Pinnacle Rehabilitation Hospital v. Rivera-Villareal

2008 OK CIV APP 115, 215 P.3d 823, 2008 Okla. Civ. App. LEXIS 92
CourtCourt of Civil Appeals of Oklahoma
DecidedNovember 26, 2008
Docket105,741. Released for Publication by Order of the Court of Civil Appeals of Oklahoma, Division No. 3
StatusPublished
Cited by1 cases

This text of 2008 OK CIV APP 115 (Pinnacle Rehabilitation Hospital v. Rivera-Villareal) is published on Counsel Stack Legal Research, covering Court of Civil Appeals of Oklahoma primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Pinnacle Rehabilitation Hospital v. Rivera-Villareal, 2008 OK CIV APP 115, 215 P.3d 823, 2008 Okla. Civ. App. LEXIS 92 (Okla. Ct. App. 2008).

Opinion

DOUG GABBARD II, Presiding Judge.

T1 Petitioners, Pinnacle Rehabilitation Hospital 1 (Pinnacle) and Dr. Tanya Wash-burn (collectively, Providers) seek review of a workers' compensation court order denying recovery of attorney fees, costs, and prejudgment interest to Providers after they prevailed on their claim for payment for medical services provided to Claimant, Armando Rivera-Villareal. We sustain in part, reverse in part, and remand.

BACKGROUND

T2 In August 2004, Claimant, an oilfield worker, was injured as a result of a heat stroke while working for Longhorn Service Company (Employer). The next month, he filed a Form 3 seeking workers' compensation benefits. Shortly thereafter, Employer and its insurance carrier, CompSource Oklahoma (CompSource), filed a response admitting compensability and liability for Claimant's injury. A few months later, however, Employer/CompSource decided to contest compensability, and on March 4, 2005, filed an amended answer denying Claimant sustained an injury arising out of and in the course of his employment. Employer/Comp-Source also refused to pay Claimant's mounting medical bills.

T3 Nevertheless, Pinnacle and Washburn provided health services to Claimant almost continually from September 4, 2004, through April 5, 2005. Ultimately, Pinnacle submitted bills totaling $338,422.57, and Washburn submitted bills totaling $10,400. On March 8, 2005, Pinnacle filed its first Form 19 with the workers' compensation court seeking payment for a portion of the health costs incurred, and simultaneously moved for a trial. Thereafter, Claimant also moved to set for trial

T4 However, on April 4, 2005, Claimant, acting through a special guardian appointed by the district court, filed a Form 100 seeking an order dismissing his cause "with prejudice 2 in exchange for Employer/Comp-Source's payment to him of $240,000. 3 The court entered the dismissal order. Indisputably, this settlement was reached without the knowledge, consent, or consultation of Pinnacle or Washburn.

T5 Employer/CompSource continued to deny compensability of Claimant's injury. Trial on that issue occurred in March 2006. Providers presented Claimant's deposition testimony supporting his allegation of an on-the-job heat stroke in August 2004 that left him virtually incapacitated and in need of round-the-clock care. 4 Providers also presented medical reports from Claimant's treating physician and a medical expert supporting the claim. Employer's evidence consisted of a medical expert's report, dated March 17, 2005, opining that based on the expert's review of certain medical records and other information, Claimant's injury was not workrelated. 5 The hearing culminated in *826 an April 5, 2006, order by the workers' compensation court finding that Claimant sustained a compensable work-related injury to the body as a whole in the form of a heat stroke. 6 It reserved the Form 19 matters for future hearing.

T6 Employer/CompSource then submitted Providers' gross bills to an outside auditing firm which recommended paying Pinnacle $177,770.87 and Washburn $6,694.83. Checks in these amounts were sent to Providers in June 2006, leaving in dispute more than $160,000 as to Pinnacle and more than $3,500 as to Washburn. The trial court required the parties to submit Pinnacle and Washburn's bills to the court's medical services department for review pursuant to the Court Administrator's "Schedule of Medical and Hospital Fees" (Fee Schedule). That review resulted in the department's finding, in February 2007, that Pinnacle's "maximum allowable reimbursement" (MAR) under the Fee Schedule was $270,738.06 (an amount $92,967.19 more than already paid by Employer/CompSource, but $67,684.51 less than Pinnacle's total request), and that Wash-burn's MAR was $8,336.06 (an amount $1,641.23 more than already paid by Employer/CompSource, but $2,068.94 less than Washburn's total request). However, Employer/CompSource continued to deny further obligation for the services rendered by Providers.

T7 The matter proceeded to trial on the Form 19 in June 2007. Pinnacle's chief executive officer, Stacy Smith, testified that prior to initially admitting Claimant, Pinnacle obtained a "pre-certification number and authorization" from CompSource, and that CompSource also provided a claims examiner and case manager who participated in Claimant's care throughout his stay at Pinnacle. Smith also testified that CompSource was provided periodic interim bills from Pinnacle pursuant to CompSource's request, and that Pinnacle regularly conducts internal audits of its own invoices, including those related to Claimant, to assure that Pinnacle's charges are consistent with industry standards. However, Smith agreed that the bill submitted with Providers' Form 19 had not been reduced in accordance with the Fee Schedule's "stop loss" method of reimbursement, which the workers' compensation court's medical services department had applied. 7

T8 Also testifying was LaDonna Williams, bill review manager for Corvel Corporation, the independent auditing firm hired by Employer/CompSource to review Providers' charges. Williams explained that in auditing a bill Corvel essentially compares a particular facility's charges, described by means of DRG ("diagnosis related groups") codes, with those that are "usual and customary" in the facility's geographic area. For bills less than $50,000, Corvel uses the codes listed by the facility and audits based on the facility's own itemized description. For bills greater than $50,000, Corvel first enters each charge and description into a separate software program, performs the audit/comparison, and then applies the 20-percent reduction under the Fee Schedule's "stop loss 8

T9 On June 19, 2007, the trial court entered an order which: (1) overruled Employer/CompSource's objection to Washburn's charges, found that $8,336.06 of Washburn's charges were reasonable, and ordered Employer to pay Washburn an additional $1,641.23, bringing her total payment to the MAR under the fee schedule (but still less than Washburn's total request); and (2) *827 overruled, in part, Employer/CompSource's objection to Pinnacle's charges, found that $245,853.74 of Pinnacle's charges were reasonable, and ordered Employer to pay Pinnacle an additional $68,082.87. The total award to Pinnacle was $24,884.32 less than the MAR calculated by the court's medical services department, and $92,568.83 less than the total requested in Pinnacle's Form 19.

T10 Thereafter, Pinnacle and Washburn applied for attorney fees, costs, and prejudgment interest. Following a February 2008 hearing, the trial court denied Providers' application, finding that Providers were required by 85 0.8. Supp.2005 § 14(F)(5) to prevail "in full" on their claim in order to recover attorney fees, and that they had not done so. The court also found no party had acted unreasonably or in bad faith in pursuing or denying Claimant's claim, and that Providers were not entitled to attorney fees, costs, or interest.

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Bluebook (online)
2008 OK CIV APP 115, 215 P.3d 823, 2008 Okla. Civ. App. LEXIS 92, Counsel Stack Legal Research, https://law.counselstack.com/opinion/pinnacle-rehabilitation-hospital-v-rivera-villareal-oklacivapp-2008.