St. Francis Physician Network, Inc. v. Rush Prudential HMO, Inc. (In Re St. Francis Physician Network, Inc.)

213 B.R. 710, 1997 Bankr. LEXIS 1707, 1997 WL 662452
CourtUnited States Bankruptcy Court, N.D. Illinois
DecidedOctober 10, 1997
Docket19-04863
StatusPublished
Cited by20 cases

This text of 213 B.R. 710 (St. Francis Physician Network, Inc. v. Rush Prudential HMO, Inc. (In Re St. Francis Physician Network, Inc.)) is published on Counsel Stack Legal Research, covering United States Bankruptcy Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
St. Francis Physician Network, Inc. v. Rush Prudential HMO, Inc. (In Re St. Francis Physician Network, Inc.), 213 B.R. 710, 1997 Bankr. LEXIS 1707, 1997 WL 662452 (Ill. 1997).

Opinion

AMENDED MEMORANDUM OPINION

RONALD BARLIANT, Bankruptcy Judge.

INTRODUCTION

This dispute arises out of a contract between the Debtor and a health maintenance organization, Rush Prudential HMO, Inc. (“Rush”). The contract required the Debtor to provide medical services to enrollees of the Rush HMO. The Debtor was required to pay the health care providers and in return Rush would pay the Debtor a monthly fee, known in the industry as a capitation fee. When the Debtor failed to pay the medical providers, Rush began withholding a portion of the capitation fees due the Debtor. This practice started pre-petition and continued after this bankruptcy case was filed.

Rush argues that pursuant to the contract, it is entitled to pay the health care providers directly and deduct such amounts from the capitation fees. Rush argues that this contractual right is consistent with theories of set off and recoupment. The parties have filed cross motions for summary judgment on these legal issues. For the reasons set forth below, this Court finds that, with a limited *713 exception, Rush has no right of set off and no right of recoupment.

UNCONTESTED FACTS

The Debtor is an independent practice association of doctors that provides health care services under agreements with health maintenance organizations (“HMO”) and insurance companies. The Debtor provided such services to Rush Prudential HMO, Inc. (“Rush”) enrollees under a Medical Provider Agreement dated July 1, 1995. The Medical Provider Agreement requires 1) the Debtor to provide medical services to Rush enroll-ees, 2) the Debtor to pay the medical professional who provides the service, and 3) Rush to pay the Debtor a monthly “capitation” fee.

The Debtor arranged for the provision of services by its members. But in emergencies, services had to be provided by other medical professionals. There are, therefore, two classes of health service providers: network and “out-of-network.” Network providers are those who had agreements with the Debtor, which, among other things, prohibited them from billing the patients directly, although many apparently breached that agreement. The out-of-network providers are those who had no agreement with the Debtor.

Rush had an obligation to its enrollees to provide them with services at no cost to them. The Medical Provider Agreement, in § 6.24, provided a mechanism by which Rush could protect its enrollees from claims:

[The Debtor] agrees to pay all claims in a timely manner, but in no event later than 45 days after receipt of the bill. In the event that [the Debtor] fails to make payment within 45 days after receipt of a bill, [the Debtor] authorizes, but may not require, [Rush] to pay such claim on its behalf, and further authorizes [Rush] to deduct such payment from any amount due to [the Debtor].

Under that provision, Rush could pay bills “on [the Debtor’s] behalf’ even if Rush itself, or its enrollees, had no obligation to the provider. (That was the case with respect to network providers, who had agreed not to bill the patients.)

Beginning in September, 1996, the Debtor failed to pay some claims. The providers then billed the enrollees, who complained to Rush. Rush began withholding payment of the capitation fees and paying providers directly. From October, 1996 to April 15, 1997, (the bankruptcy was filed in November) Rush paid $74,557.40 to health care providers who had rendered services to Rush enrollees, and deducted that amount from capitation fees due the Debtor. All the payments (except a nominal sum) were for services rendered before the Debtor filed the petition commencing this bankruptcy case. But Rush deducted all but about $3,900 of those amounts from capitation fees earned after that filing.

The Debtor filed for chapter 11 relief on November 20, 1996. In December, Rush filed a motion to compel the Debtor to assume or reject the Medical Provider Agreement, and for relief from the automatic stay to set off amounts it paid health care providers from capitation fees due the Debtor and to terminate the agreement. This Court denied the requested relief, except that it modified the automatic stay to allow Rush to exercise an “at will” termination provision. Rush terminated the Medical Provider Agreement effective May 5,1997.

The Debtor filed this adversary proceeding and a Motion for Temporary and Preliminary Injunctive Relief against Rush, requesting an order that Rush turn over all capitation fees due and refrain from withholding fees in the future. On February 14, 1997, this Court entered an order granting the Debtor’s motion and requiring Rush to turn over capitation fees for October, 1996 through January, 1997. Rush was, however, permitted to withhold “up to $23,600 from the payment due pursuant to paragraph 1 of this Order, subject to Debtor’s verification of enrollment and payment, pursuant to [Rush’s] assertion that such amounts were paid to medical providers) prior to the hearing on Debtor’s Motion.” Rush made the required payment, less $17,029.58, which it had paid to health care. providers for pre-petition services. Rush had made most of those payments ($13,129) post-petition, and the balance *714 ($3,900) within 90 days before the filing of the bankruptcy petition.

After the February order, the Debtor continued to render medical care to Rush enroll-ees until the contract terminated in May, 1997. Rush withheld an additional $57,542.82 from the monthly capitation fees as follows: 1

CAPITATION AMOUNT MONTH FEE DUE WITHHELD

February $30,535.87 $18,520.87

March $27,578.52 $19,797.50

April $27,035.07 $19,224.45

Rush used the withheld funds to pay health care providers directly. With the exception of two payments totaling $69.30, all those payments were for services provided pre-petition.

DISCUSSION

Issues

The parties have filed cross motions for summary judgment concerning Rush’s right to withhold a portion of the capitation fees due the Debtor to pay health care providers directly. Those motions bring into focus the competition between strong policies at the heart of this matter. Rush simply wants to enforce its contract as it is written. It argues that “the only real dispute can be whether [Rush] is entitled to exercise its contractual rights under the Agreement to pay providers and deduct such payments from capitation fees payable thereunder.” Rush Reply Memorandum 2. It cites the holding in Butner v. United States, 440 U.S. 48, 55, 99 S.Ct. 914, 918, 59 L.Ed.2d 136 (1979), that “[property interests are created and defined by state law. Unless some federal interest requires a different result, there is no reason why such interests should be analyzed differently simply because an interested party is involved in a bankruptcy proceeding.”

The Debtor, on the other hand, argues that federal interests, as reflected in the bankruptcy code, do require a different analysis. Equality of distribution to similarly situated creditors and debtor rehabilitation are bedrock bankruptcy policies.

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Cite This Page — Counsel Stack

Bluebook (online)
213 B.R. 710, 1997 Bankr. LEXIS 1707, 1997 WL 662452, Counsel Stack Legal Research, https://law.counselstack.com/opinion/st-francis-physician-network-inc-v-rush-prudential-hmo-inc-in-re-st-ilnb-1997.