Rehab Associates v. Blue Cross & Blue Shield of Massachusetts, Inc.

645 N.E.2d 1183, 38 Mass. App. Ct. 62, 1995 Mass. App. LEXIS 16
CourtMassachusetts Appeals Court
DecidedJanuary 25, 1995
DocketNo. 94-P-411
StatusPublished
Cited by1 cases

This text of 645 N.E.2d 1183 (Rehab Associates v. Blue Cross & Blue Shield of Massachusetts, Inc.) is published on Counsel Stack Legal Research, covering Massachusetts Appeals Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Rehab Associates v. Blue Cross & Blue Shield of Massachusetts, Inc., 645 N.E.2d 1183, 38 Mass. App. Ct. 62, 1995 Mass. App. LEXIS 16 (Mass. Ct. App. 1995).

Opinions

Fine, J.

In a complaint filed in the Superior Court on March 21, 1990, Rehab Associates of New England (RANE), sought a declaratory judgment, injunctive relief, and damages from Blue Cross & Blue Shield of Massachusetts, Inc. (Blue Cross), based upon Blue Cross’s refusal to enter into a contractual relationship with RANE. RANE relied on various statutes, which we shall discuss, and on G. L. [63]*63c. 93A. After a jury-waived trial, limited to the issue of liability, judgment was entered in favor of Blue Cross on all claims. On the unique and undisputed facts of this case, we conclude that Blue Cross had an obligation to enter into a contractual relationship with RANE. We therefore reverse the judgment and remand the case for an adjudication of damages.

We summarize the pertinent facts found by the Superior Court judge as well as some uncontested facts set forth in the record.

RANE operates a freestanding magnetic resonance imaging (MRI)1 facility, Merrimack Valley MRI, in Methuen which serves the Merrimack valley and southern New Hampshire. The facility has existed since 1987, but RANE assumed ownership in 1988. Under RANE’s ownership, the facility was licensed by the Department of Public Health (department) on February 28, 1989, and began to serve patients on March 1, 1989. As a part of the licensure process, the department issued a “determination of need”2 for new technology, as mandated by G. L. c. Ill, § 25C, in August 1988. The “determination of need” was subject to the condition that “[f]or Massachusetts residents, RANE shall not consider ability to pay or insurance status in the patient selection process.” Between its first day of operation and June 30, 1991, the facility conducted over 2,200 scans for the twenty percent of its patients who were Blue Cross subscribers. During this period, Blue Shield, and, after its merger with Blue Cross,3 Blue Cross provided reimbursement for the professional component of the MRI, that is, the interpretation of the scans by radiologists. The technical component, [64]*64i.e., the actual performance of the MRI scans, was not covered by the agreement and was not reimbursed.

Blue Cross is a nonprofit hospital service corporation regulated by the Rate Setting Commission and governed under G. L. c. 176A. It provides coverage for the technical aspect of hospital (and other institutional) services and procedures. Blue Cross offers participating diagnostic imaging facility (DIF-1) agreements for MRI facilities seeking reimbursement for the technical component of their scans. The rates of payment specified in the contracts must be approved by the Rate Setting Commission. G. L. c. 176A, § 5.

In the summer of 1989, RANE applied for a DIF-1 contract with Blue Cross. RANE completed Blue Cross’s written application, and a Blue Cross reviewer, Evelyn Callahan, conducted an on-site assessment of the facility. Blue Cross informed RANE that, to qualify for a DIF-1 contract, it would have to improve its medical necessity guidelines, its review procedures, and its clinical oversight committee. RANE complied, and, on August 16, 1989, Callahan acknowledged that it was in compliance with the requirements in the DIF-1 application. In October of 1989, however, Blue Cross suspended the processing of RANE’s application “pending review and/or resolution of issues Blue Cross and Blue Shield of Massachusetts, Inc. has with Northeast Rehab Hospital.” In a letter dated February 7, 1990, Blue Cross explained that it was not in its “best business interests” to accept RANE’s application.

The majority of the limited partners of RANE, including Dr. Howard Gardner, were also limited partners in a limited partnership that has a forty-nine percent interest in the Northeast Rehabilitation Hospital (hospital). Since 1988, Blue Cross had an ongoing dispute with the hospital administrators, including Dr. Gardner, about the hospital’s alleged failure to comply with Blue Cross’s utilization review program and medical necessity requirements. The amount in dispute was $1.7 million, and Blue Cross was required to spend $104,000 to review the matter. Blue Cross and the hospital settled the dispute in 1993. Blue Cross’s reason for [65]*65refusing to enter into a DIF-1 contract with RANE was to avoid further dealings with the principals of RANE, who are associated with the hospital.

The judge recognized that two statutes, G. L. c. 176A and G. L. c. 176B, bore on the issue before her. According to G. L. c. 176A, § 5, as appearing in St. 1969, c. 874, § 1: “In providing reimbursement for health services other than hospital services, any hospital service corporation may enter into contracts for the furnishing of such health services with providers thereof.” General Laws c. 176B, § 4, as appearing in St. 1988, c. 23, § 59, governing medical service corporations, has comparable language: “[a]ny medical service corporation may enter into contracts with . . . participating physicians, . . . and other providers of health services licensed under the laws of the commonwealth.” General Laws c. 176B, § 4, however, also contains a clause that requires: “no participating provider shall be denied the right to enter into any agreement with any medical service corporation by reason of any unfair or arbitrary discrimination.”

The judge concluded, first, that RANE had no statutory right to enter into a DIF-1 contract with Blue Cross. She determined that G. L. c. 176B, § 4, had no application to RANE’s claim as it applied only to professional providers and not to institutional providers. Relying on Goddard Memorial Hosp. v. Rate Setting Commn., 403 Mass. 736, 743-744 (1989), she interpreted G. L. c. 176A, § 5, as allowing a hospital service corporation such as Blue Cross to exercise discretion whether to enter into a contract with a particular provider. With respect to RANE’s G. L. c. 93A claim (and its corresponding claim under G. L. c. 176D, § 2), the judge concluded that Blue Cross’s refusal of a contract was not an unfair or deceptive act or practice. The refusal, for the purpose of avoiding further dealings with individuals with whom Blue Cross had problems in the past, was not, in her view, arbitrary or unreasonable. The judge found no merit in the contention that other statutes afforded RANE the right to relief.

[66]*661. RANE’s rights under G. L. c. 176A. RANE relies on this court’s interpretation of G. L. c. 176B, § 4, which governs contracts between corporations such as Blue Cross and physicians and other professional providers, to argue that Blue Cross cannot deny RANE a contract by reason of any unfair or arbitrary discrimination. See Blue Shield of Mass. v. Board of Review in the Div. of Ins., 22 Mass. App. Ct. 160, 167 (1986). RANE acknowledges, in its brief, that G. L. c. 176A, § 5, which governs contracts between nonprofit hospital service corporations and institutional providers, rather than G. L. c. 176B, § 4, is applicable to this dispute but argues that our interpretation of G. L. c. 176B, § 4, compels a similar reading of G. L. c. 176A, § 5.

The absence of an express prohibition against “unfair or arbitrary discrimination” in the award of contracts in G. L. c. 176A, § 5, distinguishes it from G. L. c. 176B, § 4. Indeed, the language authorizing Blue Cross to enter into contracts with institutional providers is permissive, and, in different contexts, it has been recognized that such relationships are “voluntary on both sides.” Commonwealth v. Mercy Hosp., 364 Mass.

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Related

Rehab Associates of New England v. Blue Cross & Blue Shield of Massachusetts, Inc.
659 N.E.2d 1183 (Massachusetts Supreme Judicial Court, 1996)

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Bluebook (online)
645 N.E.2d 1183, 38 Mass. App. Ct. 62, 1995 Mass. App. LEXIS 16, Counsel Stack Legal Research, https://law.counselstack.com/opinion/rehab-associates-v-blue-cross-blue-shield-of-massachusetts-inc-massappct-1995.