Second “Injury” of the patient – ​​Medical care billing | Fox Rothschild LLP – JDSupra


The claims are not within the doctor-patient relationship, the court says, but are also “intertwined with” and “directly linked” to the care.

Charles McNew was injured in a fall at his home in June 2021 and was later treated in the emergency room at Fletcher Hospital in Hendersonville, North Carolina. Three months later, he claims to have suffered an injury of a different kind when he was billed for that care at rates he alleged were much higher than the hospital’s published rates and those of similar providers.

In McNew v. Fletcher Hosp., Inc., 2022 NCBC 53, a purported class action found the Business Court considering the nature of the patient-biller relationship and whether billing for medical care is part of “professional services rendered by members of a learned profession.” look NCGS § 75-1.1(b).

Judge Bledsoe rejected the contention that a breach of fiduciary duty claim could lie between a patient and a hospital arising out of its billing and billing practices. The Court recognized the well-settled rule that a doctor-patient relationship is among the small list of settings where “there has been a special trust reposed in one who in equity and good conscience is bound to act in good faith.” McNew, ¶ 14 (citing Dallaire v. Bank of Am., NA, 367 NC 363, 367 (2014). In North Carolina, this limited list also includes attorney-client relationships, spouses, business partners, and guardians and wards. Id. ¶ 15 (citing Hager v. Smithfield E. Health Holdings, LLC, 264 NC App. 350355 (2019).

However, neither in law nor in fact did the Court conclude that the doctor-patient relationship included that of biller-to-patient. The Court noted that the doctor-patient duty exists because of “special knowledge and skill in the diagnosis and treatment of disease or injury” that is not present when the bond is simply “the debtor and the creditor.” Id. ¶ 17.

The Court reasoned that the biller-patient relationship sounds like a contract, as opposed to one in which the hospital “held a position of power and influence” over patients. Id. ¶ 23. It therefore found that the traditional rule that “general contractual relationships do not usually rise to the level of fiduciary relationships” should govern. Id. ¶ 21 (citing Sykes v. Health Network Sols., Inc., 372 NC 326, 340 (2019). Judge Bledsoe noted that neither plaintiff nor the Court could locate any authority in North Carolina or elsewhere to support a fiduciary construction in the billing-patient fact pattern. See, for example, Burton v. William Beaumont Hosp., 373 F. Supp. 2d 707723–24 (ED Mich. 2005) (“While Michigan courts have recognized fiduciary relationships such as . . . physicians and patients, there is no authority for the proposition that a fiduciary relationship exists between a hospital and a patient whereby plaintiffs complain).hence ie billing practices.”).

The Court also rejected plaintiff’s contention that a de facto fiduciary relationship exists in the patient-biller context. The Court noted the high bar for a de facto claim in North Carolina as one where “one party figuratively holds all the cards: all the financial power or technical information.” McNew, ¶ 20 (citing Lockerman v. S. River Elec. Membership Corp., Application 250 NC. 631, 636 (2016)). Judge Bledsoe highlighted the absence of claims about the medical care McNew received or the “medical knowledge of the Hospital staff”. Id. ¶ 23. Instead, the Court observed (Id.):

“[Plaintiff] he disputes only the amount he was billed after the services were rendered, and he provides insufficient facts to allege the substantial difference in bargaining power that our courts require to establish that he had a de facto fiduciary relationship with the Hospital.” .

Unfair business practices

The Court also dismissed plaintiff’s Chapter 75 claim against the hospital for failure to meet the “in or affecting commerce” prong of the UTP analysis. The Court’s reasoning was the statutory exception that “‘trade . . . does not include professional services rendered by a member of a learned profession.” Id. ¶ 28 (citing NCGS § 75.1.1). The Court relied substantially in Sykes and its caveat that “this exception for medical professionals has been interpreted broadly.” Id., ¶ 30.

The Court noted that a two-step analysis applies to determine whether the “learned profession” exception applies: (i) is the performer of the act a member of the profession and (ii) the conduct is a real provision of professional services. Id. ¶ 29 (quoting Sykes, 372 NC at 334). The Court considered the same fact pattern that it considered only “one of debtor and creditor” for purposes of a fiduciary duty analysis and concluded that it nonetheless demonstrated conduct that was “sufficiently related to the provision of care to the patient to fall with him [learned profession] exemption Id. ¶¶ 17, 33.

In its Chapter 75 analysis, the Court concluded that the hospital’s charges for medical care “are directly related to the provision of the plaintiff’s medical care” and that the plaintiff’s claims challenged “the conduct of the ‘Hospital in not disclosing these charges in the course of providing its emergency services and imaging.’ .” Thus, the Court concluded that the hospital’s alleged conduct was so closely related to its provision of medical care to the plaintiff that it “is bound up with and directly related to the provision of the plaintiff’s medical care in the ward Hospital emergencies”. Id. ¶ 33.

Takeaway food

Billing disputes between patients and health care providers continue to present opportunities for complex analysis and narrow legal distinctions. Here, the Business Court concludes that the conduct may be so ordinary as to be that of “debtor and creditor” not contained with a doctor-patient relationship, but also so closely “intertwined” with the “provision of care to the patient by fall into the [learned profession] the scope of the exemption”.

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