Smallwood v. Central Peninsula General Hospital

151 P.3d 319, 2006 Alas. LEXIS 178, 2006 WL 3334113
CourtAlaska Supreme Court
DecidedNovember 17, 2006
DocketS-11585, S-11406
StatusPublished
Cited by27 cases

This text of 151 P.3d 319 (Smallwood v. Central Peninsula General Hospital) is published on Counsel Stack Legal Research, covering Alaska Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Smallwood v. Central Peninsula General Hospital, 151 P.3d 319, 2006 Alas. LEXIS 178, 2006 WL 3334113 (Ala. 2006).

Opinion

OPINION

EASTAUGH, Justice.

I. INTRODUCTION

The main question here is whether John L. Smallwood, a Medicaid recipient treated at Central Peninsula General Hospital, can sue the hospital to enforce Medicaid billing standards, particularly the “balance billing” prohibition that prevents billing for amounts (apart from authorized copayments) exceeding those reimbursable under Medicaid. We conclude that Smallwood is a third-party beneficiary of the provider agreement between *321 the hospital and the state; he can therefore sue to enforce the balance billing prohibition. We also conclude that he has a viable Unfair Trade Practices Act claim. And we conclude that the hospital’s counterclaim for unpaid services is not time-barred. We therefore affirm some of the superior court’s rulings and vacate others.

II. FACTS AND PROCEEDINGS

John L. Smallwood is a Medicaid recipient who receives medical care from Central Peninsula General Hospital. The hospital is operated by Central Peninsula General Hospital, Inc., a nonprofit Alaska corporation. The hospital provides medical care to Medicaid recipients under a “provider agreement” with the State of Alaska. 1 The state, through its contractor, First Health Services Corporation (First Health), reimburses providers like the hospital for some of the costs of the services provided to Medicaid recipients. 2

Smallwood received medical services and supplies at the hospital on multiple occasions between September 1998 and April 2000. As of January 2004 Smallwood continued to receive services from the hospital. Smallwood is expected to need frequent medical care from the hospital in the future.

The hospital sent Smallwood bills with a statement of balances due on his hospital accounts. Those balances totaled $743.46. The balances included both First Health-approved copay amounts and unauthorized charges. Smallwood did not pay the balances. In February 2001 the hospital assigned its claim for debt on Smallwood’s accounts to Alaska Financial Services, Inc. (AFS). AFS filed a small claims action against Smallwood on May 3, 2001.

After being informed of the small claims action, Smallwood, through counsel, notified the hospital that he believed the hospital was “balance billing” him in violation of state and federal law. Smallwood also alleged that because the charges were not itemized, he could not “ascertain whether the charges [were] legitimate and whether or not they [were] payable under Medicaid.”

In December 2001, while the small claims action was pending, Smallwood sued the hospital and AFS. Smallwood’s complaint alleged that the hospital had violated state and federal law and breached its provider agreement with the state by charging inappropriate cost-sharing amounts to Medicaid recipients. His complaint also alleged that the hospital’s billing practices violated the Alaska Unfair Trade Practices Act (UTPA). It also asserted procedural due process claims under the federal and state constitutions. Smallwood’s complaint requested: (1) a declaratory judgment holding that the hospital’s billing practices violated state and federal Medicaid law, the UTPA, and the Alaska and United States Constitutions; (2) an order enjoining the hospital from overcharging Medicaid recipients and using a billing method that creates confusion and misunderstanding; (3) an order enjoining AFS from further attempts to collect Smallwood’s debt; and (4) damages.

After Smallwood filed suit, Smallwood and AFS agreed to dismiss AFS’s small claims action. On or about March 8, 2002 AFS assigned its claim back to the hospital. The district court dismissed the small claims action on March 18, 2002.

The hospital answered Smallwood’s complaint, denying Smallwood’s claims, and counterclaimed for the unpaid balance on Smallwood’s hospital account. The hospital’s counterclaim adjusted the hospital’s calculation of the balance due, reducing it from $743.46 to $483.63. 3 Both parties moved for summary judgment. The superior court denied both parties’ motions.

Superior Court Judge Charles T. Huguelet presided over a bench trial in January 2004. *322 At trial, Smallwood asked the court to order the hospital to change its billing statement format to include itemization or notices of the authorized copayments to ensure that Medicaid recipients not be billed in excess of the authorized copayments in the future. In its February 2004 memorandum decision and order, the superior court found Smallwood liable for the authorized copayments, but enjoined the hospital from overcharging Small-wood in the future. As to Smallwood’s specific claims, the superior court first denied Smallwood relief under the UTPA, reasoning that balance billing is already prohibited under state and federal Medicaid law. Next, the court denied Smallwood’s request that the hospital be required to modify its billing procedures because the court thought it “doubtful” that Smallwood has a private right of action for such a claim. The court also thought it “doubtful” that the hospital had violated Smallwood’s procedural due process rights. The court did not address Small-wood’s statute of limitations defense and did not decide Smallwood’s claims for declaratory relief.

The superior court noted that the hospital changed its computerized billing system twice after Smallwood was overcharged. It also noted that the hospital admitted that its system will continue to automatically bill Medicaid recipients for charges rejected by the state.

In February 2004 the superior court entered judgment for the hospital and against Smallwood for the $483.63 in charges authorized by First Health. The court also ordered the hospital to “ensure that its invoices to Mr. Smallwood do not exceed the Medicaid authorized copays as designated by First Health.”

On March 18, 2004 the hospital filed proposed final judgments in the superior court. On the same day, Smallwood filed this appeal. After the parties disagreed about whether the superior court had issued a final judgment, we issued an order holding the appeal in abeyance until a final judgment was entered. In June 2004 the superior court entered a separate final judgment that (1) awarded the hospital $585.06 ($483.63 plus five percent annual interest) against Small-wood; (2) denied Smallwood’s request for injunctive and declaratory relief; (3) renewed its prior order that the hospital ensure that its future invoices to Smallwood not exceed the Medicaid-authorized copayments; and (4) concluded that neither party had prevailed on the issues of injunctive and declaratory relief. In a subsequent order, the superior court awarded the hospital attorney’s fees of $96.73 against Smallwood.

Smallwood appeals, arguing that he, as a Medicaid recipient, has a private right of action to sue Medicaid providers for over-billing him. He maintains that the superior court should have ordered the hospital to change its billing practices so that it would no longer overcharge Medicaid recipients. He argues that the superior court erred in rejecting his UTPA claim.

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Cite This Page — Counsel Stack

Bluebook (online)
151 P.3d 319, 2006 Alas. LEXIS 178, 2006 WL 3334113, Counsel Stack Legal Research, https://law.counselstack.com/opinion/smallwood-v-central-peninsula-general-hospital-alaska-2006.