Kettering Health Network v. Caresource

2017 Ohio 1193
CourtOhio Court of Appeals
DecidedMarch 31, 2017
Docket27233
StatusPublished
Cited by8 cases

This text of 2017 Ohio 1193 (Kettering Health Network v. Caresource) is published on Counsel Stack Legal Research, covering Ohio Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kettering Health Network v. Caresource, 2017 Ohio 1193 (Ohio Ct. App. 2017).

Opinion

[Cite as Kettering Health Network v. Caresource, 2017-Ohio-1193.]

IN THE COURT OF APPEALS OF OHIO SECOND APPELLATE DISTRICT MONTGOMERY COUNTY

KETTERING HEALTH NETWORK, : et al. : : Appellate Case No. 27233 Plaintiffs-Appellees : : Trial Court Case Nos. 2013-CV-2016 v. : Trial Court Case Nos. 2015-CV-4512 : CARESOURCE : (Civil Appeal from : Common Pleas Court) Defendant-Appellee :

...........

OPINION

Rendered on the 31st day of March, 2017.

GARY J. LEPPLA, Atty. Reg. No. 0005541, and PHILIP J. LEPPLA, Atty. Reg. No. 0089075, Leppla Associates, Ltd., 2100 South Patterson Boulevard, Dayton, Ohio 45409 Attorneys for Plaintiffs-Appellees

JEFFREY A. LIPPS, Atty. Reg. No. 0005541, JOEL E. SECHLER, Atty. Reg. No. 0076320, Carpenter Lipps & Leland, LLP, 280 North High Street, Columbus, Ohio 43215 And MARK R. CHILSON, Atty. Reg. No. 0016511, CareSource, 230 North Main Street, Dayton, Ohio 45402 Attorneys for Defendant-Appellant

.............

HALL, P.J. -2-

{¶ 1} CareSource appeals the trial court’s overruling of its application to vacate an

arbitration award in favor of Kettering Health Network. Finding no error, we affirm.

I. Background

{¶ 2} CareSource is a managed care payer that administers Medicaid payments

and services for certain Ohio Medicaid beneficiaries under a contract with the Ohio

Department of Job and Family Services (ODJFS). ODJFS pays CareSource a set amount

per beneficiary, and CareSource in turn contracts with health-care providers, like

Kettering, for the health care services. The plan and provider establish the terms of

service and payment in a contract between them.

{¶ 3} CareSource and Kettering entered into such agreements, which required

Kettering to provide medical care and services to CareSource beneficiaries in exchange

for payment from CareSource. Two of these agreements are relevant in this case. The

first one went into effect in 1987, and the parties entered into a replacement in 2005.

Among the services covered by these two agreements are unlisted outpatient surgical

procedures (UOSPs). In the 1987 Agreement, for these UOSPs, CareSource agreed to

pay Kettering “compensation that is equivalent to the amount that Hospital would have

received if the State of Ohio had not contracted with the DAHP [CareSource’s former

name] to administer the Medicaid program.” 1987 Agreement, Section 3.7. The 2005

Agreement provides that CareSource will pay Kettering “100% of the current prevailing

Ohio Medicaid fee schedule.” 2005 Agreement, Attachment A.1.1 The relevant line in the

1 The 2005 Agreement provides that Kettering is to be compensated for UOSPs “as set forth in applicable Attachments attached hereto.” 2005 Agreement, Article 4.2. -3-

Medicaid fee schedule says that unlisted healthcare services are paid at “ ‘69% of

Charges.’ ” Interim Award, 5.

{¶ 4} Since 1987, for every UOSP that Kettering provided to a CareSource

member, Kettering submitted an invoice that broke down the charges into several line

items. One line item was the charge for the UOSP itself, and the other line items were

charges for related services. CareSource paid Kettering for the UOSP line item only,

paying Kettering nothing for the related services. Kettering alleges that CareSource

should have paid it for each line item. There are 588 UOSP underpayment claims at issue,

made between 2001 and 2011, arising under both the 1987 Agreement and the 2005

Agreement. In 2013, Kettering filed a complaint and a motion to compel partial arbitration.

CareSource responded by filing a motion to compel arbitration.

{¶ 5} The 1987 and 2005 Agreements each contains a dispute resolution

provision. Section 4.1 of the 1987 Agreement says that “to resolve disputes, including fee

disputes,” the parties will use a particular grievance procedure, described in an

attachment to the agreement. And Article 7.11 of the 2005 Agreement says that “[t]he

parties shall resolve complaints, grievances or disputes arising between parties * * * in

accordance with the dispute resolution procedures described in the arbitration

proceedings of the American Health Lawyers Association [AHLA].” The 2005 Agreement

also contains an integration clause, in Article 7.6, which pertinently states, “This

Agreement, Attachments, and Amendments hereto contain all the terms and conditions

agreed upon by the parties and supersedes all other agreements, express or implied,

regarding the subject matter hereof.” The question before the trial court was whether

Article 7.11 supersedes Section 4.1. The court concluded that it does, so it ordered the -4-

parties to arbitrate all of Kettering’s underpayment claims. Kettering appealed, and we

affirmed. We concluded that “Article 7.6 of the 2005 Agreement is reasonably susceptible

to CareSource’s interpretation that its effect is retroactive such that Article 7.11 of the

2005 Agreement supersedes the 1987 Agreement.” Kettering Health Network v.

Caresource, 2d Dist. Montgomery No. 25928, 2014-Ohio-956, ¶ 39.

{¶ 6} Kettering’s underpayment claims then went to arbitration under the auspices

of the AHLA, and an arbitration hearing was held over several days in March 2015. On

June 29, 2015, the arbitrator issued an “Interim Award” to Kettering ordering CareSource

to pay damages of $2,061,8032. The arbitrator then ordered the parties to submit post-

hearing briefs on the issue of prejudgment interest. Once the interest issue is resolved,

wrote the arbitrator, “a Final Award will be entered.” Interim Award, 34. On August 27,

2015, the arbitrator issued a “Final Award,” which “incorporates by reference * * * the

merits determinations of the Interim Award * * *, adds the decision on pre-award interest,

makes the costs allocation, and determines a total amount owed.” Final Award, 1. The

arbitrator awarded Kettering prejudgment interest totaling $756,660.

{¶ 7} On August 13, a couple of weeks before the arbitrator issued the Final Award,

CareSource notified the arbitrator and Kettering that it was terminating arbitration.

CareSource argued that the deadline for a final award was July 3 and that the arbitrator

was in violation of AHLA Rules. And on August 14, CareSource filed an application to

vacate the Interim Award. On August 27, Kettering filed an application to confirm the Final

Award. The cases were consolidated. Thereafter, CareSource filed an application to

2 This figure is rounded, as all figures are in this opinion. -5-

vacate the Final Award too. On August 22, 2016, the trial court denied the applications to

vacate and granted the application to confirm.

{¶ 8} CareSource appealed.

II. Analysis

{¶ 9} CareSource assigns four errors to the trial court. Each argues a particular

basis for why the court erred by not vacating the arbitration awards. The first assignment

of error argues that the Final Award was untimely and is invalid under the AHLA Rules.

The second argues that the awards conflict with provisions in the parties’ agreements.

The third argues that the arbitrator misinterpreted Ohio course-of-performance law. And

the fourth assignment of error argues that the prejudgment-interest award conflicts with

the parties’ agreements and disregards Ohio’s Prompt Pay Act. Before getting to the

assignments of error, we discuss our standard of review and the scope of the arbitrator’s

power.

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