Poole v. Guy Hopkins Construction Co.

177 So. 3d 142, 15 La.App. 3 Cir. 284, 2015 La. App. LEXIS 2089, 2015 WL 6446976
CourtLouisiana Court of Appeal
DecidedOctober 21, 2015
DocketNo. WCA 15-284
StatusPublished
Cited by2 cases

This text of 177 So. 3d 142 (Poole v. Guy Hopkins Construction Co.) 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
Poole v. Guy Hopkins Construction Co., 177 So. 3d 142, 15 La.App. 3 Cir. 284, 2015 La. App. LEXIS 2089, 2015 WL 6446976 (La. Ct. App. 2015).

Opinion

SAVOIE, Judge.

1 ,This is one of two workers’ compensation matters now before us involving an identical dispute between a health care provider and an employer/workers’ compensation insurer over reimbursement for physician-dispensed medication provided in connection with the employee’s authorized office visits with his treating physician. The two matters were tried together, but never consolidated, and they were appealed separately.1

After trial, the workers’ compensation judge (WCJ) limited the health care provider’s reimbursement for the medication to $750.00 under La.R.S. 23:1142, after finding that the medication was not authorized. The WCJ also denied the health care provider’s claim for penalties and attorney fees.

For the following reasons, we amend the judgment to award reimbursement for the medication in the full amount charged, reverse the judgment in part, and award the health care provider penalties and attorney fees.

FACTUAL AND PROCEDURAL BACKGROUND

The facts in this case are largely undisputed. On April 10, 2003, Charles Poole was injured in the course and scope of his employment with Guy Hopkins Construction, Inc. (Guy Hopkins). According to the WCJ’s ruling, LUBA Casualty Insurance Company (LUBA)2 was Guy Hopkins’ workers’ compensation self-insured fund, and later insurer. Mr. Poole was treated by Dr. John Cobb with Lafayette Bone and Joint Clinic for work-related injuries.

On June 5, 2008, LUBA sent Dr. Cobb a letter indicating generally that it would no longer provide reimbursement for medications that Dr. Cobb dispensed | ¡.to workers’ compensation claimants. The letter asked Dr. Cobb to direct patients to a retail pharmacy to fill their prescriptions. LUBA submits that it made a business decision to no longer reimburse for physician-dispensed medication because it is significantly more expensive under the workers’ compensation fee schedule than the [144]*144same medication obtained from a retail pharmacy.

LUBA also submits that it contracted ■with a Pharmacy Benefits Manager (PBM), and that the PBM sent a prescription card to all LUBA workers’ compensation claimants with a letter encouraging, but not requiring, them to use the card for drugs prescribed by an authorized workers’ compensation physician. LUBA further admits that it did not notify Mr. Poole that it would no longer pay for physician-dispensed medication.

Simone Clark testified on behalf of Lafayette' Bone and Joint Clinic and indicated that prior to June 5, 2008, LUBA had paid over $750.00 for treatment rendered to Mr. Poole. According to Sandy Guidry, a billing supervisor for medication dispensed at Lafayette Bone and Joint Clinic, prescription medication for injured workers was distributed at the time the injured worker came in for an office visit.

On the following dates, Dr. Cobb and/or Lafayette Bone and Joint Clinic dispensed medication to Mr. Poole in connection with his office visits with Dr. Cobb: July 10, 2008; August 13, 2008; September 22, 2008; October 29, 2008; and December 23, 2008. The billed charges for this medication totaled $1,359.65. The parties stipulated that the billed charges were at or below the rate set forth by the workers’ compensation fee schedule.

LUBA authorized and paid for Mr. Poole’s office visits with Dr. Cobb after June 5, 2008. However, LUBA denied the health care provider’s claims for ^reimbursement for Mr. Poole’s medication, referring to the June 5, 2008 letter. According to LUBA, Mr. Poole was authorized to take the medication that had been prescribed by Dr. Cobb, and the medication was reasonable and necessary, but Dr. Cobb and/or Lafayette Bone and Joint Clinic were not authorized to dispense the medication.

On November 3, 2008, Lafayette Bone and Joint Clinic submitted a Disputed Claim for Compensation against Guy Hopkins and LUBA seeking reimbursement for the medication dispensed to Mr. Poole in 2008, as well as penalties and attorney fees for arbitrary and capricious handling of the claim.

On February 18, 2014, the WCJ granted Lafayette Bone and Joint Clinic’s unopposed motion for leave to file an amended disputed claim form reflecting the health care provider as “John E. Cobb, MD, APMC.”

Trial of the matter was held on February 24, 2014. On November 25, 2014, the WCJ rendered judgment in favor of Lafayette Bone and Joint Clinic and against Guy Hopkins, but limited reimbursement for the medication to $750.00 under La.R.S. 23:1142, after finding that the medication was unauthorized.

In her written reasons for ruling, the WCJ indicated her reliance on Bordelon v. Lafayette Consolidated Government, 14-304 (La.App. 3 Cir. 10/1/14), 149 So.3d 421, writ denied, 14-2296 (La.2/6/15), 158 So.3d 816; Rebel Distributors Corp., Inc. v. LUBA Workers’ Comp., 12-909 (La.App. 3 Cir. 4/2/14), 137 So.3d 91; and Sigler v. Rand, 04-1138 (La.App. 3 Cir. 12/29/04), 896 So.2d 189, writ denied, 05-278 (La.4/1/05), 897 So.2d 611.

John E. Cobb, MD, APMC appealed.

[ASSIGNMENTS OF ERROR

On appeal, the health care provider asserts the following assignments of error:

1. The trial court committed manifest error insofar as it failed to order defendant to pay for all prescription medications which LUBA admits were compensable, reasonable, nec[145]*145essary, and were pre-authorized as part of the treatment of the injured worker, and which were billed at rates set by the fee schedule promulgated pursuant to the workers^] compensation act.
2. The trial court committed manifest error insofar as it failed [to] award penalties and attorney fees for complete non-payment of any amount of the prescription medications before the trial of the above[-]captioned matter.

DISCUSSION

Standard of Review:

The Louisiana Supreme Court has set forth the following standard for reviewing a trial court’s findings of fact:

A court of appeal may not set aside a trial court’s or a jury’s finding of fact in the absence of “manifest error” or unless it is “clearly wrong.” [There is] a two-part test for the reversal of a fact-finder’s determinations:
1) The appellate court must find from the record that a reasonable factual basis does not exist for the finding of the trial court, and
2) [T]the appellate court must further determine that the record establishes that the finding is clearly wrong (manifestly erroneous).
This test dictates that a reviewing court must do more than simply review the record for some evidence which supports or controverts the trial court’s finding. The reviewing court must review the record in its entirety to determine whether the trial court’s finding was clearly wrong or manifestly erroneous.
Nevertheless, the issue to be resolved by a reviewing court is not whether the trier of fact was right or wrong, but whether the factfinder’s conclusion was a reasonable one. Even though an appellate court may feel its own evaluations and inferences are more | ^reasonable than the factfinder’s, reasonable evaluations of credibility and reasonable inferences of fact should not be disturbed upon review where conflict exists in the testimony.

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Bluebook (online)
177 So. 3d 142, 15 La.App. 3 Cir. 284, 2015 La. App. LEXIS 2089, 2015 WL 6446976, Counsel Stack Legal Research, https://law.counselstack.com/opinion/poole-v-guy-hopkins-construction-co-lactapp-2015.