Beck v. Blue Cross & Blue Shield of Kansas, Inc.

44 P.3d 1237, 273 Kan. 668, 2002 Kan. LEXIS 170
CourtSupreme Court of Kansas
DecidedApril 26, 2002
DocketNo. 86,214
StatusPublished
Cited by1 cases

This text of 44 P.3d 1237 (Beck v. Blue Cross & Blue Shield of Kansas, Inc.) is published on Counsel Stack Legal Research, covering Supreme Court of Kansas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Beck v. Blue Cross & Blue Shield of Kansas, Inc., 44 P.3d 1237, 273 Kan. 668, 2002 Kan. LEXIS 170 (kan 2002).

Opinion

[669]*669The opinion of the court was delivered by

Six, J.:

This is a breach of contract action. Resolution is based on our interpretation of K.S.A. 40-2,101, a “mandated-provider” or “freedom of choice” statute. Plaintiff Mark A. Beck, a chiropractor, was a contracting provider with defendant Blue Cross and Blue Shield of Kansas, Inc. (Blue Cross) from 1992 through 1996. Dr. Beck sued Blue Cross, claiming his contracts with Blue Cross violated K.S.A. 40-2,101. The jury awarded damages to Dr. Beck in the sum of $1,602,200.50.

Blue Cross appeals from the denial of its K.S.A. 2001 Supp. 60-250 motion for judgment as a matter of law (directed verdict) asking us to vacate the jury’s verdict.

Our jurisdiction is under K.S.A. 20-3018(c) (transfer on our own motion).

The first impression issues are: (1) whether the contracts between Dr. Beck and Blue Cross violated K.S.A. 40-2,101, and (2) if the answer to issue (1) is “yes” and K.S.A. 40-2,101 prohibits disparate treatment of health care providers, whether there was evidence of a disparate impact on Dr. Beck. We hold that the contracts here do not violate K.S.A. 40-2,101. Thus, we do not reach the second issue. We reverse the judgment in favor of Dr. Beck and remand with instructions to enter judgment for Blue Cross.

FACTS

Dr. Beck is a chiropractor licensed by the Kansas Board of Healing Arts. During the relevant time period, Dr. Beck operated three chiropractic clinics in Wichita. Each clinic contracted with Blue Cross to provide chiropractic services to persons insured by Blue Cross.

The Contracts

Two types of form contracts prepared by Blue Cross between Dr. Beck and Blue Cross are at issue in here. The contracts govern the terms of reimbursement received by Dr. Beck from Blue Cross when services are provided to a Blue Cross insured. The first is the “competitive allowance program” contract (CAP contract) and [670]*670the second is the “Kansas Chiropractor Network contract” (KCN contract).

The CAP contract required Dr. Beck to perform medically necessary chiropractic services. Dr. Beck agreed to accept a maximum allowable payment, which Blue Cross would set each year for each procedure. He also agreed to a “most favored nation” clause, so Blue Cross would not pay more than Dr. Beck received from some other payor for any particular procedure. For each covered service, Dr. Beck agreed to accept the maximum allowable payment as payment in full.

In addition, Blue Cross periodically issued policy memos to supplement the provider agreement. The policy memos became a part of the agreement between Dr. Beck and Blue Cross. Both the CAP and KCN contracts said:

“Sec. Ill, GENERAL AGREEMENT OF THE PARTIES
“A. The chiropractor agrees to:
“2. . . . Future amendments shall be provided to the chiropractor at least 30 days prior to the effective date of the amendments. In the event that the changes in the policies and procedures are unacceptable to the chiropractor, this contract may be cancelled by providing written notice to Blue Cross and Blue Shield that the contract is to be terminated 30 days from the date of the notice. If the chiropractor has not exercised, in writing, a notice of cancellation of this contract on or before the effective date of such amendments, the chiropractor agrees to abide by such amendments as long as this contract shall remain in effect.” (Emphasis added.)

The KCN contract was initiated in 1990 as a pilot program with chiropractors. If a chiropractor was a contracting provider under a KCN agreement, the chiropractor’s billings would be adjusted or discounted from 0 percent to 50 percent, depending upon the chiropractor’s average allowed charge per patient per year (AACPPY) from the previous year. The higher the chiropractor’s AACPPY, the greater the discount applied to the chiropractor’s billings the following year. The applicable discount was applied to the maximum allowed payment under the CAP contract. Thus, in 1996, Blue Cross agreed to pay Dr. Beck’s usual charge for covered services, not to exceed the maximum allowed payment under the CAP contract less Dr. Beck’s 50 percent discount under the KCN con[671]*671tract. No discount was applied to Dr. Beck under the KCN contract from 1991 through 1995.

Blue Cross required health care providers to submit bills using the American Medical Association Current Procedure Technology (CPT) codes. However, the inclusion of a procedure in the codes did not mean that Blue Cross provided coverage for that procedure. The CPT code manual provided separate codes for office visits and manipulations. Blue Cross “Policy Memo No. 2 OFFICE/OUTPATIENT VISIT” said under “CONTENT OF SERVICE” that “[ujsual fees for the professional services” for office visits “are considered to include” the examination of the patient and any manipulations, the principal treatment offered by chiropractors. This policy is similar to the one used by Medicare, as Medicare did not pay chiropractors separately for an office visit during which a manipulation was performed. Dr. Beck did not exercise his right under either the CAP or the KCN contracts to declare the Policy Memo No. 2 amendment “unacceptable.” Thus, he agreed “to abide by” its terms. In 1994, however, Dr. Beck did complain to Blue Cross that he was not permitted to bill separately for an office visit and a manipulation and was not getting paid for both services.

Dr. Beck also complained about Blue Cross’ policy of paying him for adjusting the spine as one area, regardless of the number of manipulations performed on multiple areas, i.e., neck, mid back, and low back. This policy also was similar to Medicare’s policy. Medicare will not pay for more than one manipulation on a particular visit.

Dr. Beck also was displeased with Blue Cross’ policy on treatment modalities, i.e., heat packs, ice packs, ultrasound, traction, and therapy. If Dr. Beck were to bill for the use of more than two modalities per visit, Blue Cross would require additional paperwork. To avoid delays in payment, Dr. Beck chose to bill only for two modalities, even though he may have provided more during any given visit.

Although Dr. Beck disagreed with Blue Cross’ payment policies, Riere is no dispute that he knew and understood what the policies were when he signed the CAP and KCN contracts in issue here.

[672]*672 Proceedings below

Dr. Beck filed a three-count petition against Blue Cross. Count I alleged that Blue Cross violated K.S.A. 40-2

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Related

Beck v. BLUE CROSS & BLUE SHIELD OF KANSAS
44 P.3d 1237 (Supreme Court of Kansas, 2002)

Cite This Page — Counsel Stack

Bluebook (online)
44 P.3d 1237, 273 Kan. 668, 2002 Kan. LEXIS 170, Counsel Stack Legal Research, https://law.counselstack.com/opinion/beck-v-blue-cross-blue-shield-of-kansas-inc-kan-2002.