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Nestle Holdings v. Lakeview Regional Medical Center

Court of Appeals of Louisiana, First Circuit

June 14, 2017

NESTLE HOLDINGS
v.
LAKEVIEW REGIONAL MEDICAL CENTER

         APPEALED FROM THE OFFICE OF WORKERS' COMPENSATION DISTRICT 6 IN AND FOR THE PARISH OF ST. TAMMANY STATE OF LOUISIANA DOCKET NUMBER 15-08309 HONORABLE GWENDOLYN F. THOMPSON, PRESIDING

          Denis Paul Juge Christopher Whelen Metairie, Louisiana Attorneys for Plaintiff/ Appellant Nestle Holdings

          Helen Hsu, Houston, Texas Attorney for Defendant/Appellee Lakeview Regional Medical Center

          BEFORE: PETTIGREW, McDONALD, and PENZATO, JJ.

          McDONALD, J.

         This appeal involves an employer seeking review of an Office of Workers' Compensation (OWC) judgment that granted a health care provider's exception raising the objection of prematurity and an exception raising the objection of no cause of action. After a thorough review, we affirm the OWC judgment granting the objection of prematurity and pretermit discussion of the exception of no cause of action.

         FACTS AND PROCEDURAL HISTORY

         Michael J. Sliker, an employee of Nestle Holdings, was injured in the course and scope of his job, and on September 29, 2015, Mr. Sliker had outpatient umbilical hernia surgery at Lakeview Regional Medical Center (LRMC). On October 3, 2015, LRMC sent a bill to Nestle Holdings for $70, 707.27 for the procedure. By letter dated November 25, 2015, Sedgwick CMS, Inc. (the third party administrator for Nestle Holdings) sent payment of $7, 540.87 to LRMC, along with a letter stating that "[n]ot having sufficient information to determine the reasonableness of the charges, the third party administrator has issued the enclosed payment representing its determination of a reasonable reimbursement for the services rendered by your facility. This payment represents the calculation of 90% of the average charges for this procedure by hospitals in this region."

         On December 23, 2015, Nestle Holdings filed a disputed claim for compensation with the OWC, controverting the bill from LRMC. Nestle Holdings requested itemization for LRMC's charges and invoices for all supplies, and further demanded reimbursement for overpayment of its bill.

         LRMC answered the claim, denying the allegations, and specifically denying that plaintiff overpaid the medical bill for Mr. Sliker and was entitled to any reimbursement. LRMC also filed exceptions raising the objections of no cause of action and prematurity. LRMC maintained that the claim failed to state a valid cause of action because the law did not extend a remedy to recover medical payments already made to a workers' compensation payor under the factual allegations of the claim. LRMC also maintained that the matter was not ripe for judicial review because defendant had not filed suit for 90 percent outpatient reimbursement pursuant to Louisiana Administrative Code Title 40, pt. I, § 2507, [1]and had not made an issue regarding the insufficiency of plaintiff's payment.

         The matter proceeded to a hearing before the OWC on June 24, 2016, and afterward the OWC took the matter under advisement. Thereafter, the OWC ruled in favor of LRMC and against Nestle Holdings, granting LRMC's exceptions raising the objections of prematurity and no cause of action, and dismissing the claim. Judgment was signed on August 25, 2016. Nestle Holdings appealed that judgment.

         Nestle Holdings makes the following assignments of error.

1. The [Louisiana Workers' Compensation Act] LWCA requires that the medical charges providers submit to employers be "reasonable, " which this court has defined as "what is customary in a community for similar operations involving similar pre-operative and post-operative procedures and complications." When a dispute arises between a provider and payor regarding medical charges, including the reasonableness of those charges, the LWCA gives either party the right to file a petition with the OWC to have the dispute resolved. The court below, therefore, erred as a matter of law by finding that [Nestle Holdings'] petition did not state a cause of action when it expressly challenged the reasonableness of [LRMC's] charges.
2. The LWCA permits a payor to file a petition against any party, other than an injured employee, for any dispute arising out of the Act. [Nestle Holdings] filed a petition against LRMC challenging the reasonableness of the charges it submitted for payment. The court below, therefore, erred by finding that [Nestle Holdings'] petition was premature.

         THE REVISED STATUTES

Louisiana Revised Statutes 23:1314 provides:
A. The presentation and filing of the petition under R.S. 23:1310.3 shall be premature unless it is alleged in ...

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