Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca8-18-03467/USCOURTS-ca8-18-03467-0/pdf.json

Parties Involved:
CIOX Health, LLC
Appellee
Espire Concepcion
Not Party
Brandon Graham
Appellant
Tyrone Green-Smith
Not Party
Lynn Henderson
Not Party
Antonio Jones
Not Party

Document Text:

United States Court of Appeals

For the Eighth Circuit

___________________________

No. 18-3467

___________________________

Brandon Graham, individually and also on behalf of all similarly situated persons

lllllllllllllllllllllPlaintiff - Appellant

v.

CIOX Health, LLC

lllllllllllllllllllllDefendant - Appellee

------------------------------

Lynn Henderson; Espire Concepcion; Tyrone Green-Smith; Antonio Jones

lllllllllllllllllllllMovants

 ___________________________

No. 18-3468

___________________________

 Brandon Graham, individually and also on behalf of all similarly situated persons

lllllllllllllllllllllPlaintiff

v.

CIOX Health, LLC

lllllllllllllllllllllDefendant - Appellee

------------------------------

Appellate Case: 18-3467 Page: 1 Date Filed: 03/12/2020 Entry ID: 4890520
Lynn Henderson; Espire Concepcion; Tyrone Green-Smith; Antonio Jones

lllllllllllllllllllllMovants - Appellants

 ____________

Appeals from United States District Court 

for the Eastern District of Missouri - St. Louis

 ____________

Submitted: September 23, 2019

Filed: March 12, 2020

____________

Before KELLY, MELLOY, and STRAS, Circuit Judges. 

____________

KELLY, Circuit Judge.

The issue in this case is whether a Missouri statute permits health care providers

to charge patients who request their medical records a “search” fee when there are no

responsive medical records to be found. The district court1

decided that the answer

is yes. We agree and affirm the district court’s judgment.

I. Background

Brandon Graham’s attorney sent a written request to St. Mary’s Hospital for

Graham’s health care records from July 10, 2017, to October 31, 2017. CIOX Health,

LLC, which fulfills medical-records requests for St. Mary’s Hospital, searched for

Graham’s health care records from the dates requested, found none, and sent

Graham’s attorney a letter stating: “We regret to inform you that we were unable to

1The Honorable Rodney W. Sippel, United States District Judge for the Eastern

District of Missouri.

-2-

Appellate Case: 18-3467 Page: 2 Date Filed: 03/12/2020 Entry ID: 4890520
process your request as the patient did not receive services on the service date(s)

requested. No dates of treatment 7/10/17 - 10/25-17 at St. Mary’s Hospital - St.

Louis.” CIOX billed Graham’s attorney a “Basic Fee” of $24.85, a “Retrieval Fee”

of $0.00, and a “Per Page Copy” fee of $0.00 for this service.

Graham subsequently filed this proposed class action lawsuit alleging that

CIOX’s practice of charging a “Basic Fee” for unsuccessful records searches violates

Mo. Rev. Stat. § 191.227 (2017). Under that statute, health care providers “shall,

upon written request of a patient, or guardian or legally authorized representative of

a patient, furnish a copy of his or her record of that patient’s health history and

treatment rendered to the person submitting a written request.” Id. § 191.227.1. 

However, they are not required to provide this service for free. As relevant here,

Health care providers may condition the furnishing of the patient’s health

care records . . . upon payment of a fee for:

(1)(a) Search and retrieval, in an amount not more than twentyfour dollars and eighty-five cents plus copying in the amount of

fifty-seven cents per page for the cost of supplies and labor plus,

if the health care provider has contracted for off-site records

storage and management, any additional labor costs of outside

storage retrieval, not to exceed twenty-three dollars and twentysix cents, as adjusted annually pursuant to subsection 5 of this

section; or

(b) The records shall be furnished electronically upon payment of

the search, retrieval, and copying fees set under this section at

the time of the request or one hundred eight dollars and eightyeight cents total, whichever is less, if [certain conditions are met]

. . . .

Id. § 191.227.2 (emphasis added).

-3-

Appellate Case: 18-3467 Page: 3 Date Filed: 03/12/2020 Entry ID: 4890520
CIOX filed a motion to dismiss the lawsuit. It argued that the statutory

language permitting health care providers to “condition the furnishing of the patient’s

health care records . . . upon a payment of a fee for . . . [s]earch and retrieval”

authorized it to charge a “Basic Fee” for searching for a patient’s health care

records—even when the search was unsuccessful. The district court agreed,

concluding that “[t]he plain language of the statute permits the charge of this fee.”

Graham appeals. He argues that CIOX was not permitted to charge a basic fee

for searching for his health care records because (1) CIOX did not “furnish” any

“health care records” and (2) the statute only authorizes health care providers to

charge a fee for “search and retrieval,” not a standalone fee for a “search.”

II. Standard of Review

“We review de novo the district court’s grant of a motion to dismiss.”

Halbrook v. Mallinckrodt, LLC, 888 F.3d 971, 975 (8th Cir. 2018). Where, as here,

we are called upon to interpret state law, “our role is to follow the law as decided by

thatstate’s highest court. Absent clear direction from that court, we must conduct our

analysis as a predictive exercise, interpreting state law in the manner we believe the

state’s highest court would rule.” Id. (cleaned up).

III. Analysis

The statute at issue permits health care providers to “condition the furnishing

of the patient’s health care records” upon the payment of certain fees. See Mo. Rev.

Stat. § 191.227.2. Graham argues that CIOX did not “furnish his health care records”

because no such records existed. Thus, he contends that the statutory prerequisite was

not satisfied, and CIOX was not authorized to charge him a fee.

CIOX sent Graham’s attorney a letter stating that Graham “did not receive

services on the service date(s) requested. No dates of treatment 7/10/17 - 10/25-17

-4-

Appellate Case: 18-3467 Page: 4 Date Filed: 03/12/2020 Entry ID: 4890520
at St. Mary’s Hospital - St. Louis.” This letter is a “record” within the ordinary

meaning of that term because it “recalls or relates past events”—namely, Graham’s

non-treatment on the dates requested. Merriam-Webster’s Collegiate Dictionary 1040

(11th ed. 2012). CIOX “furnished” this record to Graham’s authorized representative

by giving or supplying it to his attorney. See id. at 508. And the record, sent on

behalf of St. Mary’s Hospital in response to a request for Graham’s medical records,

relates information about Graham’s health care. We thus conclude that CIOX

furnished a health care record within the meaning of the statute.

2

Health care providers “may condition” the furnishing of health care records

“upon payment of a fee for . . . [s]earch and retrieval . . . .” Mo. Rev. Stat.

§ 191.227.2(1)(a). Graham’s next argument is that this only authorizes health care

providers to charge a single fee for “search and retrieval,” not separate fees for

“search or retrieval.” He contends that where, as here, a health care provider does not

“retrieve” anything, it cannot charge a fee solely for the “search.”

As a preliminary matter, Graham’s framing of the issue as whether “and” bears

a conjunctive or disjunctive meaning in the phrase “search and retrieval” is misplaced. 

We agree that “and” should be given “its ordinary plain meaning as a conjunctive.”

Stires v. Dir. of Revenue, 477 S.W.3d 611, 615 (Mo. banc 2016). But that does not,

by itself, resolve this issue. Even if “and” is given a conjunctive meaning, we must

still decide whether the statute requires CIOX to conduct both a “search and retrieval”

before it may charge a fee, as Graham argues, or whether the statute authorizes a fee

for both “search and retrieval,” as CIOX argues.

2A subsequent amendment codifies this understanding. The statute now states:

“For purposes of subsections 1 and 2 of this section, ‘a copy of his or her record of

that patient’s health history and treatment rendered’ or ‘the patient’s health care

records’ includes a statement or record that no such health history or treatment record

responsive to the request exists.” Mo. Rev. Stat. § 191.227.3 (2018).

-5-

Appellate Case: 18-3467 Page: 5 Date Filed: 03/12/2020 Entry ID: 4890520
We think CIOX has the better position. The list in § 191.227.2(1) does not

describe what a health provider “must” or “shall” do to earn a fee; instead, it lists the

fees that a health care provider “may” charge for furnishing a record. Cf. Stiers, 477

S.W.3d at 615. In some cases, an actor may be required to do two things to earn a

single fee. But that is more likely to be the case where both activities are within the

actor’s control. Cf. Finnegan v. Old Republic Title Co. of St. Louis, 246 S.W.3d 928,

930 (Mo. banc. 2008) (concluding that “the failure of the notaries to record their

notarizations” precluded them from charging a fee for the “notarization of each

signature and the proper recording thereof”). Here, Graham acknowledges that

retrieval “is impossible when no records exist.” It would be unusual for the legislature

to require health care providers to conduct a search whenever a written request for

medical records is submitted, see Mo. Rev. Stat. § 191.227.1, permit them to charge

a “search” fee, id. § 191.227.2, but condition their ability to charge that fee upon the

happenstance of whether there are pre-existing records to be found. 

The plain language of the statute does not require this unusual result. The next

subsection separately lists “search, retrieval, and copying fees.” Mo. Rev. Stat.

§ 191.227.2(1)(b). This is a strong textual indication that the legislature thought of

“search” fees and “retrieval” fees as distinct and that it did not intend to limit health

care providers to charging only a single, indivisible fee for a “search and retrieval.”3

Accordingly, we affirm the district court’s dismissal of this action. The

movants’ appeal of the denial of their motion to intervene is dismissed as moot.

3The dissent would read this list of three fees as a list of two: a “search and

retrieval” fee and a “copying” fee. The dissent justifies this interpretation by noting

that subsection (1)(b) cross-references subsection (1)(a) and declaring that “the only

reasonable reading” of subsection (1)(a) is that it authorizes only a single fee for

“search and retrieval.” However, we believe it is reasonable to interpret subsection

(1)(a) as authorizing distinct fees for “search” and “retrieval.” The three-fee list in

subsection (1)(b) supports this interpretation.

-6-

Appellate Case: 18-3467 Page: 6 Date Filed: 03/12/2020 Entry ID: 4890520
STRAS, Circuit Judge, dissenting.

This case requires us to answer two questions. The first is whether a prior

version of Missouri’s medical-records statute authorizes a single fee for “[s]earch

and retrieval” or one fee for a “[s]earch” and a separate one for “retrieval.” If a

single fee covers both actions, then the second question is whether CIOX may

charge a customer when it searches but does not retrieve anything. I respectfully

dissent because, in my view, the statute sets a single fee that requires the

completion of both actions.

I.

Under Missouri law, the “primary rule of statutory interpretation is to give

effect to legislative intent as reflected in the plain language of the statute at issue.”

Parktown Imps., Inc. v. Audi of Am., Inc., 278 S.W.3d 670, 672 (Mo. banc 2009). 

This includes giving words and phrases their common and ordinary meaning,

Abrams v. Ohio Pac. Express, 819 S.W.2d 338, 340 (Mo. banc 1991); interpreting

statutes, including related provisions, as a whole, Gott v. Dir. of Revenue, 5 S.W.3d

155, 159–60 (Mo. banc 1999); and applying the rules of grammar when they are

helpful, see Caplinger v. Rahman, 529 S.W.3d 326, 332 (Mo. Ct. App. 2017).

A.

Applying these principles, the statute authorizes only a single fee for

“[s]earch and retrieval,” not separate fees for each of these acts. As relevant here,

subsection 2 states:

Health care providers may condition the furnishing of the

patient’s health care records to the patient, the patient’s authorized

representative or any other person or entity authorized by law to

obtain or reproduce such records upon payment of a fee for:

-7-

Appellate Case: 18-3467 Page: 7 Date Filed: 03/12/2020 Entry ID: 4890520
(1)(a) Search and retrieval, in an amount not more than

twenty-four dollars and eighty-five cents plus copying in the

amount of fifty-seven cents per page for the cost of supplies and

labor plus, if the health care provider has contracted for off-site

records storage and management, any additional labor costs of

outside storage retrieval, not to exceed twenty-three dollars and

twenty-six cents, as adjusted annually pursuant to subsection 5

of this section; . . . 

(2) Postage, to include packaging and delivery cost; and

(3) Notary fee, not to exceed two dollars, if requested.

Mo. Rev. Stat. § 191.227.2 (Supp. 2017) (emphasis added). Focusing on the

critical language, the provider “may condition the furnishing of the patient’s health

care records . . . upon payment of a fee for: (1) . . . [s]earch and retrieval . . . ;

(2) [p]ostage . . . ; and (3) [n]otary fee . . . .”

If this sounds like a list of three fees, it is. Lists with four nouns and two

conjunctions cannot contain four separate items.4 They necessarily include one

compound item—here, search and retrieval—made up of more than one noun. See

Rodney Huddleston & Geoffrey K. Pullum, The Cambridge Grammar of the

English Language 1279 (2002) (referring to this type of construction as

“layering”). The structure of the statute makes clear that there are three fees, each

of which is discussed in a separate paragraph of subsection 2: one for “[s]earch and

retrieval,” one for “[p]ostage,” and one for a “[n]otary.” The key takeaway is that

only one fee covers the compound item, “[s]earch and retrieval.”

4

If the goal was to create a list with four items, not just three, the Missouri

General Assembly could have picked one of the following structures: “search,

retrieval, postage, and notary fee” or “search and retrieval and postage and notary

fee.” See Rodney Huddleston & Geoffrey K. Pullum, The Cambridge Grammar of

the English Language 1276 (2002).

-8-

Appellate Case: 18-3467 Page: 8 Date Filed: 03/12/2020 Entry ID: 4890520
B.

If the statute creates a single search-and-retrieval fee, then the focus shifts to

whether a health-care provider must complete both actions before it can charge the

fee. In the statute, the word “and” separates the two nouns, “search” and

“retrieval.” In Missouri, there is a strong presumption that “and” is conjunctive,

not disjunctive, meaning that it is read as an “and,” not as an “or.” See Stiers v.

Dir. of Revenue, 477 S.W.3d 611, 615 (Mo. banc 2016). This presumption

“strong[ly]” suggests that both acts—search and retrieval—must be completed

before CIOX can charge the fee. Id. (citation omitted). 

Indeed, the Missouri Supreme Court has considered a statute like this one

before. In Finnegan v. Old Republic Title Co. of St. Louis, the statute authorized

notaries to charge a fee of two dollars “for notarization of each signature and the

proper recording thereof in the journal of notarial acts.” 246 S.W.3d 928, 929

(Mo. banc. 2008) (quoting Mo. Rev. Stat. § 486.350 (emphasis added)). The

plaintiffs sued, arguing that the title company should not have charged them a fee

because the notaries did not record anything in their journals. Id. The court agreed

and concluded that the fee could only be collected if notaries completed both acts:

“notarization” and “proper recording.” Id. at 930. The reason, the court said, was

that the “use of the word ‘and’ indicate[d] a legislative intent that recording . . . be

an additional requirement to a $2 charge under the statute.”5 Id.

5The court tries to distinguish Finnegan by suggesting that both notarization

and proper recording were “within the [notaries’] control.” Ante at 6. It is not clear

what difference this makes. After all, the notary statute was grammatically

indistinguishable from the one here, and Finnegan emphasized “the plain language”

and the significance of the word “and,” 246 S.W.3d at 930, not the feasibility of

completing the recording. 

-9-

Appellate Case: 18-3467 Page: 9 Date Filed: 03/12/2020 Entry ID: 4890520
I would reach the same conclusion here. To use Finnegan’s words, retrieval

of a medical record is “an additional requirement to a [$24.85] charge under the

statute.” Id. CIOX did not retrieve any records, so it was not entitled to payment. 

II.

The court disagrees and interprets the statute to allow CIOX to charge the

fee, regardless of whether it retrieves anything. It provides two reasons, but neither

is persuasive. 

The court begins with policy. It asks why the Missouri General Assembly

would prohibit health-care providers from charging a fee when they have taken the

time to search for records, but by “happenstance . . . there are [no] pre-existing

records to be found.”6 Ante at 6. It says that such a decision would be “unusual,”

but even if this were true, it would not matter because the text is unambiguous. See

Kerperien v. Lumberman’s Mut. Cas. Co., 100 S.W.3d 778, 781 (Mo. banc 2003)

(“Where the language of a statute is unambiguous, courts must give effect to the

language used by the legislature.”). 

But the court’s logic falls short on its own terms too. Viewed from the

perspective of consumers, this decision is not unusual at all. As a consumerprotection statute, one of its purposes seems to be to protect patients from

overcharges. So if a patient requests something, but receives nothing, then it is not

odd for the patient to pay nothing. Although this scheme may be unfair to CIOX,

it is the result of how the Missouri General Assembly decided to balance the

6Even if the “no records” letter is, as the court concludes, itself a record, it was

newly created in response to Graham’s inquiry and could not have been “retriev[ed]”

by CIOX. See The American Heritage Dictionary of the English Language 1500 (5th

ed. 2016) (defining “retrieve” as “[t]o gain access to (stored information)”); Webster’s

Third New International Dictionary 1940 (2002) (defining “retrieve” as “REGAIN,

REPOSSESS”).

-10-

Appellate Case: 18-3467 Page: 10 Date Filed: 03/12/2020 Entry ID: 4890520
interests of patients and health-care providers in the statute. See Goerlitz v. City of

Maryville, 333 S.W.3d 450, 456 (Mo. banc 2011) (discussing the “time-honored

principle” that “policy decisions” are left to the legislature). It is not our place to

second-guess its judgment. In re Brockmire, 424 S.W.3d 445, 450 (Mo. banc

2014).

The court ends its analysis by relying on subparagraph (1)(b)’s reference to

“search, retrieval, and copying fees,” but this phrase provides no help either.7 The

court believes it provides “a strong textual indication that . . . ‘search’ fees and

‘retrieval’ fees [are] distinct.” Ante at 6. But this reads too much into a simple

cross-reference to the fees found elsewhere “under this section”: the “[s]earch and

retrieval” fee in subparagraph (1)(a), which includes compensation for copying;

and a separate fee, contained in the next subsection, for the “reasonable cost of all

duplications of health care record material or information which cannot routinely

be copied or duplicated on a standard commercial photocopy machine.” Mo. Rev.

Stat. § 191.227.2(1)(a), .3 (Supp. 2017). It does not, in other words, change the

only reasonable reading of the statute: CIOX was only entitled to collect a fee from

Graham if it conducted a search and retrieved a medical record, the latter of which

never occurred here. 

______________________________

7As relevant here, subparagraph 1(b) says that health-care providers must

furnish records electronically, “upon payment of the search, retrieval, and copying

fees set under this section at the time of the request . . . if such person: [listing three

conditions].” Mo. Rev. Stat. § 191.227.2(1)(b) (Supp. 2017).

-11-

Appellate Case: 18-3467 Page: 11 Date Filed: 03/12/2020 Entry ID: 4890520