal.App.4th
680, 685 [“leave to amend should not be granted where . . . amendment would
be futile”].) Aton thus fails to establish that the trial court erred in granting
summary adjudication of its cause of action for violation of the UCL.
                                  DISPOSITION

      The judgment is affirmed. United is entitled to its costs on appeal.
(Cal. Rules of Court, rule 8.278(a)(1).)

                                                                            DO, J.

      WE CONCUR:

      HUFFMAN, Acting P. J.

      O’ROURKE, J.

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