counsel please sorry counsel please proceed thank you your honor my name is tim parker of represent the hospital and based on recent forty in the ninth circuit and elsewhere came out since the reason were filed in this case it is quite clear that the two year limitation on claims for benefits under the employer's plan has no application to the hospital's claim for reimbursement this case is kind of hard to understand because of all the names and the changes in corporate names so let me lay out for you what my conception is and then you educate me about why am i mistaken my conception of it is fifteen year old girl gets certain a car accident incurs hospital bills for her serious emergency care and the hospital sends out a bill for it was for five hundred thousand dollars and the little girl's mothers employer's group insurance plan fights with the hospital something about the bill they eventually get it down forty five thousand dollars it's all over then some years later the hospital gets an audit and discovers the thinks it's discovered that it under built so it sends out a bill for a couple hundred thousand more dollars and if and the judge says nope you had two years under the plan the mother's plan to make a claim and the hospital says no we have six years have because that's the general contract statute and it looks to me as though the only way you get the general contract stat a different contract but i don't see where you get a different contract it looks as though there are various contractual arrangements between the hospital and various insurance companies but the only one that applies to this little head trauma from the car accident is her mother's plan what am i missing here well two things your honor one very minor but you said that there was agreement at a forty five thousand dollar reimbursement there never was the hospital always asserted two hundred twenty seven thousand but that's not the important question it's not the important one you porton question you're asking is whether my client's claim is derivative of the employee plan another guy i don't see how you make the claim without standing in the mother's shoes using whenever you go to the hospital you have to sign an assignment of rights against your own health insurer and it seems to me the hospital stands in the mother's shoes against your group plan and that's it's only based basis for getting paid from this insurance company your honor the hospital and this is made abundantly clear in the ninth circuit opinion of blue cross versus anesthesia so is he it's in the more recent case of cedar sinai hospital a provider who is a preferred provider and there is no question and it's not contested in this case that my client is a preferred provider has two options notably they do not have the option of suing on the plan mike ross is distinguishable is that not the problem in cross was it was a fight want to jump to the pay or contracts which have no statute of limitations and then apply the washington six year general statute and i've got the same concern judge klinefelter to kill and i answered a judge can't be talking about my answer to judge other party are you i'm assuming i'm asserting that there is a contractual relationship between maple hurst plan on the one hand and a hospital on the other and meanwhile his cannot deny that because they insert a certain title with rates demonstrating there has to be a contract between the two parties serve two different things here yes and i could still be confusing them because it's so complex act you stand in the mother shoes to get paid from the mother's health plan at all your honor then you stand in your own shoes with respect to an insurance company where your preferred provider for what your rate of pay is a preferred provider at those and get nicked for as much i can't remember what their terms are but basically they knock more money off the bill if you're not a preferred provider at your preferred provider so you get paid at the better  sort of the worst rate but if you don't have any right to get paid at all under a preferred provider contract all you have a right to is a better rate from the insurance company and it looks to me as though this isn't a fight about the raid it's about a fight about whether you get paid your honor the point i'm not making here apparently is i don't have to sue in the show on the ace shoes i don't have to  keyboard in labour's versus doctors medical center just handed down in august health where a provider has chosen to sue one is preferred provider agreement it is not pursuing a claim for benefits under the plan you may be a preferred provider for blue cross blue shield and that if i have my insurance with a different company say state farm now sells medical insurance  and then even though your preferred provider you don't have a right to get paid at all from blue cross for my medical care but the difference your honor is that there is a contractual right to your hospital and state farm leaves you high and dry you can't go to  blue cross on the ground with your preferred provider if i have state farm medical we don't have that situation here but when you say you're not standing in the mother's shoes that's what it means to me what you must mean something else the cases are quite clear that if there is coverage under the plan and that's not disputed show me a base was it dependent of an employee of trauma care was covered never disputed the plan is irrelevant there after that and the only person that got medical care was the little girl the only person who was liable for the money was the mother the mother had a claim against her own insurance company she signed that claim to you incorrect to the hospital ma is directly liable to the hospital pursuant to the preferred provider agreement and the plan references and words are you saying in the preferred provider agreement say what you need them to say i thought all it covered was what the rate of reimbursement was no year under the maple hurst plan and the record at page two twenty three distinguishes between preferred providers and non preferred providers you know which we get four different contracts which contract are we looking at all look at all that's just what i just asked you about all it's talking about is the root not if and that's all that's additional in this case if you were in their medical care to somebody who is not covered by fire policy for the medical care rendered then it really wouldn't matter what the deal was on the absolutely agreed your honor there has to be coverage under the plan and the cases make clear that if there isn't a dispute about coverage under the plan then you're talking about the plan we're not talking are you saying that see if you are saying i'm standing in the mother's shoes and are dispute is about their only reimbursing us for the non preferred provider rate and we want to be reimbursed that the preferred provider rate then i can understand your argument that the contract that matters is the preferred provider contract but i understood you to say no we're not standing in the mother's shoes and it's not just a dispute about whether we get the preferred provider route your honor we are not standing in the mother's shoes if we were standing in the mother's shoes we would be suing a sensually in her name ok we've got an assignment from or does united as you just say you're not relying on but exactly and the cases hold that if we elect not to rely on the assignment which we elected to do once this to your suit limitation clause came up then we are free to pursue our state law claims based on the preferred provider agreement directly between the hospital and the pail ok and now that gets back i think the judge beezer is question and that is quote war until who had the authority to bind maple herders to this contractual obligation that the contract is going to them for then of course your third party admin how can you walk me through the contract so that i can understand how we get from the hospital back down to the employer ok's your honor referring to the agreement between bennet corp which is the third party administrator for the plan right and their agreement with the preferred provider organization all hospital right know it's one step removed this is the better course the in and agreement correct ok and as in the record that's in the record beginning at page one fifteenth ok in section one point zero five it says preferred providers our health care i could stand here under assignment but if i did i would have the two year provision to fight with i can throw that overboard there is a case i wish i had the name of it where they sued under it was saying that it was dismissed the refiled under their preferred provider agreement the ra judicata defense was just was just dismissed by the court said no this is an independent director claim on the preferred provider agreement and the plan falls out you've referred several times to a bunch of cases that say that that an a case i didn't think did the trick for you could you give me another one well the very best there are two cases you're i would call your attention to laborers versus doctors medical center that's this ninth circuit you decided in august that is the one that holds where a provider chooses to sue on its preferred provider agreement it is not pursuing a claim for benefits under the plan and if i'm suing on my preferred provider agreement and i am not pursuing a claim for benefits under the plan identify the class of beneficiaries who are entitled to the service of the preferred provider and to the extent that you're relying on that document at all that's it you're simply pointing to the fact that was there coverage for trauma care yes if she had gone in for cosmetic surgery probably wouldn't be right if her mother had quit their job the day before perhaps there wouldn't be but there is eligibility there is coverage that has never been disputed ok so to go back i know section three point five of the agreement between maple hurst and their third party administrator which is at page two thirty nine of the record ok that's the maple first then of course the rest section three point five  now there is i'll grant you that there are four contracts and while that may be factually complex it's completely irrelevant the foley case which is cited says in managed care it is frequently the situation where there are a series of contracts that contemplate delivering services from one into the other with the parties not privy to each other that's the reality of it and that's what we have in this situation this comes back to my situation if i my plan with blue cross doesn't cover as some creep just in condition i have your preferred provider agreement does not have the exclusion for my grief existing condition it seems to me that your argument would mean that when you treat me for right my preexisting condition you can recover from blue cross your expenses for the preexisting condition even though my plan doesn't cover my free system conditions i don't have those facts in this case but if those were the facts and if blue cross independently said they would pay it yes i but you can make my insurance company pay for pregnancy anyway there's a distinction that's because your preferred provider plan basically says you get the preferred provider rate for there's a distinction that i'm not getting across in call it is for that but the distinction is clear in all of the cases that are cited to you by both parties usually you're addressing it and i try to respond to just how much point on this what if there's no coverage or what if the person isn't eligible what if they're not an employee or what if it's pregnancy and it's and you know and your hypothetical that's one circumstance and if that's in dispute then that's in dispute what's a dispute if coverage or eligibility is in dispute that may or may not involve there's no dispute here pregnancy is clearly not covered by my blue grass and under your hyperloop at last group plan and it clearly is covered by your preferred provider plan so you're saying we want to that goes to coverage and eligibility and that's a whole different argument it's a whole different issue why is it different because it's in dispute it's not in dispute in my case all of my rights are guaranteed to me on the preferred provider agreement that the hospital has with maple so you're saying that in blue cross because the n s t theologists weren't happy with the amount of the reimbursement rates independent of any individual claim that might have been us under the contract we have with them and that is what we're arguing now i think i'm starting to understand your argument so you're saying they grew their plan covers a little girl's head injuries no problem there the only problem is how much do they have to pay per day at the hospital how much do they have to pay for the aspirin and the walker and whatever else the hospital provides are and there we should get the preferred providers rates and they're paying us the non preferred provide rates exactly you could have understood the dispute before before just now to be about that i thought they had video they did you preferred provider rates you just disagreed on how much due under the preferred provider rates your honor you could read the maple hurst employee benefit plan from start to finish and it is not going to tell you what level of payment my client is entitle to for trauma care not in there they didn't breach anything in there we're not suing on any provision in there so what's the purpose of the two years statue of limitations and or the employer group health care plan that is the other channel of payment that applies to a quote claim for benefits close quote by a quote covered person close quote those are the terms used in that to your suit limitation and if you look at this definition ethical matter it would only apply if the underlying claim was a dispute with a non preferred provider that didn't have any contract or relationship in practical effect that is that there are few what do you providing the patient anything what are we providing you going for the patient you're getting paid for what are we providing patients yeah we treated the patient for traumatic injuries and she incurred expensive two hundred seventy two thousand dollars they were seeking payment of that and that understand your question here and then the patient h somebody else to pay that well to the efficient was entitle to that by virtue of her parents employment right ok her parents employer elected to enter into an agreement directly with my hospital instead we will pay you one hundred percent for trauma care but they never get they never paid on her you skipped a step there with when i when i was following judge abusers writing questions he was saying he treated the little girl the little girl's mother had paid an insurance company to pay medical expenses that a little growing occurred and it says this applies to a clean by quote covered person close quote my client is not a covered person i have to seek payment from another avenue and that avenue is the preferred provider agreement i'm not even titled if my little girl wasn't  and i mean if the insurance company had said she's not actually your daughter she's your step daughter you've never adopted her we don't cover non adopted children here's a bit i don't see where you'd be entitled to get paid i wouldn't there's no question i have a preferred provider my client has a preferred provider agreement that entitles them to one hundred percent for trauma care and lesser percentages for other types of care a condition to the obligation of the a limitation issue is the timing of when the claimants submitted for payment had had everything gone right and there not been what i'll call an accounting problem at your client's billing department two hundred seventy two thousand dollars claim should have been billed within the two year period and then the hospital would have fought with the been a core of the insurance companies or whoever's actually cutting the check over how big the check was going to write well it was billed within ninety days at the correct amount no no no no but that let's not play games that the trauma occurs is that initial billing that goes out they get paid on the initial billing but that's not what th it's about this dispute is about the fact that they brought in a third party reviewer years down the road to illustrate your client's billing and these that oh my god i wish for a little michel you know we didn't ask for enough and now more than two years later i guess it was four years later you come back and say we need more money that's that's why we're here right i was responding to a point included in your recitation is incorrect and i don't know that it's really important but i don't want to go back and that is that an incorrect bill was not sent for more than two years that is not correct this trauma occurred in december of one thousand nine hundred nine and by april of two thousand and three four months later it correct bill of two hundred seventy two thousand and some dollars was sent ok number one incidentally my client can't go that direction under the plan at page one sixty one we are a preferred provider and we have to submit  for they have to build the patient directly yes they do which we didn't do ok so you're in but you and i guess your answer is for all practical purposes the two years statute really was intended to cover those situations where for whatever reason the employee who's covered gets the bill and then wants to have the bill paid under the plan and if the employee waits more than two years they might be out of luck no doubt about it if you look at the defined terms in the two year suit limitation will benefit those full court covered person close calls doesn't apply to my clients claim my claim is not a covered person and are not seeking benefits and that that last point is is big we've gone way one minute thank you thank you no obligation to pay the hospital or anybody else for the health care services that were rendered here no other document creates an odd a geisha to pay for services rendered to a particular individual and no other because they have a step correct contract that creates an obligation independent of the plant there are two problems with this first the contract in question does not create a separate payment obligation and second make the first does not even a party to the contract to which they are pointing looking at the first problem the contract that the hospital relies on is still a contract to pay for health care services under the plan both the language contract and an examination of the context lead to this conclusion the contract explicitly incorporates the plan provisions at paragraph one point for which you find it you are one sixteen that paragraph defines health services or benefits as services that are provided a person who went to a beneficiary of greenmount which in paragraph one point zero two on the same page is defined to mean plan under the terms of the plan and one of those terms is the statute of limitations common sense requires that the promise to pay is limited by the terms of the plan and these are kind of the hypothetical services are covered the hospital cannot sue maple hurst for payment more than two years after the services were rendered and the hospital acknowledges all but the last of that chain of logic the hospital  payment for services that aren't covered by the plan or that were rendered to people that were not covered by the plan but we don't have to abide by planned statute of limitations their effort to distinguish the statute of limitations from our plan terms has no rational basis that i can see you can simply announced as i do in their brief that some provisions of the plan are procedural and therefore do not condition the payment for services and it's also inconsistent also i might add are procedural and yet ignore the statute of limitations to those what would your response be to what i assume mr parker might say that theoretically we could end up with a hundred different through control just delivery of service it's not actually it's not actually clear that it isn't in a way there are there are multiple i think there may be an agency relationship between but but this isn't bringing between the preferred provider organization in other words the one that actually did the billing in this case and made that mistake logically could be seen as as an agent of the hospital but i i don't know that actually to be the case and that certainly isn't is increased that the agency claims that would only matter if the hospital was well my my they did get a discounted bill and mike my client paid the discounted bill after or actually the administrator paid the fee discounted after checking about it but i agree that  we're talking not about what the rate should be here that's a different last we're talking about anymore we're talking about the statute of limitations here quite quite clearly the rights of payment let me move network so unless there's agency here between the third party administrator any and my client the employer and some kind of general agency there is no contract employees would have doctors and hospitals that they could go to under the point it doesn't actually say that well when it actually says and i don't have the language in front of me but it says something about it asks the parker is correct that first we have to determine eligibility in coverage and there's no dispute about that and the hospital is suing on and under the terms of the pay or plan  hospital preach a little girl little girl from title to insurance coverage under her mother's employer's plan suppose the only dispute was about whether the hospital had been paid under the preferred provider rate the preferred i guess this would happen the preferred provider rate it's lower right right than a non for for providing correct it's not the preferred providers get more money because you think they're really good doctors or hospitals and so that they get less money because they've made a deal to take less money in exchange for an extra you didn't give us the expedited payment you gave us the same slow pay that a non preferred provider would get and it adds up to hundreds of thousands of dollars of interest because of the vast amounts of money to go through hospitals as so we're suing you for that it seems like for that there would be a six year statute of limitations yeah i think that it is possible to state a claim that is separate and apart from the here i mean are they saying this was coded as one trauma care but really it was trauma care and the rate of reimbursement for trauma care is higher now i don't think so i think that i mean they are and when you get medical care there's always this form with a whole bunch of little boxes and they check boxes and they have numerical codes to twenty six to thirty seven right whatever and as i understand it the doctors and hospitals get paid by the insurance company according to those codes that's my understanding as well let's say they coded it as a two thirty six and the insurance company paid as though it were to thirty seven just because  their claim that right they may be trying to cast their claim as this was coding error you paid us is that it was a two thirty six and actually it was a two thirty seven so we're just disputing the rate of the payment and then you've got to come back within a certain amount of time in order in order to do that i mean the underlying problem here is on the reimbursement form the claim for talking about payment for a particular individual and the the under that contract itself it requires you to look at the plan terms to determine whether that you or that individual would be eligible to get money under the plan for the things that you're billing for and unless that individual is that legible to get money but there's no dispute that that the patient was covered and the service was covered the only problem is that it should have been coded as trauma care rather than general hospital here at the time in it but yes i mean the reason for the statute of limitations if you will seems to come in here if that had happened and if it had been caught in usually or the mistake that never occurred in the first five years presumably what would have happened  who who covers you know items above a certain level and it would have been presented to them and they would have paid it and they had actually been involved early on and were notified because they were notified that there was a potentially large claim there but they have in their insurance policy a statute of limitations which they have assumed that they have asserted in this case and you have to give you council we can't concentrate for much more than a minute again thank you your honor i'm going to use my minute to draw your attention to four cases that are spot on on the ellipse issue that's been discussed for the last hour which is th dual approach past gak cited in the briefs coverage and eligibility in this case are not in dispute instead the resolution of this lawsuit requires interpretation of the provider agreement hospital's right to recovery if it exists depends on the operation of the provider agreement precisely the situation we have in this case in task act the court allowed the hospital to go forth in blue that's not a circuit blue cross versus upon the plan we hold that the providers claims which arise from the terms of their provider agreements and could not be asserted by patient signers are not claims for benefits under the terms of the arist goal they are not subject to procedural limitations and the risk of playing the next case cedars sinai your recent decision a provider's contractual claim against a carrier does not constitute a request for payment of a health related bill under the plan again i'm paraphrasing and even if it did it not it would not be a claim quote under the plan because it is predicated on the preferred provider agreement the final case orthopedic surgery to the extent providers are not being paid the amount to which they are entitled under their provider agreements they are suing as creditors and they are entitle to do so but what do we do with the excess insurance contract certainly the obligation is between the hospital and the payer if the payer has some other tertiary relationship where they can go and try to recover from somebody else which they have asserted in this case or get stuck on something that under their promise ended four years ago maybe they don't have to buy insurance and they certainly don't have to put a suit let's say they're totally self insured no insurance at all yet they say we'll pay medical claims that are presented to us and you can sue or through two years if we have a dispute and then it's over we destroy our records everything's gone they didn't do that and then a claim comes and several years after that that isn't what they did they entered into an agreement with my client and elected not to put submitted we're going to take a ten minute