5D08-2162 Riley v. Stein

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State: Florida

Court: Florida Fifth District Court

Docket No: 5D08-2162

Case Date: 01/25/2010

Preview:IN THE DISTRICT COURT OF APPEAL OF THE STATE OF FLORIDA FIFTH DISTRICT JANUARY TERM 2010

THE JOSEPH L. RILEY ANESTHESIA ASSOCIATES, ETC., Appellant, v. Case No. 5D08-2162 CORRECTED

AMANDA STEIN AND FLORIDA HEALTH CARE PLAN, INC., Appellee. ________________________________/ Opinion filed January 29, 2010 Appeal from the Circuit Court for Volusia County, Randell H. Rowe, III, Judge. Jamie Billotte Moses, of Fisher, Rushmer, Werrenrath, Dickson, Talley & Dunlap, P.A., Orland, for Appellant. Karina P. Gonzalez, of Law Offices of Steven M. Ziegler, P.A., Hollywood, for Appellee, Florida Health Care Plan, Inc. C. Anthony Schoder, Jr., of Smith, Schoeder & Bledsoe, L.L.P., Daytona Beach, for Appellee, Amanda Stein.

MONACO, C.J. One of the appellees, Florida Health Care Plan ("Florida Health Care"), a health maintenance organization, pre-authorized surgical procedures for each of its subscribers, the remaining appellees, through Florida Hospital Fish Memorial in Orange City ("Florida Hospital"). The appellant, Joseph L. Riley Anesthesia Associates, P.A.,

d/b/a

JLR

Medical

Group

("JLR"),

provided

anesthesia

services

to

the

subscribers/patients in conjunction with their surgical procedures. JLR, however, did not have a contractual agreement with Florida Health Care regarding the amounts to be paid for the medical services it provided to subscribers of Florida Health Care. The issue presented to us for determination is whether a hospital-based, but non-contracted, provider of health care services to the subscribers of a health maintenance organization plan may balance bill the subscribers for the unpaid portion of its statements for medical services that have not been paid by the health maintenance organization. We agree with the trial court that in light of section 641.3154, Florida Statutes (2007), the provider may not balance bill the subscriber, and affirm. The plaintiffs/appellees are a group of 52 medical patients who are subscribers to Florida Health Care.1 All 52 had surgical procedures at Florida Hospital. The hospital and all of the surgeons involved had contractual arrangements with Florida Health Care regarding insurance payment for their services. Moreover, the contract between Florida Health Care and Florida Hospital provided that the hospital was empowered to direct hospital-based physicians to provide medical services that were pre-authorized by Florida Health Care. JLR had an exclusive contract with Florida Hospital to provide anesthesia services for surgeries performed there, but had virtually no contact with any of the subscribers prior to the surgeries. What complicated the relationship between the

parties further was that although JLR provided anesthesia services to each of the

1

The trial court consolidated the 52 cases brought by the subscriber appellees. 2

subscribers, it had not contracted with Florida Health Care regarding reimbursement for services. After each surgery JLR submitted a statement for its medical services to Florida Health Care, but in each instance Florida Health Care paid a reduced amount in full payment of the bill. JLR received and retained each payment, but denied that the payments fully satisfied its statements, and then sent bills to the subscribers for the balance not paid by Florida Health Care. JLR refers to this as "balance billing." The patients brought suit seeking a declaratory judgment that JLR's balance billing violated section 641.3154, Florida Statutes (2007), and that balance billing violated Florida's Unfair Trade and Deceptive Practices Act under Chapter 501, Florida Statutes. The trial court bifurcated the proceedings and set the declaratory judgment action for trial. At the conclusion of the trial the court held that although JLR did not have a contract with Florida Health Care, it did have a contract with Florida Hospital and with the various surgeons who provided health care services to the 52 subscriber/ patients. The final judgment noted that each pre-scheduled surgery performed at

Florida Hospital went through an authorization process during which Florida Health Care would decide if each subscriber/patient was eligible, and whether the requested surgery was a covered benefit. Once approved, an authorization number was issued for use by all involved providers in order for them to submit bills to Florida Health Care for payment. The trial court noted that JLR billed Florida Health Care using the

assigned authorization number for each subscriber, and that because Florida Hospital had a contract with Florida Health Care, it was empowered to authorize or direct the

3

provision of JLR's anesthesia services to Florida Health Care members pursuant to section 641.3156(1). When the trial court reviewed section 641.3156(1), it found that under that statute a health maintenance organization was liable for services to a subscriber/patient by a provider, regardless of whether a contract existed between the health maintenance organization and the provider. It concluded further that in those circumstances the health maintenance organization would be liable for payment to the provider, but a subscriber/patient would not. appellees. A trial court's rulings on its interpretation of statutes and contracts are, of course, reviewed de novo. See Health Options, Inc. v. Palmetto Pathology Servs., P.A., 983 So. 2d 608 (Fla. 3d DCA), review denied, 994 So. 2d 1104 (Fla. 2008); Lukacs v. Luton, 982 So. 2d 1217 (Fla. 1st DCA 2008); see also Jones v. Utica Mut. Ins. Co., 463 So. 2d 1153, 1157 (Fla. 1985); Contreras v. U.S. Sec. Ins. Co., 927 So. 2d 16, 20 (Fla. 4th DCA 2006), review denied, 954 So. 2d 28 (Fla. 2007). We agree with the trial court that pursuant to Florida's "Health Maintenance Organization Act," section 641.17-.3923, Florida Statutes (2007), a health maintenance organization is liable for services rendered to a subscriber/patient by a provider, regardless of whether a contract exists between the HMO and the provider. The statute is quite specific in providing that a health maintenance organization is liable for payment of fees to the provider, and that a subscriber is not liable for payment of fees to the provider. See

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