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.