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
Paul Juge Christopher Whelen Metairie, Louisiana Attorneys
for Plaintiff/ Appellant Nestle Holdings
Hsu, Houston, Texas Attorney for Defendant/Appellee Lakeview
Regional Medical Center
BEFORE: PETTIGREW, McDONALD, and PENZATO, JJ.
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.
AND PROCEDURAL HISTORY
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."
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.
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,
had not made an issue regarding the insufficiency of
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.
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.
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 ...