PAINTER, Judge.
Defendant, First Health Group Corporation (First Health), appeals the trial court's grant of Plaintiff Class' motion for summary judgment and the denial of its own motion for summary judgment.
Plaintiffs, Drs. Clark A. Gunderson and Frank A. Lopez, Beutler-England Chiropractic Clinic (Beutler)and Southwest Louisiana Hospital Association d/b/a/ Lake Charles Memorial Hospital (LCMH) (Plaintiffs), brought this action for statutory damages against Defendants, F.A. Richard & Associates, Inc.; First Health Group Corporation (First Health); Focus Healthcare Management, Inc.; Cambridge Integrated Services Group, Inc.; National Loss Control Management, Inc.; and AIG Claim Services, Inc. (Defendants). In their petition, Plaintiffs stated that Defendants entered into contracts with them pursuant to the Preferred Provider Organization Act (hereinafter "PPOA"), La.R.S. 40:2201, et seq., which allowed Defendants' clients/payors to pay a discounted rate for health care services. They alleged that Defendants routinely reimbursed them in workers' compensation cases at the lower PPOA contracted rates, rather than at the higher mandated workers' compensation rates. In doing so, the healthcare providers claim that Defendants violated the provisions of La.R.S. 40:2203.1 by failing to provide them with prior notice of their intent to reimburse at the PPO rates, either by providing the injured worker with a PPO card or by providing thirty days' written notice of their intent to utilize an existing PPO agreement. La.R.S. 40:2203.1(B). Plaintiffs sought and received class certification.
Several Defendants entered into settlement agreements with Plaintiffs. In November 2008, Plaintiffs filed a motion for partial summary judgment as to their claims against First Health seeking payment of the minimum amount of damages mandated by La.R.S. 40:2203.1(G) for each violation indicated by First Health's records. In January 2009, First Health also filed a motion for summary judgment asserting that the choice of law clause included in the First Health provider agreements required application of California or Illinois law rather than the Louisiana Preferred Provider Statute, La.R.S. 40:2201, et seq.
Following proceedings outlined in Gunderson v. F.A. Richard & Assoc. Inc., 10-61 (La.App. 3 Cir.6/2/10), 40 So.3d 418, the trial court heard arguments on the motions. After the hearing, the trial court granted Plaintiffs' motion for partial summary judgment, awarded statutory damages, and denied First Health's motion. The court designated the judgment as final and immediately appealable pursuant to La.Code Civ.P. art. 1915(B). First Health appeals.
We first note that First Health has, with regard to several of its assignments of error, failed to provide references to the record volume and page number of the evidence to which it refers. First Health often refers in only the most general way to "evidence" it presented to the trial court without referring to the document or documents by name or pinpointing in which of the over seventy volumes of records and exhibits the document or documents can be found. Uniform Rules-Courts of Appeal 2-12.4 states that:
First Health asserts that its appeal of the trial court's denial of its motion to decertify the Plaintiff Class divested the trial court of jurisdiction to hear the motions for summary judgment. However, on review of the record, we cannot find any evidence that the appeal was perfected before the motions were heard.
Louisiana Code of Civil Procedure Article 2088(A) provides in pertinent part that:
While it appears from the transcript of the hearings that a motion for appeal was tendered to the trial court prior to the hearing on the motions for summary judgment, there is nothing of record to indicate that it was filed into the trial court record or signed before the hearings. We further note that First Health proceeded with the hearing on the motions for summary judgment without objection and without calling any lack of jurisdiction to the attention of the trial court. Therefore, we cannot conclude that the trial court heard the motions for summary judgment after it was divested of jurisdiction by filing and/or signing of the motion for appeal.
First Health argues that the trial court erred in denying its motion for summary judgment because most of First Health's provider agreements require application of California or Illinois law.
Louisiana Civil Code Article 3540 provides that: "All other issues of conventional obligations are governed by the law expressly chosen or clearly relied upon by the parties, except to the extent that law contravenes the public policy of the state whose law would otherwise be applicable under Article 3537."
La.R.S. 40:2203.1 provides in pertinent part that its notice provisions "shall apply to all preferred provider organization agreements that are applicable to medical services rendered in this state and to group purchasers as defined in this Part." The mandatory provisions of this statute evidence a strong public policy in favor of notice to health care providers that a PPO discount may be taken. First Health itself raises, in its appeal brief, the legislature's interest in preventing doctors from becoming victims of "silent" PPOs. While the law of another state may be applied to the contract in general, it may not be used to circumvent the notice requirement.
First Health asserts that the trial court erred in proceeding with the summary judgment where the U.S. District Court for the Western District of Louisiana had issued injunctions prohibiting the class representatives from pursuing their own claims against First Health. This issue has been disposed of in the companion case hereto, Gunderson v. F.A. Richard & Assoc., Inc., 10-61 (La.App. 3 Cir.6/2/10), 40 So.3d 418, wherein this court found that the injunctions did not present an impediment to the representatives acting on behalf of the class.
First Health argues that Plaintiffs' cause of action has prescribed because the appropriate prescriptive period is one year rather than the ten year prescriptive period applied by the trial court.
First Health asserts that the prescriptive period applicable to unfair trade practice claims is applicable to claims for violation of La.R.S. 40:2203.1(B). In support of this position, it cites Louisiana Attorney General Opinion 92-824, which addresses a claim under La.R.S. La.R.S. 40:2205(5)(c) which concerns a licensed physician denied access to a PPO without ever having the opportunity to submit an application. The attorney general found that the exclusion would be considered an unfair trade practice. "Opinions of the Attorney General are advisory only and not binding." McCaig v. Town of Gueydan, 01-0140, p. 3 (La.App. 3 Cir. 6/27/01), 788 So.2d 1283, 1285. Even should we find the opinion persuasive, it in no way suggests that every violation of the PPOA is an unfair trade practice and does not purport to extend the prescriptive period applicable to unfair trade practices to the entire PPOA. In Glod v. Baker, 04-1483, p. 11 (La.App. 3 Cir. 3/23/05), 899 So.2d 642, 653, cited by First Health in support of its position, this court explained that: "Conduct that violates the Unfair Trade Practices Act must involve fraud, misrepresentation, deception, or unethical conduct." Id. at 649-650 (citing JCD Mktg. Co. v. Bass Hotels & Resorts, Inc., 01-1096 (La.App. 4 Cir. 3/6/02), 812 So.2d 834).
The conduct alleged by Plaintiffs does not meet those criteria. Plaintiffs' petition alleges a cause of action for failure to comply with a statutory notice requirement.
The Louisiana PPOA does not set out a prescriptive period for bringing an action for violation of the notice requirement of La.R.S. 40:2203.1. This action is personal in nature as defined by La.Code Civ.P. art. 422, which states that:
Louisiana Civil Code Article 3499 states that personal actions are subject to a ten year prescriptive period "unless otherwise provided by legislation." Unlike the claim for past due wages considered by the court in Fishbein v. State ex rel. Louisiana State Univ. Health Sciences Ctr., 04-2482 (La.4/12/05), 898 So.2d 1260, the claim urged by Plaintiffs is not "otherwise provided by legislation." Accordingly, we find no error in the trial court's determination that a ten year prescriptive period applies to the action.
First Health asserts that the PPOA is unconstitutionally vague and that its damage provision violates due process. However, First Health has not followed the mandatory procedural steps required to dispute the constitutionality of a statute.
Rapides Parish Police Jury v. Catahoula Duck Club & Lodge L.L.C., 09-64, pp. 4-5 (La.App. 3 Cir. 11/18/09), 24 So.3d 988, 991.
These requirements have not been met. Therefore, we will not address the constitutionality of La.R.S. 40:2203.1.
First Health asserts that the trial court erred in granting Plaintiffs' motion for partial summary judgment on the issues of the applicability of La.R.S. 40:2203.1 to First Health and on the issue of partial, undisputed damages.
Fruge v. ONOB, Inc., 09-1028, p. 4 (La. App. 3 Cir. 3/10/10), 32 So.3d 1115, 1118.
Plaintiffs' motion was supported by the affidavits of a number of Plaintiffs, including at least two of the class representatives. The affidavits state that each was a health care provider who rendered services to patients under the Louisiana Workers' Compensation Act, that each was a member of the First Health PPO Network. Further, the affidavits further state that a PPO discount was applied to bills for treatment of various workers' compensation claimants, and that no notice was given of the discount, either via benefit card or via thirty day written notice. Additionally, a copy of the contract each had entered with the First Health PPO network was attached to the affidavit as an exhibit. Also included in support of the motion was the deposition of Greg Hale, designated representative of First Health. Hale stated that First Health is not a payor and that its activities involved network issues and bill review. He affirmed that no benefit cards were issued to workers' compensation clients. His testimony indicated that no notice was sent to workers' compensation health care providers since First Health did not consider La.R.S. 40:2203.1 applicable to workers's compensation. He noted that lists of benefit providers who could access the PPO network were sent to the health care providers at the time the contracts were entered but that thereafter, a provider manual listing the entities accessing the PPO network is available on their website and that no updates are sent to the health care providers. Also attached to the memorandum in support of the motion for partial summary
On appeal, First Health first asserts that the deposition of Shelly McCarthy was inadmissible because it was taken in another matter. However, even if the McCarthy deposition should not have been accepted into evidence, the Hale deposition sufficiently supports Plaintiffs' arguments.
Plaintiffs additionally relied on the deposition of Lester Langley, Jr., a certified public accountant. He affirmed that he used a spreadsheet prepared by First Health to perform calculations to ascertain PPO discounts taken. In his affidavit, he describes which records were removed from his calculations and notes that the total number of discounted accesses to Plaintiffs' services multiplied by $2,000.00 is $262,048,000.00.
Moreno Properties Two, L.L.C. v. Acadiana Inv. Group, L.L.C., 09-634, p. 5 (La. App. 3 Cir. 12/9/09), 25 So.3d 232, 236.
We find the evidence presented by Plaintiffs to be sufficient to make a prima facie case with regard to both the applicability of La.R.S. 40:2203.1 to First Health and the issue of partial damages. Accordingly, the burden shifts to First Health to show that issues of material fact remain as to these issues.
First Health asserts that the notice provisions of La.R.S. 40:2203.1 do not apply to workers' compensation patients. They argue that the legislative history of the PPO and the language of the act show that the notice provisions apply only to group health plan participants.
La.R.S. 40:2203.1 provides in pertinent part that:
Louisiana Civil Code Article 9 states that: "When a law is clear and unambiguous and its application does not lead to absurd consequences, the law shall be applied as written and no further interpretation may be made in search of the intent of the legislature." We find no ambiguity in the notice provisions of La.R.S. 40:2203.1. Therefore, we need not consider the intent of the legislature in applying the statute.
Further, as La.Civ.Code art. 11 tells us: "The words of a law must be given their generally prevailing meaning." Therefore, we find that, contrary to the arguments made by First Health, when La.R.S. 40:2203.1 states that it applies to "all preferred provider organization agreements that are applicable to medical services rendered in this state and to group purchasers as defined in this Part," it in fact, means all such agreements.
First Health next argues that it is exempt from the notice requirements because La.R.S. 40:2203.1(A) states that: "The provisions of this Section shall not apply to a group purchaser when providing health benefits through its own network or direct provider agreements or to such agreements of a group purchaser."
First Health asserts, in its appellate brief, that this provision applies to it because:
The evidence does not support the conclusion that First Health provides benefits through its own PPO network or through a direct provider agreement. Nothing of record suggests that First Health provides benefits at all. The affidavit of Greg Mast, Director of Decision Support with Coventry Workers' Compensation Services and a former employee of First Health, states that "First Health does not actually reimburse providers for medical services provided to injured workers." He states that payors, including insurance companies, third party administrators and self insureds, access the network and pay the bills. In other words, benefits are provided by employers and their insurers with First Health acting as a middleman. The cited provision of the Louisiana PPOA does not apply to entities such as First Health.
First Health next argues that it complied with the notice provisions of La.
Louisiana Revised Statutes 40:2203.1(B)(5) states:
We need not reach the question of who would be considered an entity accessing an existing group purchaser's contract, since we find that the notice cited by First Health is inadequate to fulfill the requirements of La.R.S. 40:2203.1(B).
The purpose of La.R.S. 40:2203.1(B)(5) is to give notice where no benefit card has been issued. However, the requirement is not a less stringent notification requirement. For the thirty day written notice to be effective, it must include everything which would be required by the statute of a benefit card. Anything less would defeat the purpose of the notice requirement. We are unable to find any evidence of record which fulfills the notice requirements of La.R.S. 40:2203.1 on behalf of First Health.
With regard to damages, First Health points to the affidavit of Greg Mast. He asserts in his deposition that Langley's deposition reflects a fundamental misunderstanding of what information is conveyed by the First Health spreadsheets showing discounts. He asserts that First Health neither sees the actual bill nor the explanation of benefits which would show discounts actually taken. Mast stated that the data in the spreadsheets analyzed by Langley does not reflect whether a discount or payment adjustment was taken and that such information can only be obtained through reference to the explanation of benefits issued by the payor. He states that: "Given the current litigation in the State of Louisiana and/or for other reasons, many clients have decided not to take contractually available discounts reported by First Health." He further states that the allowable amount field, used by Langley to obtain the PPO discount, may also reflect billing adjustments other than the PPO contractual discounts.
However, Mast's personal knowledge of many of his assertions has not been shown.
Denbury Onshore, L.L.C. v. Pucheu, 08-1210, p. 18 (La.App. 3 Cir. 3/11/09), 6 So.3d 386, 398.
The affidavit does not establish the basis in personal knowledge of Mast's assertion that many clients do not take contractually available discounts. No further evidence
Further, First Health's corporate representative Greg Hale affirmed in his deposition that if the bill was going to be paid in full, there would be no need for First Health's discounting software program to be applied to the bill.
Accordingly, we find that the evidence presented by First Health in opposition to the motion for summary judgment is insufficient to show the existence of a material issue of fact. Therefore, we find that the motion for partial summary judgment was correctly granted.
First Health argues, insofar as can be ascertained from a rather confused and confusing argument on this assignment of error, that the trial court erred in failing to apply the affirmative defenses of waiver, estoppel, failure to mitigate damages, and comparative fault to defeat the motion for summary judgment. Once Plaintiffs showed a prima facie case that its motion for summary judgment should be granted, the burden shifted to First Health to show that it could prove any affirmative defense that would defeat summary judgment. See Louisiana Health Care Group, Inc. v. Allegiance Health Mgmt., Inc., 09-1093 (La.App. 3 Cir. 3/10/10), 32 So.3d. 1138.
We first note that First Health does not supply, and we cannot find any authority for the idea that comparative fault principals can be applied to a penalty for a statutory violation. Therefore, we decline to apply comparative fault principals to the violation of La.R.S. 40:2203.1.
Further, we find the doctrine of equitable estoppel to be inapplicable to the situation before us. The second circuit in Commercial Nat'l Bank v. Rowe, 27,800, pp. 12-13 (La.App. 2 Cir. 1/24/96), 666 So.2d 1312, 1319, set out the requirements of equitable estoppel as follows:
La. Civ.Code art. 4 provides:
There is a rule for this situation provided expressly by positive law which we have already determined in this case is clear and unambiguous. The statute requires adequate notice and imposes statutory damages for failure to comply with the
First Health argues that Plaintiffs could have used the provider agreements to mitigate their damages. As we have stated, the notice given Plaintiffs by the provider agreement was inadequate to provide the degree of notice required by the statute. First Health may not use an inadequate notice to avoid liability under the statute in whole or in part. Louisiana Revised Statutes 40:2203.1 expressly provides: "In no instance shall any provider be bound by the terms of a preferred provider organization agreement that is in violation of this Part." We further find that, even if a defense of mitigation of damages were applicable herein, First Health has failed to show it will meet its burden to prove that Plaintiffs' conduct was unreasonable and that the unreasonable conduct resulted in aggravation of the harm. See Fletcher v. Simmons, 37,758 La.App. 2 Cir. 10/29/03, 859 So.2d 292.
First Health further asserts that Plaintiffs waived their right to recover penalties under the statute when they renewed their contracts with First Health.
L.T. v. Chandler, 40,417, p. 4 (La.App. 2 Cir. 12/14/05),917 So.2d 753, 757.
After reviewing the record, we find that nothing submitted from the filings or pleading makes waiver a genuine issue of fact in dispute. First Health offers no countervailing facts to support its defense of waiver.
First Health further argues that the trial court erred in designating the damages portion of its judgment on Plaintiffs' motion for summary judgment as final under La.Code Civ.P. art. 1915(B). This matter has been previously disposed of on a writ application filed by First Health, and we find no reason to change our decision in that regard. However, we will outline our reasoning with regard to this issue.
Louisiana Code of Civil Procedure Article 1915(B) provides, in pertinent part, the following:
Under La.Code Civ.P. art. 966(E), "summary judgment may be rendered dispositive
This court has previously set forth the procedure to be followed in reviewing an Article 1915(B) judgment designated without reasons. In Fakier v. State, Bd. of Supervisors for Univ. of La. Sys., 08-111 (La.App. 3 Cir. 5/28/08), 983 So.2d 1024, this court examined the issue of whether a partial judgment was a final judgment for purposes of an immediate appeal when reasons were not given with the designation. The Fakier court noted that in R.J. Messinger, Inc. v. Rosenblum, 04-1664 (La.3/2/05), 894 So.2d 1113, the supreme court adopted from Allis-Chalmers Corp. v. Philadelphia Elec. Co., 521 F.2d 360 (3rd Cir.1975), several non-exclusive factors for use by trial courts when determining certification of a judgment and for use by appellate courts when conducting de novo reviews when no reasons are given by the trial court for designation. The factors for examining certification are:
Fakier, 983 So.2d at 1029 (quoting Messinger, 894 So.2d at 1122).
Our analysis of the case at bar under the Fakier factors favors designation of the judgment as final. While the unadjudicated and adjudicated damages claims are related, the damages at issue are also tied to the judgment of liability before us on appeal given the fact that the damages are statutorily mandated.
Therefore, we find no error in the trial court's decision to designate the judgment as final.
For these reasons, we find that:
Therefore, the judgment of the trial court denying First Health's motion for summary judgment and granting Plaintiffs' motion for partial summary judgment is affirmed. All costs of this appeal are assessed to First Health.
COOKS, J., on rehearing.
I have examined the record again. After re-checking the record there is nothing in it suggesting that the Order of Appeal