The Supreme Court of Ohio ruled, August 30, that when a patient’s treatment is covered by both a health insurance contract and the medical payments coverage in an auto insurance policy, state law does not prohibit a health care provider from billing the auto insurance company rather than the health insurance company for the patient’s treatment.
The Court’s 6-1 decision, which reversed a ruling by the 6th District Court of Appeals, was authored by Justice Yvette McGee Brown. The Ohio Osteopathic Association, Ohio Hospital Association and Ohio State Medical Association filed a joint amicus brief supporting the right of providers to bill auto insurance companies, which has been a standard practice for many years.
The plaintiff in the case, Virginia King, was injured in a traffic accident and received medical treatment for her injuries at The Toledo Hospital, which is operated by ProMedica Health System Inc. In completing hospital paperwork, King indicated that she was covered by both a medical insurance policy issued by Aetna Insurance Company and an auto insurance policy issued by Safeco Insurance Company. ProMedica submitted its bill for King’s treatment to Safeco under the “medical payments” coverage included in King’s auto insurance policy, rather than to Aetna.
King subsequently filed a lawsuit against ProMedica in the Lucas County Court of Common Pleas, alledging that ProMedica’s billing of her treatment to her auto insurance policy rather than Aetna violated the requirement in R.C. 1751.60 (A) that: “ ... every provider or health care facility that contracts with a health insuring corporation to provide health care services to the health insuring corporation’s enrollees or subscribers shall seek compensation for covered services solely from the health insuring corporation and not, under any circumstances, from the enrollees or subscribers, except for approved copayments and deductibles.”
ProMedica filed a motion to dismiss, arguing that R.C. 1751.60(A) only barred the hospital from billing King’s treatment directly to her, and did not prohibit it from billing that treatment to an insurer other than Aetna. The trial court agreed and dismissed King’s complaint. King appealed, and the Sixth District Court of Appeals reversed. The appellate court held that under the cited statute, health-care providers that execute preferred-provider agreements with health-insuring corporations can bill only the health-insuring corporation subject to the agreement for covered services furnished to their insured, and cannot bill any other potential payors.
ProMedica sought and was granted Supreme Court review of the 6th District’s holding.
In writing the court’s opinion, Justice McGee Brown wrote: “It is undisputed that appellants never sought compensation from King. But King argues that her Safeco medical-benefit payments are an asset that belongs to her, and that by seeking medical-benefit payments available under the automobile policy, appellants essentially sought compensation from her. King’s argument is unpersuasive. Under R.C. 1751.01(G), ‘“compensation” means remuneration for the provision of health care services, determined on other than a fee-for-service or discounted-fee-for-service basis.’ Compensation by Safeco did not equate to compensation by King: by making the payment, Safeco fulfilled its contractual obligation to King to cover her medical costs in the event of an accident. When appellants received payment, they received it from Safeco. Because King was not asked to make any payment for the services she received, appellants did not violate R.C. 1751.60(A).
“King also argues that appellants violated R.C. 1751.60(A) because they sought compensation from Safeco and not Aetna. King contends that the statutory language, ‘shall seek compensation for covered services solely from the health insuring corporation and not, under any circumstances from the enrollee or subscribers,’ means that all providers that contract with a health-insuring corporation relinquish their ability to seek compensation from any other parties and can collect payment from only the health-insuring corporation. The Sixth District agreed, finding that providers that execute preferred-provider agreements with health-insuring corporations can bill only the health-insuring corporation subject to the agreement for services furnished to an insured to the exclusion of any and all other potential payors.
The Sixth District’s reasoning relied on its construction of the word ‘solely,’ defining it to mean ‘to the exclusion of others.’ ... This interpretation, however, cannot be reconciled with the statute.” “R.C. 1751.60(A) has limited application. The statute addresses the contract between a provider and a health-insuring corporation. No other entities are mentioned in the statute. The statutory language allowing a provider to recover, ‘solely from the health insuring corporation and not, under any circumstances, from the enrollees or subscribers’ relates only to this contractual relationship. Here, the term ‘solely’ does not have the meaning given to it by the Sixth District. Reading the word in this manner would impermissibly render the phrase, ‘and not, under any circumstances, from the enrollees or subscribers’ superfluous. Rather, the word ‘solely’ is part of a phrase that defines the context of the statute; it means, in this context, to the exclusion of a health-insuring corporation’s insured. This reading gives full meaning to every word of the statute. Read in context, the statute’s language allowing a provider to seek compensation from the health-insuring corporation and not the insured is limited to the situation in which a health-care services contract is in place between a provider and a health-insuring corporation. Therefore, we hold that R.C. 1751.60(A) applies only when a provider seeks payment from a health-insuring corporation’s insured with which the provider has entered into a contract.”
Justice McGee Brown’s opinion was joined by Chief Justice Maureen O’Connor and Justices Evelyn Lundberg Stratton, Terrence O’Donnell, Judith Ann Lanzinger and Robert R. Cupp. Justice Paul E. Pfeifer entered a dissent.