YDM Management Co., Inc. v. Sharp Community Med. etc.
D071244
| Cal. Ct. App. | Oct 25, 2017Background
- YDM, assignee of Doctors Express (an out-of-network urgent care provider), sued Sharp (an IPA) seeking additional reimbursement for services provided to Sharp members, alleging those services were emergency services entitled to "reasonable and customary" rates under Cal. Code Regs., tit. 28, § 1300.71.
- Doctors Express submitted claims to Sharp using CPT (Current Procedural Terminology) codes; Sharp's records showed no use of the CPT codes (99281–99285) that identify emergency services.
- Sharp moved for summary judgment, submitting the declaration of Carol Wanke (Sharp VP) showing spreadsheets of claims and CPT/place-of-service codes indicating nonemergency billing.
- YDM opposed with a declaration from Dr. Jonathan Nissanoff (YDM president), opining the services were emergency in nature; the trial court struck Nissanoff's conclusory paragraph asserting all claims were emergency services for lack of foundation.
- Trial court granted summary judgment for Sharp, concluding Doctors Express’s own billing codes conceded the services were nonemergency and YDM’s expert did not create a triable issue.
- Appeal affirmed: the court held Sharp made a prima facie showing that no emergency CPT codes were billed and YDM failed to raise a triable factual dispute because Nissanoff’s opinion lacked foundation and contradicted Doctors Express’s own billing.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether urgent care services can qualify as "emergency services" for reimbursement at reasonable/customary rates | YDM: Emergency status depends on patient condition, not location; urgent care can furnish emergency services and thus seek §1300.71 reimbursement | Sharp: Only licensed hospital EDs (or licensed facilities obligated to provide emergency care) should obtain §1300.71 emergency reimbursement; urgent cares cannot as a matter of law | Court: Did not decide the categorical issue; resolved case on record-specific showing that Doctors Express billed nonemergency CPT codes and thus conceded nonemergency status |
| Whether Sharp's evidence (Wanke declaration and claim summaries) was admissible and created a prima facie showing | YDM: Wanke lacked foundation and relied on hearsay summaries; Garibay requires original records or foundation for summaries | Sharp: Wanke had personal knowledge of claims-processing, created proper spreadsheet summary under Evid. Code §1521, and statements by Doctors Express (the assignor) are party admissions | Court: Wanke’s declaration and summaries admissible; statements (CPT codes) are admissible against assignee YDM; Sharp met prima facie burden |
| Whether Nissanoff’s expert declaration raised a triable issue of material fact | YDM: Nissanoff reviewed claims and opined services were emergency | Sharp: Nissanoff’s opinion is conclusory, lacks foundation/exhibits, and conflicts with billing codes | Court: Trial court properly struck the conclusory paragraph; even if considered, it lacked basis and could not overcome the billing evidence—no triable issue shown |
| Whether summary judgment was improper because Sharp presented new evidence in reply | YDM: Reply declarations improperly introduced new supporting evidence | Sharp: Trial court relied on original moving evidence (Wanke), not reply; appellate review did not rely on reply evidence | Court: No reversible error; decision rests on Wanke’s original declaration |
Key Cases Cited
- Inland Empire Health Plan v. Superior Court, 108 Cal.App.4th 588 (discusses nature of IPAs and provider contracts)
- Prospect Medical Group, Inc. v. Northridge Emergency Medical Group, 45 Cal.4th 497 (addresses balance billing and reimbursement for emergency services)
- Aguilar v. Atlantic Richfield Co., 25 Cal.4th 826 (summary judgment burden-shifting framework)
- People ex rel. Allstate Ins. Co. v. Muhyeldin, 112 Cal.App.4th 604 (describes CPT codes as standardized billing nomenclature)
- Garibay v. Hemmat, 161 Cal.App.4th 735 (expert may not supply underlying facts via unsupplied records; limits on hearsay reliance)
- McGonnell v. Kaiser Gypsum Co., 98 Cal.App.4th 1098 (expert opinions lacking basis cannot create triable issues)
- Heaps v. Heaps, 124 Cal.App.4th 286 (admissibility of summaries where underlying documents are voluminous)