KRUGER CLINIC ORTHOPAEDICS, LLC. v. Regence BlueShield

138 P.3d 936, 157 Wash. 2d 290
Washington Supreme Court·Decided July 13, 2006·No. 76719-0, 76886-2·Published·Cited by 16 cases

Opinion

138 P.3d 936 (2006)

KRUGER CLINIC ORTHOPAEDICS, LLC, a Washington limited liability company, Petitioner,
v.
REGENCE BLUESHIELD, a Washington corporation, Respondent.
Tacoma Orthopaedic Surgeons, Inc., a Washington corporation; Arthur J. Ozolin, M.D.; John D. Stewart, M.D.; Richard E. Gray, M.D.; John J. Jiganti, M.D.; Peter E. Krumins, M.D.; James J. Wyman, M.D.; Douglas M. Hassan, M.D.; Franciscan Medical Group, a Washington nonprofit corporation, Petitioners,
v.
Regence Blueshield, a Washington corporation, Respondent, and
The Regence Group, an Oregon corporation, Defendant.

No. 76719-0, 76886-2.

Supreme Court of Washington, En Banc.

Argued February 28, 2006.
Decided July 13, 2006.

*937 John Richard Creatura, James Walter Beck, Gordon Thomas Honeywell, Tacoma, Thomas Jeffrey Keane, Law Offices of Jeffrey Keane PLLC, Bellevue, for Petitioner.

David Donald Swartling, Stephania Camp Denton, Mills Meyers Swartling, Seattle, for Respondent.

Timothy Lee Ashcraft, Williams Kastner & Gibbs, Tacoma, for Amicus Curiae (Pierce County Medical Soc.).

Andrew Kevin Dolan, Seattle, for Amicus Curiae (Snohomish County Medical Soc.).

Elizabeth Christina Beusch, Atty. Generals Office Govt. Compliance, Olympia, for Amicus Curiae (Wash. State Ins. Com'r).

Andrew Kevin Dolan, Seattle, for Amicus Curiae (Wash. State Medical Ass'n).

Martin Lowell Ziontz, Seattle, for Amicus Curiae (Wash. State Podiatric Medical Ass'n).

Debra Leigh Williams Stephens, Bryan Patrick Harnetiaux, Spokane, for Amicus Curiae (Wash. State Trial Lawyers Assoc.).

OWENS, J.

¶ 1 Insurance carrier Regence BlueShield (Regence) provides its insureds with health care services on a prepaid basis through subscriber agreements. Regence contracts with health care providers who agree to serve Regence's insureds on a fee-for-service basis. At issue in these consolidated cases is the enforceability of the arbitration clauses in the provider agreements that Regence entered into with Kruger Clinic Orthopaedics (Kruger) and with Tacoma Orthopaedic Surgeons and others (collectively, the Tacoma Orthopaedic providers).

¶ 2 We conclude that the Federal Arbitration Act (FAA), 9 U.S.C. § 2, does not preempt RCW 48.43.055 and WAC 284-43-322(4), which prohibit health insurance carriers from requiring providers to engage in "alternative dispute resolution to the exclusion of judicial remedies." WAC 284-43-322(4) (emphasis added). We hold that, by permitting only limited judicial review of the arbitration decision, the arbitration provisions in both cases exclude "judicial remedies" in violation of the governing statute and regulation. We therefore invalidate the arbitration provisions in the provider agreements and reverse the Court of Appeals in both cases.

FACTS

¶ 3 Kruger. In April 1995, Kruger signed a "Participating Provider's Agreement" with Regence. Under the agreement, Kruger was required to accept payment for services at rates set by Regence outside the contract.[1] When Regence notified Kruger in early 2000 that Kruger would have to accept a reduction in pay rates, Kruger objected and questioned, in particular, Regence's practice of *938 paying other similarly situated providers at higher rates for the same services. A second dispute arose over Regence's refusal to reimburse Kruger for the cost of implant materials essential in certain surgeries. Kruger's informal efforts to resolve the underpayment issues failed.

¶ 4 On April 25, 2002, Kruger filed suit in Snohomish County Superior Court for breach of contract. Regence immediately moved to compel arbitration, based on the following provision:

In the event that any problem or dispute concerning the terms of this Agreement is not satisfactorily resolved, the COMPANY and the PROVIDER agree to arbitrate such problem or dispute. Such arbitration may be initiated by either party by making a written demand for arbitration on the other party. Within twenty days of that demand, the COMPANY and the PROVIDER shall confer to select a mutually agreeable arbitration [sic]. The arbitrator shall hold a hearing and decide the matter within thirty days thereafter. The arbitration shall be conducted pursuant to the rules of the American Arbitration Association then in effect unless agreed otherwise by the parties. The results of the arbitration shall be binding on both parties, and the parties agree that all determinations of the COMPANY shall be afforded deference, and the standards to be applied by the arbitrator shall be whether the COMPANY has acted arbitrarily and capriciously with the burden of proof being on the PROVIDER. Neither party subsequently shall commence an action to litigate the dispute.

Kruger Clerk's Papers (CP) at 59 (emphasis added). After the trial court denied Regence's motion to compel arbitration, Regence sought review in the Court of Appeals.

¶ 5 In a published decision filed September 20, 2004, Division One of the Court of Appeals reversed the trial court and held that the arbitration agreement was valid and enforceable. Specifically, the court determined that the FAA governed the issue of the arbitration provision's validity; that the arbitration provision was not procedurally unconscionable; and that, although the arbitration provision contained some substantively unconscionable terms,[2] those terms were severable, permitting enforceability of the remainder of the arbitration provision. Kruger Clinic Orthopaedics, L.L.C. v. Regence BlueShield, 123 Wash.App. 355, 98 P.3d 66 (2004).

¶ 6 Tacoma Orthopaedic. On March 22, 2002, the Tacoma Orthopaedic providers filed a class action complaint against Regence in Pierce County Superior Court, alleging that Regence had repeatedly breached its agreements with the Tacoma Orthopaedic providers by systematically reducing payments for services. The Tacoma Orthopaedic providers stated several causes of action, including breach of contract and breach of the implied covenant of good faith and fair dealing. Regence filed a motion to dismiss for failure to exhaust nonjudicial remedies and an alternative motion to compel arbitration. Regence's motions were based on the following provision:

Arbitration. Prior to seeking judicial remedy, any claims or disputes between the parties arising out of or relating to this Agreement that cannot be resolved through the internal appeals process shall be submitted to arbitration in accordance with the Commercial Arbitration rules and regulations of the American Arbitration Association then in effect. . . .
. . . .
. . . Judgment upon an award rendered by the arbitrator may be entered in any court having jurisdiction thereof.

Tacoma Orthopaedic CP at 255-56 (emphasis added). Holding as a matter of law that the arbitration clause was enforceable, the trial court granted Regence's motion to compel arbitration. The trial court denied the Tacoma Orthopaedic providers' subsequent motion to certify an arbitral class. The providers voluntarily dismissed all of their claims *

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KRUGER CLINIC ORTHOPAEDICS, LLC. v. Regence BlueShield, 138 P.3d 936, 157 Wash. 2d 290 (Wash. 2006).

138 P.3d 936 (KRUGER CLINIC ORTHOPAEDICS, LLC. v. Regence BlueShield) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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