Court Opinion

ID: 9584352
Source: CourtListenerOpinion
Date Created: 2023-08-21 22:47:12.664741+00
Date Added: 2024-06-11T15:07:37.819245
License: Public Domain

Cavanagh, J.
(concurring). Because the evidence supported Blue Cross and Blue Shield’s assertion that Dr. Matthews was improperly billing technical surgical assistance at a teaching hospital, as that term is defined in either the 1979 or the 1984 Physician’s *393Manual, I concur in the result reached by the majority.
At the civil trial, Officer Rumbly was asked whether finding out about the 1984 definition caused him to question whether the police had a case against Dr. Matthews. He answered, “Well, at the time that it came out, obviously I wanted to know exactly what the definition was, and where it was, and why it wasn’t in my file. However, given the other evidence in the case, it did not cause me any hesitation in terms of the issue of probable cause . . . .” When asked what those other factors were, and what was argued in the criminal trial, Rumbly replied:
The defendant was charged with having submitted false health care claims to Blue Cross and Blue Shield. . . . Our theory of the case is that the defendant was not entitled to be paid for the benefit of having acted as a technical surgical assistant. It went beyond the definition to the extent that either definition existed, there were conditions that were attached to that definition. Now, I can’t recite them word for word, but there were conditions that existed because of the fact that these procedures took place in what Blue Cross defined as a teaching hospital. It was at Sinai Hospital. Because that was a teaching hospital, there had to be some certification that at the time of the procedure, there was no intern or resident available to assist the surgeon who was in charge of the procedure before this provider, Dr. Matthews, could claim the benefit of tsa. There was no evidence to indicate that at any time, anybody ever certified that there was a resident or intern unavailable. That was one item.
On the basis of this factor, specifically relied on by both Blue Cross and the prosecutors, I find that probable cause existed to bring charges against Dr. Matthews for improper billing practices. I do not express *394any opinion regarding the other matters raised in the majority opinion.