Musculoskeletal Institute of Louisiana v. McDonald's Corp.

48 So. 3d 359, 2010 La. App. LEXIS 1267, 2010 WL 3666998
CourtLouisiana Court of Appeal
DecidedSeptember 22, 2010
DocketNos. 45,628-WCA, 45,629-WCA
StatusPublished
Cited by4 cases

This text of 48 So. 3d 359 (Musculoskeletal Institute of Louisiana v. McDonald's Corp.) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Musculoskeletal Institute of Louisiana v. McDonald's Corp., 48 So. 3d 359, 2010 La. App. LEXIS 1267, 2010 WL 3666998 (La. Ct. App. 2010).

Opinion

GASKINS, J.

11 These consolidated appeals involve a dispute between the same health care provider and two different employers concerning underpayment of workers’ compensation benefits. The health care provider asserts that it was reimbursed at a rate below the Louisiana workers’ compensation medical reimbursement schedule because of preferred provider organization (“PPO”) network agreements. The workers’ compensation judge (“WCJ”) ruled in favor of the health care provider in both cases; he also awarded penalties and attorney fees against the employers. The employer in No. 45,629-WCA appealed. The health care provider appealed in both cases, contending that the attorney fees awarded by the WCJ were abusively low; it also answered the appeal in No. 45,629-WCA, seeking additional attorney fees for defending the judgment in that case. For the reasons set forth below, we affirm the judgment in No. 45,628-WCA. As to the judgment in No. 45,629-WCA, we affirm the WCJ’s ruling on the merits; however, we reverse the portion of the judgment awarding penalties and attorney fees.

FACTS

Musculoskeletal Institute of Louisiana, A.P.M.C. (“Musculoskeletal”), is a group of physicians who specialize in the areas of orthopedics, neurosurgery and pain management. It rendered necessary and reasonable medical treatment, which was approved by their employers, to two employees who were injured in the course and scope of their respective employments. Al Pertuz (No. 45,628-WCA) was an employee of McDonald’s Corporation who was injured in December 2006. Carl Peacock (No. 45,629-WCA) was an employee of Rollins, Inc.; he was injured in 12September 2005. Both employers were self-insured for workers’ compensation and used a third-party administrator, Gallagher Bassett, Inc., to administer the workers’ compensation claims. In both cases, Musculoskeletal was reimbursed at a rate below the reimbursement schedule. The charges were first reduced to the allowed amount under the reimbursement schedule, then reduced another 10 percent through the use of a PPO contract that Musculoskeletal had had with First Health Group Corporation.

[362]*362In August 2008, Musculoskeletal filed disputed claims for compensation -with the Office of Workers’ Compensation (“OWC”) in both cases. It asserted underpayment/late payment of medical bills and sought penalties and attorney fees for arbitrary and capricious handling of the claim. McDonald’s filed an answer and several exceptions (including one to subject matter jurisdiction); it also asserted affirmative defenses. Rollins also filed an answer and several exceptions. In February 2009, Rollins’ exceptions of no cause of action and prescription were denied.

The two cases were tried together in September 2009. Testimony was given by Lee McClendon, the former chief executive officer of Musculoskeletal, as to the company’s billing procedures for patients. He explained the difference in the handling of workers’ compensation patients and regular group health patients. In particular, he addressed the complexity of the bureaucratic procedures for obtaining approval to treat workers’ compensation patients. He stated that while a regular group health patient presents an identification card, Musculoskeletal has never received |ssuch a card in any workers’ compensation setting. Additionally, he testified that they have never received a written notice in a workers’ compensation setting prior to treating an injured worker stating that their charges will be discounted through some kind of network. According to McClendon, Musculoskeletal’s charges are above the fee schedule.

McClendon also testified that Musculo-skeletal had a contract with First Health PPO but that it was cancelled several years ago; First Health wanted to pay a reimbursement that was inadequate given the workload. However, Musculoskeletal still receives payments reflecting that the payor had applied discounts pursuant to the First Health PPO. He admitted that at one time Musculoskeletal had entered into an agreement with Willis-Knighton physician hospital organization (“PHO”), that Willis-Knighton PHO contracted with First Health, and that Musculoskeletal was bound to the terms of the PHO. However, he also testified that when Musculoskeletal entered into a direct contract with First Health in 2002, it replaced Musculoskele-tal’s participation in the contract that First Health had with the Willis-Knighton PHO.

Among other evidence admitted were deposition excerpts from Emil Bravo of Gallagher Bassett, the third-party administrator for both employers. He testified that ID cards were not issued for workers’ compensation; also, they did not issue any written notice containing the PPO networks on it to the providers in lieu of a card.

On December 8, 2009, the WCJ signed written judgments with reasons in which he ruled in favor of Musculoskeletal in both cases. The |4WCJ found that Muscu-loskeletal’s claims against the employers were based solely on its obligation to Mus-culoskeletal under the Louisiana Workers’ Compensation Act (“LWCA”). Under La. R.S. 23:1208, the employer was required to reimburse Musculoskeletal the lesser of its billed charges or the amount set forth in the reimbursement schedule. However, Musculoskeletal’s charges were improperly reduced a second time through the use of the PPO contract that Musculoskeletal had with Health Group Corporation and that this discounting was in violation of La. R.S. 28:1033. The WCJ further found that the employers failed to provide the statutorily required notice under La. R.S. 40:2203.1 (the Louisiana Preferred Provider Organization Act or PPOA) to Musculo-skeletal and that failure made their use of a PPO contract discount that Musculoskel-etal had entered into with First Health unenforceable by the employers.

[363]*363In the Pertuz case, the WCJ awarded reimbursement of the underpaid charges in the amount of $40.60, with legal interest from the date the underpayments were due. Concluding that McDonald’s failed to make an adequate and reasonable investigation of Musculoskeletal’s disputed claim for compensation benefits, the WCJ awarded a statutory penalty of $2,000 and attorney fees of $1,500. Likewise, in the Peacock case, the WCJ awarded $31.60 in underpaid charges, with legal interest from the date the underpayments were due, as well as a statutory penalty of $2,000 and attorney fees of $1,500 against Rollins. Costs were assessed against the employers.

| Jn No. 45,628-WCA, McDonald’s did not appeal the WCJ’s ruling. However, Musculoskeletal appealed, asserting that the award of attorney fees was abusively low.

In No. 45,629-WCA, Rollins appealed suspensively from the WCJ’s ruling. Mus-culoskeletal appealed devolutively, contending that the attorney fees awarded by the WCJ were abusively low. Additionally, Musculoskeletal answered the appeal, seeking additional attorney fees for defending the judgment against Rollins’ appeal.

VALIDITY OF PPO DISCOUNT

AGREEMENTS

Rollins argues that the WCJ incorrectly held that the LWCA does not allow contracting or discounting below the reimbursement schedule. Since various statutes provide for the maximum reimbursement, it contends that it must be permissible for the parties to agree to a lesser reimbursement rate. Musculoskel-etal, on the other hand, maintains that the PPO discounts taken by Rollins were not authorized under and/or were expressly prohibited by the LWCA.

Statutory law

La. R.S. 23:1038 provides:

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Bluebook (online)
48 So. 3d 359, 2010 La. App. LEXIS 1267, 2010 WL 3666998, Counsel Stack Legal Research, https://law.counselstack.com/opinion/musculoskeletal-institute-of-louisiana-v-mcdonalds-corp-lactapp-2010.