SoCal Hospitals Sue Kaiser for $150 Million
5-22-2014 14:01:00
LOS ANGELES (CN) –
Thirteen Southern California hospitals claim in court that Kaiser Foundation
Health Plan has refused for a decade to pay more than $150 million for emergency
medical services to its policyholders, including Medicare patients, and has
forced patients to be transferred, at risk to their health.
Lead plaintiff
Prime Healthcare La Palma claims that in the past 10 years it and its Prime
Healthcare associates “have provided medical care to thousands of patients who
are enrolled in health insurance plans offered by defendant Kaiser Foundation
Health Plan, Inc. (‘KFHP’), including Medicare Advantage (‘MA’) plans
administered by KFHP under agreements with the federal government for Medicare
beneficiaries under Part C of the Medicare program. This dispute arises from
KFHP’s wrongful refusal to pay plaintiffs for emergency services provided to
KFHP members, including MA members, who presented to plaintiff’s emergency rooms
seeking emergency medical care.”
Under state and
federal laws, the 13 plaintiff hospitals must provide emergency care to patients
who show up, and need it, in their emergency rooms.
Also under state
and federal laws, “KFHP must pay Prime the contracted amount, or if there is no
contract between the MA and the provider, the Medicare allowable amount, for
that episode of care,” according to the 27-page federal
lawsuit.
“Plaintiffs cannot
refuse the physician’s orders for necessary stabilizing care, and KFHP, as the
health plan, cannot refuse to pay for that care.”
But that’s just
what Kaiser has done for a decade, the hospital claim in the
lawsuit.
The hospitals call
it a Kaiser “scheme to improve its financial bottom line by (a) failing to
properly pay plaintiffs for emergency medical services they provide to KFHP
members, including MA members, (b) attempting to pressure emergency room and
hospital treating physicians to transfer (or, to use Kaiser’s term,
‘repatriate’) these members from plaintiff hospitals to KFHP-designated
hospitals for nonmedical reasons before the patients are stable and ready for
transfer even though such transfers present a substantial risk of deterioration
of the patients’ medical conditions, and (c) engaging in a variety of unlawful,
unfair and fraudulent practices to not pay, only partially pay, or underpay the
plaintiffs’ claims to KFHP for emergency medical services provided to its
members in order to economically coerce and pressure plaintiffs to accede to
Kaiser’s ‘repatriation’ policies and practices.”
The hospitals claim
Kaiser has refused to pay or underpaid more than 50,000 claims for emergency
services, totaling more than $150 million, including more than $14 million for
9,000 Medicare Advantage patients.
The hospitals want
to be paid, “and to put an end to Kaiser’s unlawful, fraudulent and dangerous
practices.”
The plaintiffs seek
declaratory judgment, payment due, with interest, and damages for breach of
contract.
They are
represented by Jerome Friedberg with Isaacs, Friedberg &
Labaton.
The plaintiff hospitals are La Palma Intercommunity Hospital, Huntington Beach Hospital, West Anaheim Medical Center, Desert Valley Hospital, Sherman Oaks Hospital, Chino Valley Medical Center, Centinela Hospital Medical Center, Encino Hospital Medical Center, Garden Grove Hospital Medical Center, San Dimas Community Hospital, Paradise Valley Hospital, and Alvarado Hospital Medical Center.
The defendant is Kaiser Foundation Health Plan.