Kaiser Refuses to Honor Network Agreement, Hospital Claims

12-26-2013 23:55:00

     MODESTO, Calif. (CN) - Kaiser "systematically" denies claims for plan members' out-of-network treatment and owes a hospital $60,000, it alleges in Stanislaus County Court.

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     Doctors Medical Center of Modesto sued Kaiser Foundation Health Plan Inc., Kaiser Permanente Insurance Company and Kaiser Foundation Hospitals.
     The hospital alleges it provided three Kaiser patients with emergency and “medically necessary” treatment, and that Kaiser denied some or all of the claims for reimbursement.
     The parties' agreement prohibits Kaiser from denying claims for medical services provided to members when the services are determined to have been medically necessary, according to the complaint.
     Kaiser did not deny its claims on the grounds that treatment was not medically necessary, but that it did not provide timely billing, or that the treatment was not authorized, according to the complaint.
     “Defendants’ unlawful, unfair and fraudulent business practices routinely and systematically contradict its contractual requirement that prohibits [it] from denying claims on the basis of no authorization when the services were medically necessary,” the complaint states.
     The hospital says it provided timely discounted billing for all three patients, as required under the contract.
     Plaintiffs argue that the breach requires Kaiser to pay full price for the patient's care, instead of receiving the discount.
     The hospital sues for breach of contract, unjust enrichment and unfair business practices, and is seeking money damages and penalties.
     The plaintiff is represented by Jonathan F. Buck, Steven D. Sperling, and Kelly L. Dingwell of Helton Law Group APC in Huntington Beach.