« The Defeat of the California Health Bill | Main | Heat is on California Health Insurers »

February 13, 2008

Southern California Hospital System Sues Kaiser Permanente

Prime Healthcare Services announced today that eight of its hospitals have filed lawsuits in four different Southern California counties against Kaiser Permanente seeking more than $25 Million for Kaiser's failure to properly pay thousands of claims for emergency medical services provided to Kaiser's HMO members. Under both federal and California law, each of these hospitals were required to provide medical screening examinations to each patient who sought emergency care and such further stabilizing care as was necessary to stabilize the patient's emergency medical condition regardless of the patient's insurance status. Kaiser, as well as other HMOs, is required to reimburse the hospitals for the reasonable and customary value of the emergency services provided. Although Prime Healthcare's hospitals provided emergency care to thousands of Kaiser's enrollees, Kaiser failed to properly reimburse Prime Healthcare's hospitals for the emergency services provided to its members. Instead, Kaiser has routinely denied claims in their entirety, paid only small portions of the claims, and/or reimbursed the hospitals at rates which are far below the reasonable and customary value of the emergency services. For example, Kaiser has failed to pay any portion of Sherman Oaks Hospital's $1.6 Million claim for emergency burn services provided to a critically-injured Kaiser member at the world-renowned Grossman Burn Center who was hospitalized for more than thirty days.

Given the rising costs of providing healthcare and the dramatic increase in the number of uninsured and underinsured patients, many hospitals have been forced to close, file bankruptcy, or limit services. Since 2001 more than 17 hospitals throughout Southern California have closed due to financial constraints and several others were forced to file bankruptcy. As noted by Roger Krissman, Chief Financial Officer of Prime Healthcare Services, "it is especially important that HMOs like Kaiser fairly and properly reimburse providers of emergency medical services because otherwise more hospitals may be forced to close". Mr. Krissman commented further that "Prime Healthcare had no choice but to file lawsuits against Kaiser in order to ensure continued access to healthcare for the members of the communities in which its hospitals are located."

In contrast to financially distressed hospitals, Kaiser reported profits of $1.3 Billion in 2006 and $2.5 Billion in 2007. This is not surprising given that although insurance premiums have increased; the amount of revenue spent on patient care has remained the same or decreased. Rather than spending the increased premiums on patient care, HMOs are using the money on increased layers of bureaucracy and middle management whose job it is to refuse necessary patient care, deny provider claims or find other ways to not pay provider claims properly. According to Dr. Prem Reddy, a board certified Cardiologist and Chairman of Prime Healthcare Services, "HMOs, including Kaiser, ought to be focused on effectively managing patients' care; but unfortunately, they are focused on managing bills". Also, in order to implement a process of working efficiently with Kaiser, Dr. Hassan Alkhouli, Medical Director of Prime Healthcare's Orange County Hospitals, attempted numerous times to arrange for a meeting with Kaiser's utilization managers to address utilization issues but his telephone calls went unanswered.

Click here for your free California health insurance quote today!

Posted by healthinsurance at February 13, 2008 07:16 PM

Comments