Kern Health Systems v. Allied Management Group Investigation Unit CA2/7s

CourtCalifornia Court of Appeal
DecidedApril 25, 2016
DocketB258326
StatusUnpublished

This text of Kern Health Systems v. Allied Management Group Investigation Unit CA2/7s (Kern Health Systems v. Allied Management Group Investigation Unit CA2/7s) is published on Counsel Stack Legal Research, covering California Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kern Health Systems v. Allied Management Group Investigation Unit CA2/7s, (Cal. Ct. App. 2016).

Opinion

Filed 4/25/16 Kern Health Systems v. Allied Management Group Investigation Unit CA2/7s NOT TO BE PUBLISHED IN THE OFFICIAL REPORTS California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions not certified for publication or ordered published, except as specified by rule 8.1115(b). This opinion has not been certified for publication or ordered published for purposes of rule 8.1115.

IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

SECOND APPELLATE DISTRICT

DIVISION SEVEN

KERN HEALTH SYSTEMS, B258326

Plaintiff and Respondent, (Los Angeles County Super. Ct. No. PC052482) v.

ALLIED MANAGEMENT GROUP SPECIAL INVESTION UNIT, INC., et al.,

Defendants and Appellants.

APPEAL from a judgment and postjudgment order of the Superior Court of Los Angeles County, Melvin Sandvig, Judge. Reversed and remanded with directions. Raines Feldman, Richard J. Decker and Robert M. Shore, for Defendant and Appellant Allied Management Group Special Investigation Unit, Inc. Sheppard Mullin Richter & Hampton, Robert J. Stumpf, Jr.; Law Offices of Joseph K. Johnson, and Joseph K. Johnson, for Defendants and Appellants Dennis Demetre and Lori Lewis. Dowling Aaron, Lynne Thaxter Brown; Clifford & Brown, Stephen T. Clifford and T. Mark Smith for Plaintiff and Respondent, Kern Health Systems. ____________________ Kern Health Systems, a managed care health plan, sued Allied Management Group Special Investigation Unit, Inc. (AMG) and its former owners and principal officers, Dennis Demetre and Lori Lewis, on several related contract and tort theories based on their allegedly false promises and deficient performance during an audit engagement. Following a seven-week trial the jury returned a special verdict form finding against Kern Health on its causes of action for breach of contract, professional negligence, intentional misrepresentation and unfair business practices. As to Kern Health’s remaining cause of action for negligent misrepresentation, the jury found that AMG, Demetre and Lewis honestly believed and had reasonable grounds for believing the truth of their false representations. Nonetheless, the trial court ruled there was an inconsistency in the special verdict form and the jury’s intent was to find AMG, Demetre and Lewis liable and for Kern Health to recover $1.38 million on that claim. AMG, Demetre and Lewis appeal from the judgment in favor of Kern Health based on the court’s interpretation of the special verdict form and from its denial of their motion to vacate the judgment. They also appeal the denial of their motion for attorney fees pursuant to Civil Code section 1717 (section 1717) as the prevailing parties on Kern Health’s breach of contract claim. We reverse the judgment and the postjudgment order denying attorney fees and remand with instructions to the trial court to enter a new judgment in favor of AMG, Demetre and Lewis and to award them reasonable attorney fees after determining the extent to which, if at all, the fees incurred may be apportioned between the contract and noncontract-based causes of action. FACTUAL AND PROCEDURAL BACKGROUND 1. The Retention of AMG Kern Health, a public agency and the largest health care plan in Kern County, receives payments from the State of California on a per member, per month basis (capitation) and compensates medical providers for their services to its members, who are typically Medi-Cal patients or participants in the Healthy Families program. Many providers in Kern Health’s service area have contracts with Kern Health, which specify

2 fixed rates for various services. Providers who do not have contracts with Kern Health, however, are obligated to provide emergency care to all patients without regard to their ability to pay and are then compensated at the lower of the Medi-Cal or billed rates. Compensation under the Medi-Cal rates vary based on the provider’s level of service to the patient. In late 2007 two groups of emergency room physicians asserted Kern Health had underpaid them for their services to the plan’s members for several years by “down- coding” their claims, that is, paying them at a rate utilizing a medical code lower (and thus less costly) than they had submitted and believed was warranted. Based on a review of medical records provided with the claims for payment, in contrast, Kern Health had concluded the physicians were reporting higher levels of services than warranted by the actual services provided (“up-coding”). Kern Health settled with one of the two groups; the second group filed a lawsuit against Kern Health in May 2008. As the dispute with the emergency room physicians continued, Kern Health contacted AMG and ultimately retained it to review medical records and claims data for the two groups for the period 2004-2007 and to determine, based on its audit, whether Kern Health’s position regarding up-coding was correct. The parties’ Consulting Service Agreement/Emergency Claims Review, dated April 28, 2008, stated AMG would provide audit and consulting services as described in Attachment A to the contract, which contained a detailed listing of services and specified that compensation would be on a per hour basis for services provided, with hourly rates as set forth in the attachment. The contract also contained an attorney fee provision: “If a legally binding mediation does not resolve legal disputes, any action at law or in equity is necessary to enforce or interpret the terms of this Agreement, and the prevailing Party shall be entitled to reasonable attorney’s fees and costs in addition to any other relief to which such Party 1 may be legally due through adjudication.”

1 Although AMG prepared the Consulting Service Agreement, paragraph 8.8 provided, “This Agreement shall be considered drafted by both Client [Kern Health] and 3 2. Kern Health’s Dissatisfaction with AMG and Its Lawsuit for Breach of Contract, Fraud and Negligent Misrepresentation Between its retention and its final invoice on February 24, 2009, less than one year later, AMG billed Kern Health more than $7.4 million. Kern Health instructed AMG to stop work although its audit was not yet finished. Work resumed in the fall of that year when AMG agreed to complete its analysis at its own expense. Because of staff shortages, AMG hired a separate company to undertake the project. In its report the new company concluded AMG incorrectly coded more than 80 percent of the claims it had reviewed and, rather than overpaying the emergency room physicians, Kern Health in fact owed them money. Kern Health ultimately settled the lawsuit with the second group of physicians. In addition to the apparent errors in its work product and concern as to the large amount it had billed, a number of disputes arose between Kern Health, on the one hand, and AMG, Demetre, its chief executive officer, and Lewis, its chief operations officer, on the other hand. One issue was whether AMG stated in an initial telephone call with Kern Health that it had previously provided expert testimony and whether it had agreed to do so for Kern Health without a separate agreement addressed to expert witness services. A second issue was whether AMG had suggested conducting its audit through a random sampling procedure, rather than comprehensively testing all claims the Kern Health medical directors had down-coded. A third dispute concerned the qualifications and experience of the AMG coders who would be used in the project. In August 2011 Kern Health filed a complaint and in August 2012 the operative 2 first amended complaint against AMG for breach of the Consulting Service Agreement

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Kern Health Systems v. Allied Management Group Investigation Unit CA2/7s, Counsel Stack Legal Research, https://law.counselstack.com/opinion/kern-health-systems-v-allied-management-group-investigation-unit-ca27s-calctapp-2016.