Quality Infusion Care, Inc. v. Health Care Service Corp.

224 S.W.3d 369, 2006 Tex. App. LEXIS 9002, 2006 WL 2974351
CourtCourt of Appeals of Texas
DecidedOctober 19, 2006
Docket01-05-00753-CV
StatusPublished
Cited by30 cases

This text of 224 S.W.3d 369 (Quality Infusion Care, Inc. v. Health Care Service Corp.) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Quality Infusion Care, Inc. v. Health Care Service Corp., 224 S.W.3d 369, 2006 Tex. App. LEXIS 9002, 2006 WL 2974351 (Tex. Ct. App. 2006).

Opinion

OPINION

JANE BLAND, Justice.

In this contract dispute, the trial court rendered judgment in favor of appellees, Health Care Service Corporation d/b/a Blue Cross and Blue Shield of Texas (“BCBSTX”) and Southwest Texas HMO, Inc. d/b/a HMO Blue Texas (“HMO Blue”), after a bench trial. Quality Infusion Care, Inc. (“QIC”) appeals, contending that the trial court misconstrued both the meaning of the contractual term “provider” and the payment provisions of the contract, and therefore erred in concluding that it— rather than appellees — breached the contract. QIC further contends the trial court erred in awarding appellees their attorney’s fees. In addition, QIC asserts the trial court erred in granting a no-evidence summary judgment for appellees on its claims for fraud, fraudulent inducement, negligent misrepresentation, and tortious interference with existing and prospective business relations. We modify the trial court’s judgment and affirm.

BACKGROUND

QIC provides infusion therapy services, such as chemotherapy, to patients who are seriously ill. In March 2002, QIC contracted with BCBSTX to provide home infusion therapy services to patients who are subscribers of various health insurance plans administered by BCBSTX and its affiliates, including HMO Blue. The contract, which became effective June 1, 2002, requires QIC to obtain precertification from BCBSTX before providing infusion therapy services to a particular subscriber. Following treatment, QIC must submit its claims for payment at the rates specified in an exhibit attached to the contract (the “Exhibit A rates”).

In May 2002, one month before the contract became effective, and again in July 2002, appellees advised QIC in writing that *373 they did not recognize QIC as a “network” provider. As a result, appellees refused, in many instances, to precertify QIC’s provision of infusion therapy services to subscribers whose health care coverage does not include “out-of-network” benefits. Though it failed to obtain precertification, QIC nonetheless administered treatment to several of these subscribers and subsequently submitted claims to appellees for payment. Following appellees’ refusal to pay, QIC brought suit, alleging fraud, fraudulent inducement, constructive fraud, negligent misrepresentation, tortious interference with existing and prospective business relations, breach of contract, and promissory estoppel.

In the meantime, as the result of an audit, appellees learned that they had overpaid several claims submitted by QIC. In accordance with a contractual provision requiring QIC to reimburse appellees for any overpayments, appellees tendered their reimbursement claim to QIC. Following QIC’s refusal to pay, appellees counterclaimed for breach of contract.

After granting appellees’ no-evidence summary judgment motion on QIC’s claims for fraud, fraudulent inducement, constructive fraud, negligent misrepresentation, and tortious interference with existing and prospective business relations, the trial court held a bench trial on QIC’s remaining claims for breach of contract and promissory estoppel. The parties submitted the case on an agreed stipulation of facts and stipulated exhibits. In pertinent part, the stipulation of facts provides as follows:

2.The only contract that is a subject of this cause became effective on June 1, 2002 and its termination was effective on June 6, 2003.... There are two slightly different versions of the contract attached to the Agreed Exhibit List as Exhibit 1 and Exhibit 1A. If the dispute between these two versions of the Contract should prove material to the Court’s decision, the evidence the Court can use to resolve that dispute is [found in certain exhibits].
3. ... QIC provided home infusion pharmaceuticals and home infusion therapy services under the Contract to patients who were covered under medical insurance plans administered by BCBSTX and HMO Blue.
4. The patients whose claims that are the subject of QIC’s only remaining cause of action for breach of the contract and the counterclaim of BCBSTX and HMO Blue are identified in the documents attached as Exhibits 2 and 3 to the Agreed Exhibit List.... The parties agree the Patient names, dates of service, codes, Exhibit A rates, billed charges, amounts paid, payment dates, and patient share figures in Exhibits 2 and 3 are true and correct.
5. Various hospitals such as Texas Childrens’ Hospital, doctors, and medical clinics referred the Patients to QIC with prescriptions for infusion pharmaceuticals and infusion therapy. QIC did make calls to obtain precertification from BCBSTX and HMO Blue to administer pharmaceuticals and infusion therapy to the Patients. In some instances BCBSTX and HMO Blue gave QIC pre-certification, and in some instances they refused to give precertification.
6. HMO Blue maintains a network of providers who provide services to HMO Blue patients. For HMO Blue patients who had no out-of network benefits, HMO Blue would usually not precertify services by providers that HMO Blue did not recognize as a provider within its network if there was a provider in the network that provided the same services. There were several home infusion therapy providers in HMO Blue’s *374 “Houston network.” Although the Contract refers to QIC as a “Provider,” HMO Blue did not recognize QIC as one of its “network” providers. In fact, QIC was advised in writing that it was not a “network” provider for the HMO Blue “Houston network” in May 2002 and again in July 2002.
7. BCBSTX also maintains a managed care “network” of providers in Houston for subscribers of its PPO plans. In some of these PPO plans, the subscribers have no out-of network benefits. For those BCBSTX PPO patients who had no out-of-network benefits, BCBSTX would usually not precertify services by providers that BCBSTX did not recognize as a provider within its Houston PPO network, if there was a provider in the network that provided the same services. There were several home infusion therapy providers in BCBSTX’s “Houston PPO network”. Although the Contract refers to QIC as a “Provider”, BCBSTX did not recognize QIC as one of its “network” providers. In fact, QIC was advised in writing that it was not a “network” provider for the BCBSTX “Houston PPO network” in May 2002 and again in July 2002.
8. HMO Blue did not give QIC pre-certification for its services that it provided to the following HMO Blue members: [patients are listed], because HMO Blue’s records showed that none of these HMO Blue members had “out-of network” benefits on the respective dates of service.... BCBSTX did not give QIC precertification for its services that it provided to the following BCBSTX PPO members: [patients are listed], because BCBSTX’s records showed that neither of these BCBSTX PPO members had “out-of-network” benefits on the respective dates of service ....
9. For the claims QIC submitted that are reflected on [the agreed exhibits], ... QIC administered the pharmaceuticals it billed for and provided the infusion therapy services it billed for, and those pharmaceuticals and services were administered as prescribed by the Patients’ referring doctor and were medically necessary.

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Bluebook (online)
224 S.W.3d 369, 2006 Tex. App. LEXIS 9002, 2006 WL 2974351, Counsel Stack Legal Research, https://law.counselstack.com/opinion/quality-infusion-care-inc-v-health-care-service-corp-texapp-2006.