Financial Review Services, Inc. v. Prudential Insurance Co. of America

50 S.W.3d 495, 1998 Tex. App. LEXIS 5835, 1998 WL 1749995
CourtCourt of Appeals of Texas
DecidedSeptember 10, 1998
Docket14-96-01121-CV
StatusPublished
Cited by11 cases

This text of 50 S.W.3d 495 (Financial Review Services, Inc. v. Prudential Insurance Co. of America) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Financial Review Services, Inc. v. Prudential Insurance Co. of America, 50 S.W.3d 495, 1998 Tex. App. LEXIS 5835, 1998 WL 1749995 (Tex. Ct. App. 1998).

Opinions

MAJORITY OPINION

FOWLER, Justice.

Appellant, Financial Review Services (FRS), sued appellee, The Prudential Insurance Company of America, for breach of contract and tortious interference with contractual and business relationships. A partial summary judgment against FRS was followed by a directed verdict at trial, resulting in a take-nothing judgment in favor of Prudential on all claims. FRS appeals, raising three points of error. We affirm the partial summary judgment, concluding that Prudential owed no duty to FRS to pay any claims, including those at issue in this lawsuit, and affirm the trial court’s directed verdict on FRS’s breach of contract claim, concluding that FRS failed to present probative evidence that Prudential breached an agreement. We reverse and remand FRS’s tortious interference claims not disposed of in the summary judgment, because we conclude FRS presented some evidence to support these claims.

Background

FRS went to trial with two causes of action: tortious interference with business and contractual relations and breach of contract. The tortious interference claim had five components: (1) Prudential refused to pay the claims on its insureds; (2) Prudential maligned FRS to its insureds and HCA personnel; (3) Prudential harassed HCA representatives with sham audits and unreasonable, bad faith demands and pressure tactics; (4) “Prudential triggered patient complaints by uselessly stirring up patients under pretexts adopted with no justification;” and (5) Prudential started false rumors about FRS which Prudential knew (or should have known) would reach — and intended to reach— HCA management. Regarding the contract claim, FRS claimed that FRS and Prudential reached an agreement that an audit of some of FRS’s work would govern whether Prudential would pay the remainder of FRS’s bills. The following facts, plus some additional facts related throughout the remainder of the opinion, form the basis for our conclusions on these issues.

FRS is in the business of auditing hospital bills — after the initial bills have been paid — to determine whether additional amounts are owed for services and supplies that were not initially billed. FRS contracts with hospitals to perform these services in exchange for 50% of all collected “late charge bills.” The principals of FRS are its president, Mike Lewis, and its chief financial officer, Sheryl Kapella, who is a nurse. Kapella hired and trained other nurses to work for FRS auditing the bills of its hospital clients. In June 1991, FRS entered into two six-month contracts with hospitals affiliated with Hospital Corporation of America (HCA) — Woman’s Hospital of Texas and HCA Medical Center Hospital — known collectively as the HCA Center for Health Excellence (CHE).1 The contracts were executed by Mike Lewis and [500]*500John Gilbert, chief financial officer of the hospitals. Under these two contracts, FRS was appointed as the hospitals’ agent to identify, evaluate, bill and collect for services rendered at the hospitals. In January 1992, the contracts were renewed for another six-month period. Before this dispute arose, FRS received payments totaling well over $1 million on the two CHE contracts. In June 1992, FRS entered into an identical six-month contract with another HCA hospital, Rio Grande Regional Hospital.

Prudential, a large medical insurer, was asked to approve for payment some of the bills for which FRS had determined that additional amounts were owed. The dispute at issue in this case centers around a batch of approximately two hundred claims from Woman’s Hospital that FRS submitted in bulk to Prudential in the fall of 1991. In response to the FRS late charge bills, Prudential sent form letters, known as explanations of benefits (EOB), to its insureds to advise the covered persons of the status and disposition of the claims. Prudential later sent follow-up letters to its insureds. Prudential also communicated with Gilbert, who had included a letter with the billing stating that the patients had not been billed for the expenses charged. Prudential advised him that it required that the patient first be billed and considered financially liable for the expenses before it could give further consideration to the claims.

Prudential initially denied the claims and sought additional documentation, including the complete medical records for the patients. To resolve the disputed claims, Connie Clark and Liz Allen, Prudential employees, conducted an audit of ten randomly selected sample claims out of ninety claims.2 While the audit was pending, Clark put a hold on payment of these remaining ninety late charge claims.

•Allen conducted an on-site audit at Woman’s Hospital on April 27, 1992. Ka-pella was also present at the audit. Prudential asserts Allen was unable to complete the audit because Woman’s Hospital denied her access to the hospital’s charge master, the computerized listing of prices for a hospital’s services and supplies. Without the charge master, Allen could not determine whether the billed amounts were calculated by the hospital or FRS.3 In addition, Prudential complains it was not able to obtain the hospital’s charging protocols to determine what was included in a particular hospital charge. When the charge master was made available to Prudential in June 1992, the auditors conducted a second on-site audit over several days. They discovered FRS billed for items not included in the hospital’s charge master, and it had instead used its own charge master. The hospital used “packaged pricing” or “level charges” for many items, and Prudential claimed FRS improperly billed for items that had been previously included in the hospital’s origi[501]*501nal bills.4 FRS also billed separately for nursing, and Prudential took the position that nursing charges had been previously included in room and board charges. Prudential also maintained that those matters not listed as separate charges on the hospital’s charge master could not be charged to its insureds. As a result of the audit, Prudential reached two important conclusions. First, FRS’s late charge claims were not supported by hospital documentation and second, it had made a net overpayment rather than the substantial underpayment claimed by FRS. Based on these conclusions, Prudential ultimately rejected all ninety remaining claims and, thereafter, the HCA hospitals terminated their relationships with FRS. FRS believed Prudential caused the termination, but Prudential disagreed.

Prudential asserts that HCA terminated the relationships with FRS based on patient and physician complaints made to the hospitals’ business office. For example, Wanda Morris, patient account manager for Woman’s Hospital, testified she received daily calls from patients who were confused as to why they had received a bill two years after their hospital stay, when they thought the bill had been paid. She testified the volume of complaints resulted in an undue burden on her staff. In addition, the record shows complaints to the hospital by patients insured by other companies and patient complaints to the Better Business Bureau.

Judith Novak, the chief executive officer for CHE, first learned of patient eom-plaints in March 1992. Novak testified that (a) the complaints disrupted the hospital, (b) the staff in the business office was unable to do their work, and (c) both patients and physicians were upset. She first met with Gilbert, who had negotiated and signed the contracts with FRS, to try to resolve the issue.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Amanda Culbertson v. Pat Lykos
790 F.3d 608 (Fifth Circuit, 2015)
Hansen v. Jackson
519 S.W.3d 614 (Court of Appeals of Texas, 2014)
Jackson v. State Farm Mutual Automobile Insurance
600 S.E.2d 346 (West Virginia Supreme Court, 2004)
Roof Systems, Inc. v. Johns-Manville Corp.
130 S.W.3d 430 (Court of Appeals of Texas, 2004)
Shaw v. Maddox Metal Works, Inc.
73 S.W.3d 472 (Court of Appeals of Texas, 2002)
Financial Review Services, Inc. v. Prudential Insurance Co. of America
50 S.W.3d 495 (Court of Appeals of Texas, 1998)

Cite This Page — Counsel Stack

Bluebook (online)
50 S.W.3d 495, 1998 Tex. App. LEXIS 5835, 1998 WL 1749995, Counsel Stack Legal Research, https://law.counselstack.com/opinion/financial-review-services-inc-v-prudential-insurance-co-of-america-texapp-1998.