CLASC.(LIGGINS) v. Rapides Parish Sch. Bd.

81 So. 3d 664, 2010 WL 4322985
CourtLouisiana Court of Appeal
DecidedOctober 24, 2011
Docket10-0555
StatusPublished

This text of 81 So. 3d 664 (CLASC.(LIGGINS) v. Rapides Parish Sch. Bd.) 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
CLASC.(LIGGINS) v. Rapides Parish Sch. Bd., 81 So. 3d 664, 2010 WL 4322985 (La. Ct. App. 2011).

Opinion

81 So.3d 664 (2010)

CENTRAL LOUISIANA AMBULATORY SURGICAL CENTER, INC. (Lawrence LIGGINS)
v.
RAPIDES PARISH SCHOOL BOARD.

No. 10-0555.

Court of Appeal of Louisiana, Third Circuit.

Rehearing Not Considered October 24, 2011.
November 3, 2010.

*665 R. Bray Williams, Joseph Payne Williams, Sr., Williams Family Law Firm, LLC, Natchitoches, LA, for Plaintiff/Appellee Central Louisiana Ambulatory Surgical Center, Inc.

Roger A. Javier, Amanda H. Baxter, The Javier Law Firm, New Orleans, LA, for Defendant/Appellant Rapides Parish School Board.

Court composed of JOHN D. SAUNDERS, JIMMIE C. PETERS, and JAMES T. GENOVESE, Judges.

PETERS, J.

The Rapides Parish School Board (School Board) appeals a judgment rendered by the workers' compensation judge (WCJ) in favor of the Central Louisiana Ambulatory Surgical Center, Inc. (CLASC), awarding CLASC recovery of $1,403.10 for medical services rendered to one of the School Board's injured employees, $2,000.00 in statutory penalties, and $4,500.00 in attorney fees. We reverse the WCJ award of statutory penalties, but affirm the judgment in all other respects. Additionally, we render judgment in favor of CLASC and against the School Board in the amount of $1,500.00 as an additional attorney fee for work performed on appeal.

DISCUSSION OF THE RECORD

This appeal is one of eleven cases now before this panel involving the same litigants and raising the same legal issue. In each case, an employee of the School Board sustained a injury compensable under the Louisiana Workers' Compensation Act and received medical treatment through CLASC. In each case, the School Board, through its workers' compensation administrator, Gallagher Bassett Services, Inc. (Gallagher Bassett), initially applied La.R.S. 23:1034.2 and La.Admin.Code tit. 40, part I, § 2507 to reduce CLASC's medical charges by ten percent. However, the School Board further reduced the charges by an additional twenty percent before tendering payment to CLASC. The correctness of the twenty percent reduction is the single issue in all eleven cases.

All of the disputes now before us have the same undisputed factual background and arise from a series of contracts involving a preferred provider organization (PPO) which discounts its payments to CLASC by twenty percent. They begin with a 1996 contract between CLASC and Affordable Health Care Concepts (Affordable) which had as its purpose CLASC's participation in a Preferred Provider Panel by which Affordable would offer discounted medical services to those insured under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).

Section 1 of Article 4 of the CHAMPUS contract addressed provider billing and payment and provided, in pertinent part, that "[f]or claims covered under Workers' Compensation, contract rate shall not exceed the amount otherwise allowed for a workers [sic] compensation claim." Section D of Appendix A, entitled "AFFORDABLE OUTPATIENT CARE NETWORK REIMBURSEMENT," and attached to the contract, provided:

Reimbursement from Workers' Compensation Payors for services rendered to occupationally ill/injured employees shall be as follows:
(1) If any state law or regulation establishes rules or guidelines for the payment of health care services, reimbursement shall not exceed 80% of the maximum amount payable under such rules or guidelines. Any procedure code which is unvalued shall be reimbursed pursuant to Section A, Paragraph (3), of this Appendix. *666 This rate of reimbursement shall apply whether such rules or guidelines are in existence at the time of execution of this agreement or established at a later time.
(2) In the absence of any state law or regulation set forth in Section D, Paragraph (1), reimbursement shall be the method set forth in Section A, Paragraph (1), (2) and (3) of this Appendix, but in no event shall reimbursement exceed the usual and customary charge for the services, as determined by AFFORDABLE or Payor.

Sometime after CLASC entered into the contract, Affordable evolved into what is now the defendant in this case, First Health.

In 2001, the School Board contracted with Gallagher Bassett to provide it with, among other things, services relating to the administration of its workers' compensation claims. At the time, Gallagher Bassett had contracts with various other entities, including First Health. Gallagher Bassett's relationship with First Health gave it access to First Health's network and the advantages of First Health's bill review and front-end processing services. In other words, there was no direct contract between CLASC and the School Board. Rather, the basis of this suit and the remaining ten suits is the School Board's underpayment of medical services that CLASC provided to its employees based on contracts emanating from First Health.

In the matter now before us, the School Board's injured worker is Lawrence Liggins, and it is not disputed that Mr. Liggins sustained an injury compensable under the Louisiana Workers' Compensation Act, that CLASC provided medical care to Mr. Liggins totaling $7,795.00, and that medical care was for the treatment of his compensable injuries. In handling CLASC's claim for payment, Gallagher Bassett first deducted $779.50 (the statutory ten percent) from the total submitted. It then reduced that sum by an additional twenty percent, or $1,403.10. The additional twenty percent was based on the provisions of First Health's contract with CLASC. After making both reductions, the School Board then tendered $5,612.40 to CLASC as payment in full for the services rendered to Mr. Liggins.

CLASC brought this claim to recover the twenty-percent underpayment from the School Board, and the litigants submitted the issue to the WCJ based on stipulations and briefs. The WCJ ultimately rendered judgment in this case as well as the other ten now before us, awarding CLASC judgment for the twenty percent at issue, penalties, and attorney fees. In doing so, the WCJ concluded that the School Board could not rely on contracts with a PPO to reduce the amounts paid for medical services provided by CLASC to its injured employee. This appeal followed.

In their appeal of this and the other ten cases now before us, the School Board raised four assignments of error:

1. The trial court erred in ruling that, although parties may contract for discounts from the maximum amount payable under the Louisiana Workers' Compensation Reimbursement Schedule, the contracts utilized by the medical provider and Rapides Parish School Board. [sic] ("RPSB") for discounts are not authorized by the Louisiana Workers' Compensation Act.
2. The trial judge erred in ruling that the contract utilized by the medical provider and RPSB for discounts from the maximum amount payable under the Louisiana Workers' Compensation Reimbursement Schedule must be specifically and affirmatively *667 authorized by the Louisiana Workers' Compensation Act.
3. The trial court erred in ruling that RPSB was arbitrary and capricious in relying upon contracts voluntarily entered into by the parties providing for discounts from the maximum amount allowed under the Louisiana Workers' Compensation Reimbursement Schedule and awarding penalties and attorney fees against RPSB.
4. The trial court erred in assessing penalties and attorney's fees against RPSB under La.Rev.Stat. 23:1201

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Bluebook (online)
81 So. 3d 664, 2010 WL 4322985, Counsel Stack Legal Research, https://law.counselstack.com/opinion/clascliggins-v-rapides-parish-sch-bd-lactapp-2011.