16 Cal. App. 5th 613
Cal. Ct. App. 5th2017Background
- YDM purchased accounts receivable from Doctors Express (an out‑of‑network urgent care operator) and sued Sharp IPA for additional reimbursement, alleging Doctors Express provided "emergency medical services" to Sharp members and thus was entitled to "reasonable and customary" reimbursement under California regulations.
- Sharp paid claims but moved for summary judgment, presenting Sharp VP Carol Wanke’s declaration showing Doctors Express’s claims to Sharp used CPT billing codes and that none of the CPT codes used were the emergency CPT codes (99281–99285) or place‑of‑service codes indicating an emergency department.
- YDM (as assignee) opposed with a declaration from its expert, Dr. Jonathan Nissanoff, asserting he reviewed claims and opining the services were emergency in nature; the trial court struck Nissanoff’s conclusory paragraph asserting that all assigned services were emergency services for lack of foundation.
- The trial court granted summary judgment for Sharp, finding Doctors Express’s own billings (as shown by Sharp’s evidence) did not assert emergency services and YDM failed to raise a triable issue to rebut that showing.
- On appeal the court affirmed: it held Sharp made a prima facie showing that no emergency CPT codes were used and YDM’s expert opinion was conclusory and inconsistent with Doctors Express’s billing, so summary judgment was proper.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether an urgent care provider may recover "reasonable and customary" reimbursement as a noncontracted provider for "emergency services" | YDM: Emergency status depends on the patient’s condition, not facility; nothing in law limits "emergency services" to hospital EDs | Sharp: Only licensed hospital EDs are the intended recipients of emergency‑service reimbursement; Doctors Express did not bill as emergency | Court: Did not decide whether urgent care can ever qualify; held on the record that Doctors Express did not bill as emergency, so YDM cannot recover |
| Whether Sharp’s evidence (Wanke decl.) was admissible and sufficient for prima facie summary judgment showing | YDM: Wanke’s spreadsheet/summary is hearsay/lacks foundation | Sharp: Wanke has personal knowledge; spreadsheet is admissible secondary evidence and statements are party admissions | Court: Wanke’s declaration and summary were admissible and sufficient to show no emergency CPT codes were billed |
| Whether YDM’s expert declaration created a triable issue of fact | YDM: Nissanoff’s review/opinion shows services were emergency | Sharp: Nissanoff’s opinion is conclusory, lacks foundation, and conflicts with billings | Court: Trial court properly excluded the conclusory paragraph; even if considered, it was insufficient to create a triable issue because it lacked basis and contradicted billing codes |
| Whether summary judgment was improper because Sharp allegedly submitted new evidence in reply | YDM: Reply declarations improperly introduced new evidence | Sharp: Trial court relied on original moving papers; appellate court need not consider reply evidence | Court: No reliance on reply declarations; summary judgment affirmed based on Wanke’s original declaration |
Key Cases Cited
- Prospect Medical Group, Inc. v. Northridge Emergency Medical Group, 45 Cal.4th 497 (California 2009) (providers of emergency services may not balance bill because plans must pay reasonable and customary rates)
- Aguilar v. Atlantic Richfield Co., 25 Cal.4th 826 (California 2001) (summary judgment burden‑shifting framework)
- Garibay v. Hemmat, 161 Cal.App.4th 735 (California 2008) (expert opinion may be inadmissible where based on nonproduced records lacking foundation)
- Allstate Insurance Co. v. Muhyeldin, 112 Cal.App.4th 604 (California 2003) (CPT codes are standardized nomenclature used in insurance claims)
- Collin v. CalPortland Co., 228 Cal.App.4th 582 (California 2014) (defendant can show plaintiff cannot establish an element to obtain summary judgment)
- Children's Hospital Central California v. Blue Cross of California, 226 Cal.App.4th 1260 (California 2014) (regulatory context for reimbursement of emergency vs nonemergency services)