Emergency Medical Care Facilities, P.C. v. BlueCross BlueShield of Tennessee, Inc.

CourtTennessee Supreme Court
DecidedApril 25, 2025
DocketM2021-00174-SC-R11-CV
StatusPublished

This text of Emergency Medical Care Facilities, P.C. v. BlueCross BlueShield of Tennessee, Inc. (Emergency Medical Care Facilities, P.C. v. BlueCross BlueShield of Tennessee, Inc.) is published on Counsel Stack Legal Research, covering Tennessee Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Emergency Medical Care Facilities, P.C. v. BlueCross BlueShield of Tennessee, Inc., (Tenn. 2025).

Opinion

04/25/2025

IN THE SUPREME COURT OF TENNESSEE AT NASHVILLE May 29, 2024 Session

EMERGENCY MEDICAL CARE FACILITIES, P.C. v. BLUECROSS BLUESHIELD OF TENNESSEE, INC., ET AL.

Appeal by Permission from the Court of Appeals Chancery Court for Davidson County No. 20-0885-BC Anne C. Martin, Chancellor ___________________________________

No. M2021-00174-SC-R11-CV ___________________________________

We granted review in this case to decide whether our collateral estoppel doctrine bars relitigation of a prior class certification denial which was affirmed on appeal. In 2014, Plaintiff Emergency Medical Care Facilities, P.C. filed a putative class action against Defendant BlueCross BlueShield of Tennessee, Inc. EMCF alleged that BCBST had breached various contracts with it and other similar entities by applying a cap on certain payments for medical services after an action by TennCare. The trial court denied class certification, and the Court of Appeals affirmed and remanded. EMCF subsequently voluntarily nonsuited its claims. After getting a favorable ruling in a separate lawsuit against TennCare, EMCF refiled its case against BCBST, again seeking class certification. The trial court held that collateral estoppel precluded relitigation of class certification, but the Court of Appeals reversed. We hold that the trial court got it right. In this case, the same plaintiff filed suit against the same defendant for the same claims on behalf of the same putative class based on the same common questions. Our collateral estoppel doctrine exists to prevent this type of second-chance relitigation. Certain decisions are final and binding, including when a trial court and appellate court conclude that a particular class cannot be certified. The plaintiff here is certainly entitled to have the merits of its substantive claims heard in its refiled action, but it does not get a do-over on class certification.

Tenn. R. App. P. 11 Appeal by Permission; Judgment of the Court of Appeals Reversed; Remanded to the Chancery Court

DWIGHT E. TARWATER, J., delivered the opinion of the Court, in which HOLLY KIRBY, C.J., JEFFREY S. BIVINS, ROGER A. PAGE, and SARAH K. CAMPBELL, JJ., joined. Gary C. Shockley and Caldwell G. Collins, Nashville, Tennessee, for the appellants, BlueCross BlueShield of Tennessee, Inc. and Volunteer State Health Plan, Inc.

Gregory S. Reynolds and Joshua S. Bolian, Nashville, Tennessee, for the appellee, Emergency Medical Care Facilities, P.C.

OPINION

I. FACTUAL AND PROCEDURAL HISTORY

This case is the latest in a line of claims filed by Plaintiff Emergency Medical Care Facilities, P.C. (“EMCF”) related to a TennCare cap on certain reimbursement payments to healthcare providers. EMCF—for the second time—is attempting to bring a class action against Defendant BlueCross BlueShield of Tennessee, Inc. (“BCBST”) regarding these capped payments on behalf of a broadly-defined class of plaintiffs. We are tasked with determining whether EMCF can make this repeated attempt at class certification.

EMCF is a professional corporation of physicians and other health care professionals who provide services to TennCare recipients in the emergency departments of various hospitals throughout Tennessee. Defendant BCBST is a non-profit corporation organized in Tennessee involved in health insurance, benefits administration, and related operations. Volunteer State Health Plan, Inc. (“VSHP”), a health maintenance organization licensed by the Tennessee Department of Commerce and Insurance, is a wholly owned subsidiary of Southern Diversified Business Services, Inc., which is itself a wholly owned subsidiary of BCBST. VSHP contracted with the State of Tennessee as a managed care organization (“MCO”) participating in TennCare and operating under the MCO plans BlueCare and TennCare Select.1

TennCare is our state’s Medicaid program, which is operated under an integrated, full-risk, managed-care model. TennCare Overview, Dep’t of Fin. & Admin. Div. of TennCare, https://www.tn.gov/tenncare/information-statistics/tenncare-overview.html (last visited Mar. 31, 2025). Services are covered by private health insurance companies that have contracted as MCOs with the Division of TennCare. Id.; Mandy Spears, Understanding Medicaid and TennCare, The Sycamore Institute (June 1, 2017), https://www.sycamoreinstitutetn.org/what-is-tenncare/. TennCare is considered an “at- risk” Medicaid program, meaning the State pays the MCOs a fixed amount per-member, per-month, and the MCOs bear the risk of any costs which exceed these payments. Emergency Med. Care Facilities P.C. v. BlueCross BlueShield of Tenn. Inc., No. W2017- 02211-COA-R3-CV, 2018 WL 6266529, at *1 (Tenn. Ct. App. Nov. 29, 2018) (“EMCF

1 For clarity, we will generally refer to BCBST and VSHP collectively as “BCBST.” -2- I”). The State also maintains the TennCare Select program, which is a fee-for-service program run by the State for certain narrow groups of citizens such as children in state custody. BCBST serves as a third-party administrator for TennCare Select but is not at financial risk.

The State and the MCOs enter into contracts known as “Contractor Risk Agreements,” which detail the mandatory benefits, network adequacy, program integrity, reporting, financial, and administrative requirements for the MCOs. See Tenn. Comp. R. & Regs. 1200-13-13-.01(72)(a), -.06, -.08(3)(f) (2025); TennCare Contracts, Dep’t of Fin. & Admin. Div. of TennCare, https://www.tn.gov/tenncare/information-statistics/tenncare- contracts.html (last visited Mar. 31, 2025). These Contractor Risk Agreements also specify certain terms to be included in contracts between the MCO and the physicians, hospitals, and providers within that MCO’s network. See TennCare Contracts, Dep’t of Fin. & Admin. Div. of TennCare, supra.

BCBST entered into such a contract with EMCF in October 2008. This “Group Practice Agreement” provided the duties and responsibilities of each party, including the services to be provided by EMCF’s physicians and the compensation to be paid by BCBST. The parties incorporated two additional documents into the Group Practice Agreement: the “BlueCare Attachment” and the “TennCare Select Amendment.” These documents are form agreements used by BCBST for all of its network providers who treat TennCare and TennCare Select patients. EMCF I, 2018 WL 6266529 at *1. The BlueCare Attachment and the TennCare Select Amendment each list fee schedules and specify that EMCF shall be compensated for provided services at the lesser of either the applicable fee schedule or billed charges. However, the Group Practice Agreement contains a provision (hereinafter the “applicable law provision”) stating that BCBST will pay EMCF according to all applicable “State or Federal laws or regulations.”

In July 2011, BCBST began to operate as if one such applicable state “law or regulation” changed. Effective that month, TennCare announced a $50.00 cap on the amount that entities could recover for non-emergency services provided in emergency departments. Emergency Med. Care Facilities, P.C. v. Div. of Tenncare, 671 S.W.3d 507, 511 (Tenn. 2023) (“EMCF II”). Rather than promulgating an emergency rule as first announced, TennCare instead “sent an email to all MCOs announcing that, ‘[f]or non- emergent [emergency-department] visits, professional claims that would otherwise have been reimbursed at rates higher than $50 will be paid at a rate of $50.’”2 Id.

2 As discussed infra, this Court held that TennCare’s implementation of the $50.00 cap was done without proper rulemaking. EMCF II, 671 S.W.3d at 520. -3- In response, BCBST, through VSHP, began capping such payments at $50.00 pursuant to the Group Practice Agreement’s applicable-law provision. EMCF I, 2018 WL 6266529, at *1.

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