859 F.3d 381
6th Cir.2017Background
- Raymond and Strunk, insured patients treated at Mercy Health facilities, were not billed to their insurers but Mercy Health/Avectus sought payment from any tort settlement or judgment instead.
- Mercy Health and Avectus sent letters to the patients’ attorneys demanding that funds be paid directly to Mercy Health from any settlement or judgment.
- The letters asked attorneys to withhold settlement funds from their clients to reimburse Mercy Health for unpaid charges.
- The district court dismissed, holding § 1751.60 did not apply; plaintiffs appealed.
- Ohio Rev. Code § 1751.60(A) prohibits providers from seeking payment from enrollees or insureds, and King v. ProMedica held applicability depends on a contract between provider and insurer.
- The court reverses and remands, holding Mercy Health violated § 1751.60(A) by seeking payment from insureds through settlements or judgments.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether § 1751.60(A) applies to Mercy/Avectus | Raymond/Strunk argue statute applies | Mercy/Avectus contend third-party collection not from insureds | Yes, statute applies and was violated |
Key Cases Cited
- King v. ProMedica Health Sys., Inc., 955 N.E.2d 348 (Ohio 2011) (limited to contracts between provider and health insurer; insulates only insurer’s insured)
- Hayberg v. Robinson Mem’l Hosp. Found., 995 N.E.2d 888 (Ohio Ct. App. 2013) (no contract between hospital and third-party insurer; statute inapplicable)
- Holeton v. Crouse Cartage Co., 748 N.E.2d 1111 (Ohio 2001) (tort claimant has property interest in tort recovery; affects resting on settlement)
- Spectrum Health Continuing Care Group v. Anna Marie Bowling Irrecoverable Trust Dated June 27, 2002, 410 F.3d 304 (6th Cir. 2005) (addressed Medicaid balance-billing; not controlling here)