Bio-Medical Applications of Columbus, Inc. v. Blue Cross of Central Ohio

492 N.E.2d 450, 23 Ohio App. 3d 154, 23 Ohio B. 396, 1985 Ohio App. LEXIS 10122
CourtOhio Court of Appeals
DecidedMarch 28, 1985
Docket84AP-473
StatusPublished

This text of 492 N.E.2d 450 (Bio-Medical Applications of Columbus, Inc. v. Blue Cross of Central Ohio) is published on Counsel Stack Legal Research, covering Ohio Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bio-Medical Applications of Columbus, Inc. v. Blue Cross of Central Ohio, 492 N.E.2d 450, 23 Ohio App. 3d 154, 23 Ohio B. 396, 1985 Ohio App. LEXIS 10122 (Ohio Ct. App. 1985).

Opinion

*155 Whiteside, J.

Defendant Blue. Cross of Central Ohio appeals from a judgment of the Franklin County Court of Common Pleas, and raises four assignments of error as follows:

“L The Court erred in its judgment that the existence of a provider contract between Appellant, a hospital service association, and Appellee, a health care facility, is not a condition precedent to the reimbursement of Ap-pellee for out-patient renal dialysis services rendered under Appellant’s subscriber contracts, which is contrary to the provisions of § 1739.01, Revised Code.

“II. The Court erred in its judgment that by virtue of the provisions of § 1739.06, Revised Code, Appellant is required to provide payment to Ap-pellee, a non-contracting health care facility, for out-patient renal dialysis services rendered to subscribers under Appellant’s subscriber contracts.

“HI. The Court erred in its judgment that by virtue of the provisions of § 1739.06, Revised Code, the sole condition precedent to reimbursement of Ap-pellee by Appellant for out-patient renal dialysis services rendered under Appellant’s subscriber contracts is that such services be rendered under the approval of a hospital.

“IV. The Court erred in its finding of no genuine issue of any material fact that the referral of subscribers to Ap-pellee by staff doctors of Riverside Hospital and Ohio State University Hospital constituted approval by said hospitals for the rendition of such services.”

Plaintiff Bio-Medical Applications of Columbus, Inc. (“Bio-Medical”), brought this action against defendant Blue Cross of Central Ohio (“Blue Cross”), seeking to recover compensation for outpatient renal dialysis services rendered to subscribers of Blue Cross, a hospital service association operated pursuant to the provisions of R.C. Chapter 1739. Blue Cross contends that Bio-Medical is not entitled to payment or reimbursements under the subscriber contracts issued by Blue Cross because Bio-Medical not only has not entered into a provider contract with Blue Cross, but has also refused to do so.

The trial court found for BioMedical and, pursuant to a stipulation of damages, entered judgment against Blue Cross in the amount of $210,653.55 for all claims for dialysis services rendered prior to November 1, 1982, with interest from the date of judgment, resulting in this appeal by Blue Cross. In addition, Bio-Medical has filed a cross-appeal, raising a single assignment of error contending that “[t]he trial court erred in holding that the plaintiff/cross-appellant was not entitled to prejudgment interest under Ohio law.”

The trial court entered a declaratory judgment upon the issues involved, specifically declaring the rights of the parties, as follows:

“1. That pursuant to § 1739.06 Revised Code, Defendant is required to provide payment to Plaintiff for outpatient renal dialysis services rendered to subscribers under Defendant’s subscriber contracts;

“2. That the existence of a provider contract between Plaintiff and Defendant is not a condition precedent to the reimbursement of Plaintiff for out-patient renal dialysis services rendered under Defendant’s subscriber contracts.

“3. That the sole condition precedent to such reimbursement of Plaintiff by defendant is that the out-patient renal dialysis services be rendered under approval by the hospital as provided by § 1739.06 Revised Code.

“4. That the referral of subscribers to Plaintiff by staff doctors of Riverside, OSU and Doctors Hospitals constitute^] approval by the hospital for purposes of § 1739.06, Revised Code, and coverage *156 is required under Defendant’s subscriber contracts.”

The issues raised involve construction of statutory provisions, specifically, the provisions of R.C. 1739.06, that:

“Any subscriber contract for hospital care, skilled nursing services, or home health services authorized by this chapter that is issued, delivered, or renewed in this state on or after July 1, 1972, and provides for kidney dialysis benefits shall be deemed to include such benefits on an equal basis for kidney dialysis performed by a hospital on an outpatient basis. For purposes of this paragraph, ‘outpatient basis’ includes care rendered at any location whether or not at a hospital, upon approval by the hospital.”

Clearly, plaintiff Bio-Medical is not a hospital as defined by R.C. 1739.01(B); however, there appears to be no eviden-tiary dispute but that Bio-Medical provided renal dialysis services on an outpatient basis for patients referred by doctors having staff privileges at hospitals. Blue Cross contends that an issue of fact exists as to whether the acts of such doctors constitute action of a hospital, the issue raised by the fourth assignment of error.

Blue Cross’ basic contention, however, is that there must be a provider contract in existence between Blue Cross, a hospital service association, and Bio-Medical, a health-care facility, before Bio-Medical is entitled to reimbursement by Blue Cross for outpatient renal dialysis services. In other words, Blue Cross concedes that the subscriber contract provides for payment for such services, but disputes Bio-Medical’s right to compensation therefor because no provider contract exists between the parties.

R.C. 1739.06 also provides for provider contracts, stating that:

“Such association, upon application by any hospital located in this state, may contract with such hospital for hospital care to be rendered to the subcribers to the hospital service plan. Such contract shall provide that such hospital shall be paid by the association, for hospital care rendered to its subscribers * * * .

“Such association, upon application by any skilled nursing facility, home health agency, community mental health board, mental health service facility, or ambulatory health facility located in this state * * * may contract with such ambulatory health facility for the performance of specified services under a hospital service plan to be rendered to the subscribers whose contracts provide for such service * * *. Such contract may provide that such * * * ambulatory health facility shall be paid by the association for such care rendered to its subscribers on the basis of a rate formula or on the basis of an agreed per diem or otherwise mutually agreed to basis. A hospital service association, as a condition to entering into a contract with an ambulatory health facility * * * may require the furnishing of a reasonable bond by such ambulatory health facility * * * to assure the performance of its obligations under such contract and under the hospital service association’s contracts with its subscribers which provide for skilled nursing service, home health service, or community mental health service.”

R.C. 1739.06 further provides for an application for such a provider contract by the facility and confers a right of appeal to the Superintendent of Insurance if the hospital service association refuses to contract with the facility.

R.C.

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Related

Braverman v. Spriggs
426 N.E.2d 526 (Ohio Court of Appeals, 1980)
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Cite This Page — Counsel Stack

Bluebook (online)
492 N.E.2d 450, 23 Ohio App. 3d 154, 23 Ohio B. 396, 1985 Ohio App. LEXIS 10122, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bio-medical-applications-of-columbus-inc-v-blue-cross-of-central-ohio-ohioctapp-1985.