Crowe v. Examworks, Inc.
| Decision Date | 30 September 2015 |
| Docket Number | CIVIL ACTION NO. 13-10249-DPW |
| Citation | 136 F.Supp.3d 16 |
| Parties | Anna Maria Crowe, et al, Plaintiffs, v. Examworks, Inc., et al, Defendants. |
| Court | U.S. District Court — District of Massachusetts |
Daniel W. Rice, Glynn, Landry & Rice, LLP, Braintree, MA, Peter Francis Russell, Russell & Associates, Needham, MA, for Plaintiffs.
Christopher Cole, Sheehan, Phinney, Bass and Green, Manchester, NH, David L. Hansen, Mark J. Ventola, Sheehan Phinney Bass & Green, P.A., Boston, MA, for Defendants.
DOUGLAS P. WOODLOCK
The plaintiffs here are a group of former and present employees of the defendants ExamWorks and MES Group, Inc., an entity that was acquired by ExamWorks in 2012. They allege that they were not paid for overtime work in violation of the federal fair labor standards and Massachusetts wage and hour law. The plaintiffs seek to represent a class of former and present employees of the defendants in Massachusetts. They now move for certification of the class, and both parties respectively move for partial summary judgment on various counts.
ExamWorks is a national company with headquarters in Atlanta, Georgia, that provides independent medical examinations ("IMEs"), peer reviews, utilization reviews, and IME-related services. In 2012, through a stock purchase agreement, ExamWorks purchased substantially all the assets of MES Group, which provided similar services. ExamWorks now has—as had MES Group previously—an office in Norwood, Massachusetts, where employees perform peer review and utilization review work. Defendant Crystal Patmore served as Vice President of Human Resources at ExamWorks during the relevant time period.
The plaintiffs either work or previously worked for MES and/or ExamWorks in Norwood as Utilization Review Nurse Auditors ("URNAs"), Clinical Quality Assurance Coordinators ("CQACs"), and Clinical Coordinators ("CCs"). Plaintiff Anna Maria Crowe worked as an URNA from March 12, 2012 until June 2013; Plaintiff Joanne Clarke has worked as an URNA from November 2007 and continues to be employed in that capacity with the defendants; and Plaintiff Suzanne O'Rourke Chansky worked as an URNA from October 18, 2010 until August 2012. Plaintiff Kathleen O'Day worked as a CQAC from March or April 2007 until February 2013, and Plaintiff Diane Bowen worked a CQAC from July 2010 until September 2011. Plaintiff Tia Finley worked as a CC, but the summary judgment record does not provide the specific time period of her employment.1
The named plaintiffs in the URNA role—Crowe, Clarke, and Chansky—all hold bachelor's degrees in nursing and are registered nurses ("RNs"). In addition, before working for the defendants, Crowe had over six years of nursing experience; Clarke had over twenty years of nursing experience in various capacities, including as a nurse, nurse field supervisor, patient case manager, and utilization review specialist; and Chansky had over ten years of nursing experience.
The named plaintiffs in the CQAC role—Bowen and O'Day—are both RNs with bachelor's degrees in nursing and clinical experience. The summary judgment record does not indicate whether Finley was an RN or what her background is; in any event, neither Finley nor the CC position is the subject of the summary judgment motions now before me.
As a general matter, utilization review "concerns the quality of care provided to injured employees, including whether the service is appropriate and effective, the proper costs of services, and the quality of treatment." 452 Mass. Code Regs. 6.02
; see Clark v. Centene Co. of Tex. , 44 F.Supp.3d 674, 676 (W.D.Tex.2014). In performing utilization review work, the defendants must comply with requirements promulgated by the Massachusetts Department of Industrial Accidents ("DIA") and by URAC (formerly the Utilization Review Accreditation Commission), through which they are accredited.
URNAs —Utilization Review Nurse Auditors—are tasked with reviewing requests for medical treatment from physicians or physical therapists for individuals who are eligible for worker's compensation. URNAs assess whether a proposed treatment or diagnostic test is medically necessary based on the patient's medical records and the applicable medical guidelines promulgated by various state agencies—in Massachusetts and other states—or third parties. Among the essential duties and responsibilities of the position, as defined by the job description, are "work[ing] directly with providers to identify level, intensity and duration of care"; documenting findings and "evaluat[ing] medical necessity for frequency, intensity and length of required care"; and ensuring that quality utilization reviews are "completed within the required client, federal and state or URAC mandated turnaround times."
After reviewing a patient's medical records—including x-rays, MRIs, CT scans
, lab test results, provider notes, and prescribed drugs—an URNA must identify the applicable guideline related to the request and determine if the requested treatment is medically necessary under that guideline. An URNA can either approve the treatment request or refer a treatment request for review by a physician in the same licensure category as the requesting physician. When approving a request, the URNA prepares a summary paragraph called a guideline application that restates the medical provider's request, restates the provider's basis for making the request, cites to the applicable guideline or the provider's assertion as to why treatment is medically necessary, indicates that approval should be permitted, and states the URNA's rationale for approval. An URNA's determination—that is, approval or referral for review—is reviewed only for purposes of an audit or performance review; URNAs' determinations are not subject to regular review by a supervisor.
In reaching a determination, URNAs are also guided by the Massachusetts "10% Rule," under which an URNA may approve a proposed treatment for a case that falls outside of the particular guideline where the requesting physician deems the treatment necessary "in light of all circumstances presented by the injured employee and the needs and resources particular to the locality or facility." 452 Mass. Code Regs. 6.06(2)
. The impetus for this rule is the recognition that although the "Treatment Guidelines are meant to cover the usage of a vast majority of tests and treatments ... approximately 10% of cases will fall outside [the] guidelines and thus require a review on a case by case basis."2
To obtain an URNA position with the defendants, an individual must have graduated from "an accredited nursing program" and have a minimum of three to five years of direct professional patient care. He or she also must be registered and licensed as an active registered nurse ("RN"), licensed practical nurse ("LPN"), or licensed vocational nurse ("LVN"), and must have "strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values." Although there is apparently an internal policy under which LPNs working as URNAs are supervised by RNs in performing their duties, the plaintiffs contend that LPNs and RNs perform the same type of work without distinction when functioning as URNAs. The parties also dispute whether any third-party or government agency requirements direct additional supervision of LPNs.3
CQACs —Clinical Quality Assurance Coordinators—perform two functions. The first is assignment. When a case comes in for peer review from an insurance company client, a CQAC assigns the case to a particular peer reviewer, using a database of physicians, and ensures that the case file has the appropriate documentation for the physician's review. These case files, like those reviewed by URNAs, contain a variety of medical documents, including MRI reports and provider notes.
The second CQAC function is quality assurance. CQACs ensure that peer review reports and other correspondence or supplemental reviews have been conducted by an appropriate board specialist; that the reviews contain "clear, concise evidence-based rationales ... in support of all recommendations and/or determinations," provider credentials and a signature, and "clinical citations and references when applicable," and that such references "are current and obtained from reputable medical journals and/or publications"; and ensure that "all client instructions and specifications have been followed" and "the content, format, and professional appearance of the reports are of the highest quality," among other tasks. In short, as the job description states, CQACs are responsible for ensuring that "Peer Review case reports are of the highest quality and integrity and in full compliance with client contractual agreement, regulatory agency standards and/or federal and state mandates."
CQACs employed by the defendants are not required to have any certificates, licenses, or registrations, but they must have at least "two years clinical or related field experience; or equivalent combination of education and experience," and they must have "strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values."
At MES, URNAs and CQACs had been classified as "exempt" from the overtime pay requirements imposed by state and federal law. However, shortly after ExamWorks acquired MES, it reclassified both positions as "non-exempt." CCs had been classified as "non-exempt" at MES, and their status did not change at any point in the relevant time period.
The CQACs were reclassified as non-exempt in April 2012 and informed by letter that effective April 16, 2012, they would be paid based on their actual hours worked—and not on the basis of a set bi-weekly amount—and that they would be eligible for overtime compensation. The URNAs were reclassified as...
To continue reading
Request your trial
-
Rego v. Liberty Mut. Managed Care, LLC
...and because LMMC requires that all UMNs have RN licensure, Plaintiffs should be classified as exempt. Citing Crowe v. ExamWorks, Inc. , 136 F.Supp.3d 16 (D. Mass. 2015), LMMC argues further that, regardless of the express language of § 541.301(e)(2), Plaintiffs' primary duty of performing u......
-
Cronin v. United States Postal Serv.
...... omitted), superseded in part on other grounds by. regulation as stated in Crowe v. Examworks ,. Inc. ,. . 9 . . 136 F.Supp.3d 16, 28 n.8 (D. Mass. 2015). Thus, the Board. ......
-
Scalia v. World Marble & Granite Corp.
...must also show that the "employer knew or should have known that [the employees] were working overtime." Crowe v. Examworks, Inc., 136 F. Supp. 3d 16, 43 (D. Mass. 2015) (citing Manning, 725 F.3d at 43). Employers must consider the actual number of hours worked when calculating overtime owe......
-
Dasilva v. Border Transfer of Ma, Inc.
...issue may suffice. Id. at 359, 131 S.Ct. 2541 ; see also Parsons v. Ryan, 754 F.3d 657, 675 (9th Cir. 2014) ; Crowe v. Examworks, Inc., 136 F.Supp.3d 16, 47 (D. Mass. 2015).1. Choice of Law Defendants argue that individualized evidence is required to determine whether Massachusetts law appl......