Rehab Associates v. Blue Cross & Blue Shield of Massachusetts, Inc.
Rehab Associates v. Blue Cross & Blue Shield of Massachusetts, Inc.
Opinion of the Court
In a complaint filed in the Superior Court on March 21, 1990, Rehab Associates of New England (RANE), sought a declaratory judgment, injunctive relief, and damages from Blue Cross & Blue Shield of Massachusetts, Inc. (Blue Cross), based upon Blue Cross’s refusal to enter into a contractual relationship with RANE. RANE relied on various statutes, which we shall discuss, and on G. L.
We summarize the pertinent facts found by the Superior Court judge as well as some uncontested facts set forth in the record.
RANE operates a freestanding magnetic resonance imaging (MRI)
Blue Cross is a nonprofit hospital service corporation regulated by the Rate Setting Commission and governed under G. L. c. 176A. It provides coverage for the technical aspect of hospital (and other institutional) services and procedures. Blue Cross offers participating diagnostic imaging facility (DIF-1) agreements for MRI facilities seeking reimbursement for the technical component of their scans. The rates of payment specified in the contracts must be approved by the Rate Setting Commission. G. L. c. 176A, § 5.
In the summer of 1989, RANE applied for a DIF-1 contract with Blue Cross. RANE completed Blue Cross’s written application, and a Blue Cross reviewer, Evelyn Callahan, conducted an on-site assessment of the facility. Blue Cross informed RANE that, to qualify for a DIF-1 contract, it would have to improve its medical necessity guidelines, its review procedures, and its clinical oversight committee. RANE complied, and, on August 16, 1989, Callahan acknowledged that it was in compliance with the requirements in the DIF-1 application. In October of 1989, however, Blue Cross suspended the processing of RANE’s application “pending review and/or resolution of issues Blue Cross and Blue Shield of Massachusetts, Inc. has with Northeast Rehab Hospital.” In a letter dated February 7, 1990, Blue Cross explained that it was not in its “best business interests” to accept RANE’s application.
The majority of the limited partners of RANE, including Dr. Howard Gardner, were also limited partners in a limited partnership that has a forty-nine percent interest in the Northeast Rehabilitation Hospital (hospital). Since 1988, Blue Cross had an ongoing dispute with the hospital administrators, including Dr. Gardner, about the hospital’s alleged failure to comply with Blue Cross’s utilization review program and medical necessity requirements. The amount in dispute was $1.7 million, and Blue Cross was required to spend $104,000 to review the matter. Blue Cross and the hospital settled the dispute in 1993. Blue Cross’s reason for
The judge recognized that two statutes, G. L. c. 176A and G. L. c. 176B, bore on the issue before her. According to G. L. c. 176A, § 5, as appearing in St. 1969, c. 874, § 1: “In providing reimbursement for health services other than hospital services, any hospital service corporation may enter into contracts for the furnishing of such health services with providers thereof.” General Laws c. 176B, § 4, as appearing in St. 1988, c. 23, § 59, governing medical service corporations, has comparable language: “[a]ny medical service corporation may enter into contracts with . . . participating physicians, . . . and other providers of health services licensed under the laws of the commonwealth.” General Laws c. 176B, § 4, however, also contains a clause that requires: “no participating provider shall be denied the right to enter into any agreement with any medical service corporation by reason of any unfair or arbitrary discrimination.”
The judge concluded, first, that RANE had no statutory right to enter into a DIF-1 contract with Blue Cross. She determined that G. L. c. 176B, § 4, had no application to RANE’s claim as it applied only to professional providers and not to institutional providers. Relying on Goddard Memorial Hosp. v. Rate Setting Commn., 403 Mass. 736, 743-744 (1989), she interpreted G. L. c. 176A, § 5, as allowing a hospital service corporation such as Blue Cross to exercise discretion whether to enter into a contract with a particular provider. With respect to RANE’s G. L. c. 93A claim (and its corresponding claim under G. L. c. 176D, § 2), the judge concluded that Blue Cross’s refusal of a contract was not an unfair or deceptive act or practice. The refusal, for the purpose of avoiding further dealings with individuals with whom Blue Cross had problems in the past, was not, in her view, arbitrary or unreasonable. The judge found no merit in the contention that other statutes afforded RANE the right to relief.
The absence of an express prohibition against “unfair or arbitrary discrimination” in the award of contracts in G. L. c. 176A, § 5, distinguishes it from G. L. c. 176B, § 4. Indeed, the language authorizing Blue Cross to enter into contracts with institutional providers is permissive, and, in different contexts, it has been recognized that such relationships are “voluntary on both sides.” Commonwealth v. Mercy Hosp., 364 Mass. 515, 518 (1974). Cf. Goddard Memorial Hosp. v. Rate Setting Commn., 403 Mass. at 743-744. We, thus, acknowledge that Blue Cross generally may exercise its reasonable discretion in determining whether to enter into a contract with a particular institutional health care provider under G. L. c. 176A.
We do not think, however, the instant case falls within the general rule. RANE’s application for a “determination of need” from the Department of Public Health was approved on August 11, 1988, on the express condition that RANE “shall not consider ability to pay or insurance status in the patient selection process.”
But for the statutory scheme, in such a situation we might be inclined to rule in RANE’s favor and award the fair value of its services on the basis of the traditional common law theory of unjust enrichment. Restatement of Restitution § 1 (1936). Cf. Salamon v. Terra, 394 Mass. 857, 859 (1985). The statute, however, contemplates reimbursement of certain providers without a contract only in very limited circumstances not present here.
2. RANE’s claims under G. L. c. 93A and G. L. c. 176D, § 2. There is ample support in the record for the crucial underlying facts found by the judge with respect to the G. L.
Accordingly, we remand the case to the Superior Court for a determination of damages due RANE for Blue Cross’s failure to enter into a DIF-1 contract with RANE. As to the other counts of the complaint, we affirm the judgment for Blue Cross.
So ordered.
An MRI provides an image of the body through the use of magnetic fields, radiowaves, and computer reconstruction.
The department’s determination of need is based on the proposed facility’s financial and operational feasibility, the need in the community, and an assessment of alternative ways of meeting the health care needs of the population involved.
A merger between Blue Cross and Blue Shield was approved by the Legislature in 1988. St. 1988, c. 160.
Although there was some brief testimony at trial that such conditions have appeared in other determinations of need, the record does not indicate whether such conditions are common.
General Laws c. 176A, § 5, provides for such contracts and requires advance approval by the Rate Setting Commission of the rates of payment set forth in the contracts. General Laws c. 176A, § 1, however, provides: “Nothing in this chapter shall prevent such a corporation from reimbursing a subscriber for services received in a non-participating hospital within or outside the commonwealth in the event of accident, illness or maternity or, upon the written direction of the subscriber, from making payment to said hospital for such services. . . .”
Concurring Opinion
I write separately, not because I am troubled by the majority’s reasoning, but because I think that, in this era of rapidly rising health care costs (with all the attendant scrutiny and study focused on them), physicians or other medical practitioners should not refer their own patients to major medical testing laboratories or facilities, particularly such an MRI unit as here, owned by them.
The certificate of need for the instant MRI facility provides:
“The Department found that because RANE is a limited partnership comprised of neurologists and neurosurgeons, a condition should be attached to the approval of RANE’s MRI application requiring that all patients referred to Merrimack Valley MRI be informed in writing that RANE physicians have a financial interest in the facility and that patients are free to seek MRI services in a number of alternative settings.”
Case-law data current through December 31, 2025. Source: CourtListener bulk data.