Central Louisiana Ambulatory Surgical Center, Inc. v. Payless Shoesource, Inc.

46 So. 3d 689
CourtLouisiana Court of Appeal
DecidedOctober 20, 2010
Docket10-86, 10-91, 10-92, 10-96, 10-97, 10-99, 10-100, 10-115, 10-117, 10-118
StatusPublished
Cited by33 cases

This text of 46 So. 3d 689 (Central Louisiana Ambulatory Surgical Center, Inc. v. Payless Shoesource, Inc.) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Central Louisiana Ambulatory Surgical Center, Inc. v. Payless Shoesource, Inc., 46 So. 3d 689 (La. Ct. App. 2010).

Opinions

THIBODEAUX, Chief Judge.

hThe plaintiff-appellee, Central Louisiana Ambulatory Surgical Center, Inc. (CLASC), filed ten disputed claim forms with the Office of Workers’ Compensation (OWC) for the underpayment of medical bills for services provided by CLASC to ten injured workers. The named defendants, all appellants, were the employers of the injured workers: Payless Shoe-source, Inc. (one worker); Gilchrist Construction Co. (one worker); and, Rapides Parish School Board (eight workers). The defendants-appellants will be collectively referred to as “the Employers.”

The disputes arose from a web of contracts with a preferred provider organization (PPO) which discounted its payments to CLASC by twenty percent (20%). This 20% reduction in medical fee reimbursement was calculated upon a fee that had already been reduced by ten percent (10%) in accordance with La.Admin.Code tit. 40, part I, § 2507 promulgated in conjunction with La.R.S. 23:1034.2 of the Louisiana Workers’ Compensation Act (LWCA or the Act). Following two hearings on the partially consolidated claims, the OWC entered judgment in favor of CLASC on each of the ten claims for underpayments ranging from approximately $137.00 to $2,200.00. The OWC also awarded CLASC $1,500.00 in attorney fees, along with a penalty of $2,000.00, on each of the ten claims. The Employers appealed the judgment.1

Finding that the issues, as well as the plaintiff and the pertinent contracts, are the same in all ten cases, we have consolidated the ten appeals. For the reasons set forth below, we affirm the OWC’s awards for underpayments to CLASC. |2Finding, however, that the Employers reasonably controverted the claims by CLASC, we reverse all awards for attorney fees and penalties.

[692]*692I.

ISSUES

We must decide:

(1) whether the PPO contracts are legally valid and enforceable against the established, mandatory fee rates set forth in the medical fee reimbursement schedule of the LWCA;

(2) whether the claims of CLASC for penalties and attorney fees have prescribed; and,

(3) whether the Employers in these consolidated cases reasonably controverted CLASC’s claims of underpayments, thereby rendering the OWC’s assessment of penalties and attorney fees against the Employers a reversible manifest error.

II.

FACTS AND PROCEDURAL HISTORY

In December of 1995, the business director of CLASC signed a document entitled “Affordable Health Care Concepts Participating Provider Agreement.” The document was signed by Affordable Health Care Concepts (Affordable) in February 1996 and became effective the following month. The document’s stated purpose was to create a “Preferred Provider Panel” which would “agree to comply with the reimbursement mechanisms established by AFFORDABLE.” It further stated that Affordable would “offer to certain Payors the opportunity to participate” in a PPO plan that used the services of the “Preferred Provider Panel.”

The nine-page Affordable PPO document addressed requirements that medical providers had to meet, such as cooperating with “Payors” in “expediting the |sreturn to work of Participating Patients” in workers’ compensation cases, as well as maintaining staff privileges, professional licenses, and professional liability insurance. Couched in terms relating to what the “Payor” agreed to pay, the Affordable PPO document referenced “the lesser of the Provider’s charges or the fee schedule listed in Appendix A.” Attached to the Affordable PPO Agreement is a one-page, unsigned, undated document entitled “Appendix A — First Health Outpatient Care Network Reimbursement” (First Health Appendix or Appendix A). The First Health Appendix does not contain the name of the main document or bear reference to the Affordable PPO document to which it is attached.

However, Subpart (D) of the First Health Appendix provided that reimbursement from workers’ compensation Payors would not exceed 80% of the maximum amount payable under governing state law, whether the state rules were in existence at the time of the execution of the agreement or established at a later time. Affordable changed its operating name to First Health Group Corporation (First Health) at some point in time, but apparently no efforts were made to notify CLASC of the corporate changes or to provide proper documentation in that regard.

On January 1, 2002, First Health entered into an agreement with Gallagher Bassett Services, Inc. (Gallagher). The title of that document was “Workers’ Compensation Managed Care Services Agreement” (Gallagher/First Health Agreement). It provided that First Health would perform services including clinical management, bill review, access to the First Health network, and “Front-End Processing” (electronic data capture from paper claims documents). Gallagher was identified as the “Client” in the agreement, and the entities for whom the “Client” would make managed care services available were referred to as “Sub-Clients.” [693]*693The document further provided that neither First Health nor Gallagher, as “Client,” would render any medical services to the claimants and that Gallagher was responsible for |4“all decisions regarding the payment or denial of payment of medical benefits to Claimants.”

While clearly dated January 1, 2002, on the first line identifying the parties, the Gallagher/First Health Agreement was signed by Gallagher on January 12, 2005, and was signed by First Health on January 24, 2005. In addition to the internal date discrepancies in the Gallagher/First Health Agreement, vague and disparate terminology further lends to the confusion where the Affordable PPO document refers to the Employer-defendants in these cases as “Payors” while the Gallagher/First Health Agreement refers to them as “Sub-clients.”

In addition to the above-described contract between CLASC and Affordable, and the above contract between Gallagher and First Health, each of these consolidated cases contains approximately five other contracts, which are between Gallagher or First Health and the adjusting companies, or between Gallagher and the Employers. There are no contracts between CLASC and the Employers or the Employers’ insurance company. Notably, the only contract that CLASC signed is the Affordable PPO contract.

Beginning in June 2005, CLASC provided surgeries and medical procedures for ten injured employees of the three Employers in these ten consolidated cases.2 When CLASC received the Employers’ payments on its medical bills, the payments were reduced by the ten percent (10%) mandatory reduction of the LWCA; this 10% reduction is not an issue of dispute. The reduced payments were then reduced again by twenty percent (20%) for the PPO discounts, as reflected by Gallagher on the explanation of benefits (EOB) forms that it sent to CLASC in each |ficase. CLASC filed the ten disputed claims forms against the Employers for the 20% payment reductions on CLASC’s bills for medical services.

III.

LAW AND DISCUSSION

Validity of the PPO Discount Agreements Under the Framework of the LWCA

The Employers argue that the OWC erred in concluding that the PPO discounts are not authorized by the LWCA. We find no error in the OWC’s judgment. An examination of the underlying goals of the LWCA instructs us as to the validity of the PPO discounts.

(1) Goals of the LWCA

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Bluebook (online)
46 So. 3d 689, Counsel Stack Legal Research, https://law.counselstack.com/opinion/central-louisiana-ambulatory-surgical-center-inc-v-payless-shoesource-lactapp-2010.