Jolley v. BLUESHIELD

220 P.3d 1264
Court of Appeals of Washington·Decided December 8, 2009·No. 38061-7-II·Published·Cited by 1 cases

Opinion

220 P.3d 1264 (2009)
153 Wash.App. 434

Timothy B. JOLLEY, M.D., Appellant,
v.
Regence BLUESHIELD, Respondent.

No. 38061-7-II.

Court of Appeals of Washington, Division 2.

December 8, 2009.

*1265 Edward R. Coulson, Foster Pepper PLLC, Kelly Ann Lonergan, Attorney at Law, Seattle, WA, for Appellant.

Stephania Camp Denton, Mills Meyers Swartling, Seattle, WA, for Respondent.

PUBLISHED OPINION

BRIDGEWATER, P.J.

¶ 1 Dr. Timothy B. Jolley appeals the Pierce County Superior Court's grant of summary judgment, dismissing his claim that Regence BlueShield (Regence) failed to provide him with a fair review after Regence terminated him as a health care provider. Dr. Jolley also appeals the summary judgment dismissal of his claim under the Washington Consumer Protection Act (CPA), chapter 19.86 RCW. We hold that Regence provided Jolley a fair review and his CPA claim fails. We affirm.

FACTS

¶ 2 Dr. Jolley is a pediatrician in Puyallup, Washington. In 1999, Dr. Jolley and Regence *1266 entered into a practitioner agreement under which Dr. Jolley provided services for Regence health care subscribers. The agreement provided for a two-phase dispute resolution process. WAC 284-43-320(11) requires a provision for dispute resolution.[1]

¶ 3 The dispute resolution provision applicable to Regence providers requires that the provider first exhaust the Regence internal appeal process, which itself has two stages. In the level one appeal, the provider submits a written request for reconsideration of the adverse decision, giving a detailed description of the issues in dispute and any evidence or documentation supporting the provider's position. The level one appeal committee is a panel of other Regence providers, medical management representatives, and administrative personnel.

¶ 4 If the provider is not satisfied with the level one appeal, the provider can submit a written request for an in-person meeting for a level two appeal. The provider may submit additional, pertinent information supporting the provider's perspective. The level two appeal committee is a panel of Regence medical management, a chief medical officer, one or two medical directors, the vice president of provider network management, a legal representative, the assistant vice president of health care services, the manager of credentialing, and administrative personnel. If the provider disagrees with the resolution of the internal appeal process, the provider may demand arbitration.

¶ 5 In 2000, the parties amended the practitioner agreement to satisfy WAC 284-43-322, which provided that no process for dispute resolution arising out of a participating provider contract will be fair under RCW 48.43.055 unless it includes a formal process for dispute resolution and provides at least 30 days after the action giving rise to the complaint to initiate the dispute resolution process. WAC 284-43-322(1), (3). Carriers cannot require alternative dispute resolution to the exclusion of judicial remedies, although they can require it before judicial remedies. WAC 284-43-322(4). Under RCW 48.43.055, health carriers must file with the insurance commission their procedures for review and adjudication of complaints initiated by health care providers. "Procedures filed under [RCW 48.43.055] shall provide a fair review for consideration of complaints." RCW 48.43.055.

¶ 6 The amended agreement included three provisions addressing termination. The first is an at-will provision.[2]

The parties agree that they are contracting at will. Notwithstanding any written or oral representations to the contrary, either party may terminate this Agreement at any time and for any reason upon sixty (60) days written notice to the other party. The terminating party has sole discretion to determine whether a reason exists for termination and whether that reason justifies termination. When the Company terminates this Agreement, the Company will provide the Provider Appeals Process for the Practitioner to obtain the Company's reconsideration of the bases for its decision, but the Company retains sole and ultimate discretion to decide whether a reason exists and justifies termination.

I CPat 81.

¶ 7 The second termination provision provides:

*1267 This Agreement shall terminate immediately upon the suspension, revocation or nullification of the Practitioner's license to practice medicine in the state(s) where the Practitioner practices. It shall also terminate immediately in the event the Practitioner is convicted of a felony or is expelled or suspended from the Medicare or Medicaid programs.

I CPat 82.

¶ 8 The third provision involving termination states:

For and in consideration of the parties' agreeing to enter into this agreement it is agreed and acknowledged by the parties that ability to contract with the other is a privilege and not a right.
The Practitioner agrees that if he or she does not meet the Company's Credentialing criteria at any time, including during the Recredentialing process, this Agreement may be immediately terminated at the Company's option, and the Practitioner shall have no right to be a participating provider with the Company.
I CP at 82. Regence's credentialing criteria include the following:
To be eligible for participation, practitioners must meet and maintain the following criteria[:]
....
5. The practitioner's professional State license, registration or certification in any State must be current and free of any informal or formal disciplinary action(s) (i.e. restriction, probation, limitation or condition) relating to the practitioner's clinical conduct.
III CP at 494.

¶ 9 On October 16, 2003, the Washington State Department of Health Medical Quality Assurance Commission (MQAC) issued a statement of charges against Dr. Jolley, alleging that he had ongoing sexual relationships with several of his patients' mothers.

¶ 10 The statement of charges indicated that MQAC had previously charged Dr. Jolley with similar improper actions in the late 1980s and early 1990s and suspended his license for five years. MQAC agreed to stay that suspension if Dr. Jolley agreed to conditions on his license. Such conditions included requiring him to have a female chaperone accompany him in the presence of female patients and participating in therapy. The statement of charges indicates that MQAC reinstated Dr. Jolley's license in full in 1992, after determining that Dr. Jolley complied with the conditions.

¶ 11 On October 20, 2003, MQAC again suspended Dr. Jolley's license to practice medicine. On October 24, 2003, the trial court granted a 30-day stay of Dr. Jolley's suspension, subject to several conditions. The conditions included that Dr.

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