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HomeMy WebLinkAbout97-2288 civilLESLIE WENRICH, D.C., : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA : v. NO. 97-2288 CIVIL TERM : HIGHMARK, INC. d/b/a : PENNSYLVANIA BLUE : SHIELD, : Defendant : CIVIL ACTION - LAW IN RE: DEFENDANT'S PRELIMINARY OBJECTIONS BEFORE HOFFER, P.J. AND HESS, J. ORDER OF COURT ANDNOW, (~¥~ '~ ,1998, Plaintiff's Complaint is dismissed for failure to submit this dispute to the required alternative dispute resolution process. Plaintiff is hereby required to submit his complaint to the appropriate Review Committee. By the Court, ~ p.j. Spero T. Lappas, Esquire 205 State Street, P.O. Box 808 Harrisburg, PA 17108-0808 Bridget E. Montgomery, Esquire Eckert, Seamans, Cherin & Mellot LLC 213 Market Street, P.O. Box 1248 Harrisburg, PA 17108-1248 LESLIE WENRICH, D.C., : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA : v. : NO. 97-2288 CIVIL TERM : HIGHMARK, INC. d/b/a : PENNSYLVANIA BLUE : SHIELD, : Defendant : CIVIL ACTION - LAW IN RE: DEFENDANT'S PRELIMINARY OBJECTIONS BEFORE HOFFER, P.J. AND HESS, J. OPINION HOFFER, P.J.: This opinion concerns Defendant's preliminary objections to Plaintiff's complaint. Leslie Wenrich, D.C. ("Plaintiff") filed suit against Highmark, Inc. ("PBS" or "Defendant") for defamation. Plaintiff is a doctor of chiropractic who is a participating provider with PBS. Wenrich claims he sent bills to PBS for payment in accordance with the PBS provider agreement. Wenrich alleges that PBS refused to pay these bills and sent notices to the applicable patients stating that the reason for non-payment was that Wenrich's equipment was substandard. Defendant claims that Plaintiff failed to provide the necessary information that would have allowed PBS to determine the quality of Plaintiff's equipment. PBS has filed a preliminary objection requesting that this case be dismissed and sent to 97-2288 CIVIL TERM alternative dispute resolution as required under the Regulations for Participating Providers.~ We now find that Plaintiff is required to submit his complaint to the appropriate alternative dispute resolution process before pursuing a remedy in the court system. DISCUSSION Defendant is a Pennsylvania non-profit professional health services corporation which was organized and is currently operating pursuant to the Pennsylvania Health Services Plan Corporation Act. This Act states that "Ia]Il matters, disputes or controversies relating to the professional health services rendered by the health service doctors...shall be considered and determined only by health service doctors as selected in a manner prescribed in the by-laws of the professional health service corporation." 40 Pa. C.S.A. Section 6324(c) (1995). The By-Laws of the Medical Service Association of Pennsylvania state that "Ia]Il matters, disputes or controversies arising out of the relationship between the Corporation and the professional health care providers...shall be considered and ~ Defendant's second preliminary objection requests that, in the alternative of sending this complaint to alternative dispute resolution, this Court dismiss Plaintiff's Complaint for failure to state a claim upon which relief can be granted. Because of the action this Court is taking today, there is no need to decide Defendant's alternative request. 97-2288 CIVIL TERM determined by one of two Review Committees." Article X, Sec. 1 (1995). PBS' Regulations for Patient Providers further explain how these controversies shall be decided. The regulations state that "all matters, disputes or controversies relating to the services performed by Participating Providers...shall be considered, acted upon, disposed of and determined only by providers in a manner provided by Article X of the By-Laws of Blue Shield. Regulations for Participating Providers, General Regulations B(20). The Review Committee Guidelines go on to say that "matters referred to the Review Committee generally concern disputes with respect to overutilization and/or misutilization of services, quality of care, service benefits and usual charge problems." PBS Review Committee Guidelines, Appendix B. In an opinion somewhat similar to the one at bar, this Court was asked to determine whether a claim brought against PBS for interpretation of a providing participant agreement between a health services provider and PBS was required to initially go through an alternative dispute resolution process. The Court held that 40 Pa. C.S.A. Section 6324 of the Professional Health Services Plan Corporation Act "gives PBS power to elect an administrative panel to hear and resolve disputes concerning the professional health services rendered by its participating physicians." RRS Imaging Assoc v. Medical Service Assn., 42 D & C 3d 42, 43 97-2288 CIVIL TERM (1985). Additionally, the Pennsylvania Supreme Court has already recognized that various statutes now encourage arbitration and alternative dispute resolution is favored by the courts. Borough of Ambridge Water Authority v. Columbia, 458 Pa. 549, 328 A.2d 498, 500 (1974). Based upon the above requirements, this Court finds that the Plaintiff is required under his agreement with PBS to first submit his complaint to alternative dispute resolution rather than initially filing it with the court system. The Pennsylvania Health Services Plan Corporation Act clearly states that PBS has the right to prescribe the manner used to settle disputes and controversies. PBS, in its by-laws, has determined that all matters arising out of the relationship between participating providers and PBS shall be disposed of via one of two Review Committees. Based upon this reading, any dispute which falls under this requirement must be determined by the Review Committee before it can be removed to the court system. The case at bar meets the requirement of a matter which arises out of the relationship between a participating provider and PBS. Wenrich is a participating provider who is required under the PBS agreement to forward certain information to the Defendant in order for PBS to determine the quality of Wenrich's equipment. 4 97-2288 CIVIL TERM In turn, Wenrich can submit his bills to PBS which then pays or denies the claim and sends notices to the participating patients whom Wenrich has treated. Were Wenrich not a participating provider for PBS, Defendant would not have had any reason to send the supposedly defamatory letters to any of Wenrich's patients. Therefore, this case arose from the relationship between Wenrich and PBS. Furthermore, the PBS guidelines go on to say that the matters referred to by the Review Committee generally concern disputes with respect to overutilization, quality of care, service benefits and usual charge problems. Plaintiff alleges that his claim does not fall within the list of disputes. Plaintiff fails to see that this list is just a generality produced by PBS to show what disputes are commonly dealt with by the Review Committee. However, there is no limitation placed upon this list, nor does PBS specifically list any disputes which are not covered under the Review Committee's jurisdiction. Plaintiff characterizes his claim as one of defamation in a possible attempt to avoid alternative dispute resolution. This Court finds that the dispute between Plaintiff and Defendant is actually one based upon the requirements of Plaintiff as a PBS provider. Although Plaintiff couches his complaint in terms of defamation, this Court will not allow mere linguistics to prevent this case from going to 5 97-2288 CIVIL TERM alternative dispute resolution? Additionally, this case could be viewed as dispute over quality of care. Plaintiff's claim of defamation is based upon the fact that PBS found Plaintiff's equipment to be substandard. This claim obviously goes to the quality of care being offered by Plaintiff in his role as a participating provider in the PBS program. For these reasons, Plaintiff is required to submit his complaint to the appropriate PBS Review Committee. 2 Even if this Court were to find that Plaintiff's case is based upon defamation, there is still authority to show that defamation can be arbitrated. The Pennsylvania Superior Court has said that "although the intentional tort of defamation is not normally arbitrated," if the agreement is broad enough to encompass defamation, such as allowing arbitration for any dispute arising out of the relationship between the parties, then defamation cases may be arbitrated. Waddell v. Shriber,, 357 A.2d 571 (Pa. Super. 1976).