Source: https://casetext.com/case/pearson-v-cp-buckner-steel-erection-co
Timestamp: 2019-09-22 02:25:31
Document Index: 401900177

Matched Legal Cases: ['§ 220', '§ 220', '§ 97', '§ 97', '§ 1396', '§ 1396', '§ 108', '§ 1396', '§ 447']

Pearson v. C.P. Buckner Steel Erection Co, 348 N.C. 239 | Casetext
348 N.C. 239 (N.C. 1998)
Pearsonv.C.P. Buckner Steel Erection Co.
Supreme Court of North CarolinaMay 1, 1998
348 N.C. 239•498 S.E.2d 818•
Filed 8 May 1998
1. Workers' Compensation § 220 (NCI4th) — medical expenses — amount exceeding Medicaid — liability of employer — subject matter jurisdiction The Industrial Commission had subject matter jurisdiction to decide whether an employer who had previously been ordered to pay an injured employee's reasonable and necessary medical expenses was required to pay medical providers the difference between the amount paid by Medicaid and the amount allowable under the Workers' Compensation Act. The Commission's supervisory power over its judgments includes the authority to enter orders to enforce those judgments.
2. Workers' Compensation § 220 (NCI4th) — medical expenses — amount exceeding Medicaid — liability of employer An employer who denies liability but is ordered to pay an injured employee's reasonable and necessary medical expenses under the workers' compensation law may not fulfill this obligation by merely reimbursing Medicaid where Medicaid has paid medical providers a portion of the cost of treatment, but must also pay medical providers the difference between the amount covered by Medicaid and the full amount authorized under the Industrial Commission fee schedule for medical expenses. The obligation of the employer to pay reasonable and necessary medical expenses under the workers' compensation law, and the ability of medical providers to accept such payments, is not controlled or preempted by federal Medicaid statutes or regulations.
The Jernigan Law Firm, by Leonard T. Jernigan, Jr., and N. Victor Farah, for plaintiff-appellant; and Lore McClearen, by R. James Lore, for intervenor-appellant Cary Health Care Center, Inc.
Hedrick, Eatman, Gardner Kincheloe, L.L.P., by Jeffrey A. Doyle, for defendant-appellees.
Defendants contend that the Commission did not have statutory jurisdiction to determine whether a medical provider's agreement with Medicaid precludes that provider from receiving payment pursuant to workers' compensation law subsequent to accepting payment under Medicaid. The primary issue, defendants argue, involves the interpretation and application of federal and state statutes and regulations enacting and implementing the Medicaid program. In this way, defendants frame the issue as a collateral dispute outside the scope of the Commission's jurisdiction. Defendants rely on Eller v. JS Truck Servs., 100 N.C. App. 545, 397 S.E.2d 242 (1990), disc. rev. denied, 328 N.C. 271, 400 S.E.2d 451 (1991), in which the Court of Appeals held that, despite its authority to approve attorneys' fees under N.C.G.S. § 97-90, the Commission's jurisdiction did not extend to cover a dispute between the plaintiff's attorneys over the division of those fees. We do not find Eller persuasive.
The Workers' Compensation Act, N.C.G.S. ch. 97 (1991 Supp. 1997), was enacted "in 1929 to both `provide swift and sure compensation to injured workers without the necessity of protracted litigation,' and to `insure a limited and determinate liability for employers.'" Charlotte-Mecklenburg Hosp. Auth. v. N.C. Indus. Comm'n, 336 N.C. 200, 203, 443 S.E.2d 716, 718-19 (1994) (quoting Rorie v. Holly Farms Poultry Co., 306 N.C. 706, 709, 295 S.E.2d 458, 460 (1982)) (alteration in original). The rights of the employee and the liability of the employer under the Act "are founded upon mutual concessions" by which each party "surrenders rights and waives remedies" previously available. Lee v. American Enka Corp., 212 N.C. 455, 462, 193 S.E. 809, 812 (1937). "The basic operating principle of the Act is that an employee is automatically entitled to certain benefits whenever he suffers either a personal injury by accident occurring in the course of the employment and arising out of it, or incurs an occupational disease." Charlotte-Mecklenburg Hosp. Auth., 336 N.C. at 204, 443 S.E.2d at 719. The Act requires the employer to provide medical compensation to the injured employee, and the Commission may order medical compensation if the employer does not provide it. Id.; N.C.G.S. § 97-25.
Medicaid, Title XIX of the Social Security Act, 42 U.S.C. § 1396-1396v (1994), was enacted by Congress in 1965 to establish a federal-state cooperative system of providing medical assistance to "families with dependent children and . . . aged, blind, or disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services." 42 U.S.C. § 1396. Each participating state must develop a plan for medical assistance which complies with the requirements of Title XIX. See Harris v. McRae, 448 U.S. 297, 301, 65 L.Ed.2d 784, 794 (1980); see also Lackey v. N.C. Dep't of Human Resources, 306 N.C. 231, 235, 293 S.E.2d 171, 175 (1982). North Carolina has elected to participate in the Medicaid program and has adopted a state plan for medical assistance. N.C.G.S. §§ 108A-54 to -70.5 (1997); 10 NCAC ch. 26. Medicaid, as implemented by the coordinate state plans, is intended only as a safety net for those unable to otherwise obtain adequate medical care, and thus, state plans must take steps to ensure that Medicaid is the payor of last resort. See, e.g., 42 U.S.C. § 1396a(a)(25)(A) (directing that a state plan for medical assistance must provide "that the State or local agency administering such plan will take all reasonable measures to ascertain the legal liability of third parties . . . to pay for care and services").
Louisiana Pub. Serv. Comm'n v. FCC, 476 U.S. 355, 368-69, 90 L.Ed.2d 369, 381-82 (1986) (citations omitted).
Defendants contend, and the Court of Appeals agreed, that federal law controls the outcome of this case because the portion of the state medical assistance plan allowing providers to accept payment from third parties, formerly 10 NCAC 26K .0006(c) (Apr. 1990), now .0006(e) (Jan. 1996), conflicts with federal Medicaid regulations. Defendants assert that intervenor and other medical-care providers may not receive the outstanding portion of the cost of plaintiff's treatment ordered by the Commission because they previously accepted payment from Medicaid. They point to 42 C.F.R. § 447.15, which states that a participating provider must accept, as payment in full, amounts paid by the Medicaid agency and any copayment required by the plan to be paid by the individual. By invoking this federal regulation, defendants seek to avoid full compliance with the order of the Commission that they pay the medical expenses of plaintiff which the Commission may determine to be reasonable and necessary.
Defendants rely on Evanston Hosp. v. Hauck, 1 F.3d 540 (7th Cir. 1993), cert. denied, 510 U.S. 1091, 127 L.Ed.2d 215 (1994), in which a hospital filed an action against the Illinois Department of Public Aid (IDPA), the state Medicaid agency. The plaintiff-hospital sought to return a partial payment made by IDPA for the care of a formerly indigent patient in order to file a suit against the patient after he won a $9.6 million judgment in a tort action stemming from his accident. The United States Court of Appeals for the Seventh Circuit rejected the hospital's attempt to return the Medicaid payment and seek the full amount of the original bill from the now-solvent patient. In so holding, the Evanston court accused the hospital of attempting "to turn Medicaid upside down by converting the system into an insurance program for hospitals rather than for indigent patients." Id. at 544.