RESTON SURGERY CENTER v. CITY OF ALEXANDRIA and PMA Management Corp.

750 S.E.2d 214, 62 Va. App. 549, 2013 WL 6062534, 2013 Va. App. LEXIS 333
CourtCourt of Appeals of Virginia
DecidedNovember 19, 2013
Docket0022132
StatusPublished
Cited by8 cases

This text of 750 S.E.2d 214 (RESTON SURGERY CENTER v. CITY OF ALEXANDRIA and PMA Management Corp.) is published on Counsel Stack Legal Research, covering Court of Appeals of Virginia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
RESTON SURGERY CENTER v. CITY OF ALEXANDRIA and PMA Management Corp., 750 S.E.2d 214, 62 Va. App. 549, 2013 WL 6062534, 2013 Va. App. LEXIS 333 (Va. Ct. App. 2013).

Opinion

GLEN A. HUFF, Judge.

Reston Surgery Center (“appellant”), a medical provider, appeals the decision of the Virginia Workers’ Compensation Commission (“commission”) denying a claim for full reimbursement from the City of Alexandria (“employer”) and PMA Management Corp. (“PMA”) (collectively “appellee”) for medical treatment rendered to David Woodson, a police officer with employer, pursuant to a workers’ compensation claim. On appeal, appellant contends that the commission erred as follows:

1) in concluding that there was sufficient evidence to support the deputy commissioner’s finding that appellant had been properly enrolled as a participating provider in the Aetna Workers’ Compensation Access (“AWCA”) program;
2) in affirming the findings of fact and conclusions of law regarding notice and waiver contained in the deputy commissioner’s opinion, and in holding that appellant had accepted, acquiesced in, or waived any right to object to, its inclusion in the AWCA program; and
8) in affirming the findings of fact and conclusions of law contained in the deputy commissioner’s opinion as to whether PMA or employer were intended third-party beneficiaries of any agreement between appellant and Aetna, such that they would be entitled to apply reductions to the charges submitted by appellant.

For the following reasons, this Court reverses the decision of the commission and remands the case to the commission to enter judgment consistent with this holding.

*553 I. BACKGROUND

“On appeal from a decision of the Workers’ Compensation Commission, the evidence and all reasonable inferences that may be drawn from that evidence are viewed in the light most favorable to the party prevailing below.” Artis v. Ottenberg’s Bakers, Inc., 45 Va.App. 72, 83, 608 S.E.2d 512, 517 (2005) (en banc) (citing Clinchfield Coal Co. v. Reed, 40 Va.App. 69, 72, 577 S.E.2d 538, 539 (2003); Tomes v. James City (County of) Fire, 39 Va.App. 424, 429, 573 S.E.2d 312, 315 (2002)). So viewed, the evidence is as follows.

On July 6, 2011, appellant provided medical treatment to David Woodson (“Woodson”), a police officer with employer, for a compensable injury sustained during his employment. When the injury occurred, employer was self-insured for its workers’ compensation coverage and used a third-party administrator, PMA, to administer its workers’ compensation claims. After providing the necessary treatment, appellant sent a medical bill to employer in the amount of $27,937. Employer paid only $5,687.25 of the bill, stating that it had applied reductions to appellant’s charges pursuant to a contract between appellant and healthcare network company AWCA. 1 The purpose of the contract was to allow workers’ compensation claimants to access a broad range of providers to obtain medical care at a reduced rate.

On November 14, 2011, appellant applied for a hearing, seeking full reimbursement for its charges. Appellant asserted that it had never entered into a contract with AWCA or *554 any Aetna affiliate to provide workers’ compensation care at a reduced rate. In response, appellee referenced a Facilities Service Agreement (“FSA”) that appellant had entered into with Aetna Health, Inc. (“Aetna”). Section 2.5 of the FSA stated the following, in pertinent part, with regard to the introduction of new programs:

Facility [Reston Surgery Center] agrees to participate in the Plans and other health benefit products listed on the Product Participation Schedule attached hereto and made a part hereof. Company reserves the right to introduce and designate Facility’s participation in new Plans, Specialty Programs and products during the term of this Agreement and will provide Facility with written notice of such new Plans, Specialty Programs and products and the associated compensation.
Nothing herein shall require that Company identify, designate or include Facility as a preferred participant in any specific Plan, Specialty Program or product; provided, however, Facility shall accept compensation in accordance with this Agreement for the provision of any Covered Services to Members under a Plan, Specialty Program or product in which Facility has agreed to participate hereunder.
Company may sell, lease, transfer or otherwise convey to payers (other than Plan Sponsors) which do not compete with Company’s product offerings (e.g. workers’ compensation or automobile insurers) in the geographic area where Facility provides Covered Services, the benefits of this Agreement, including, without limitation, the Services and Compensation Schedule attached hereto, under the terms and conditions which will be communicated to Facility in each such case. For those programs and products which are not health benefit products (e.g. worker’s [sic] compensation or auto insurance), Facility shall have thirty (30) days from receipt of the aforementioned notice from Company to notify Company in writing if Facility elects not to participate in such product(s).

Section 9.1 of the FSA, governing amendments to the contract, stated as follows:

*555 This Agreement constitutes the entire understanding of the Parties hereto and no changes, amendments or alterations shall be effective unless signed by both Parties, except as expressly provided herein. Notwithstanding the foregoing, at Company’s discretion, Company may amend this Agreement upon written notice, by letter, newsletter, electronic mail or other media, to Facility to comply with applicable law or regulation, or any order or directive of any governmental agency.
Section 9.2 of the FSA, governing waivers, stated as follows: The waiver by either Party of a breach or violation of any provision of this Agreement shall not operate as or be construed to be a waiver of any subsequent breach thereof. To be effective, all waivers must be in writing and signed by an authorized officer of the Party to be charged. Facility waives any claims or cause of action for fraud in the inducement or execution related hereto.

Appellee argued that Section 2.5 allowed Aetna to introduce new programs and notify appellant of the opportunity to join such programs. To that end, appellee stated that Aetna had sent appellant an invitation letter in May of 2005 in which Aetna introduced the new AWCA program. The invitation letter informed appellant that it would automatically become enrolled as a participating provider in the AWCA program unless appellant opted out of the program by June 30, 2005.

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750 S.E.2d 214, 62 Va. App. 549, 2013 WL 6062534, 2013 Va. App. LEXIS 333, Counsel Stack Legal Research, https://law.counselstack.com/opinion/reston-surgery-center-v-city-of-alexandria-and-pma-management-corp-vactapp-2013.