Northbay Healthcare Grp. - Hosp. Div. v. Blue Shield of Cal. Life & Health Ins.

342 F. Supp. 3d 980
CourtDistrict Court, N.D. California
DecidedOctober 26, 2018
DocketCase No. 17-cv-02929-WHO
StatusPublished
Cited by4 cases

This text of 342 F. Supp. 3d 980 (Northbay Healthcare Grp. - Hosp. Div. v. Blue Shield of Cal. Life & Health Ins.) is published on Counsel Stack Legal Research, covering District Court, N.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Northbay Healthcare Grp. - Hosp. Div. v. Blue Shield of Cal. Life & Health Ins., 342 F. Supp. 3d 980 (N.D. Cal. 2018).

Opinion

William H. Orrick United States District Judge

INTRODUCTION

Plaintiff NorthBay Healthcare Group Hospital Division d/b/a NorthBay Medical Center and VacaValley Hospital ("NorthBay") filed a suit over reimbursements that it believes were not for the reasonable and customary value of the services given to members of defendant Blue Shield of California Life & Health Insurance Company and California Physicians' Service d/b/a Blue Shield of California ("Blue Shield"). Count Eight of NorthBay's complaint alleges that Blue Shield's reimbursement methodology constituted an unfair business practice under California's Unfair Competition Law ("UCL"), California Business and Professions Code Section 17200 et seq. , and Count Nine seeks related declaratory relief. NorthBay asserts that Blue Shield uses a flawed methodology or manipulates data, did not properly apply criteria for setting reimbursement rates, and engaged in an unfair payment pattern.

Blue Shield moves for partial summary judgment on those counts, contending that there is no private right of action to challenge the methodology used to determine reasonable reimbursements and urging that even if there were the court should abstain from functioning like an administrative body on issues of complex economic policy. Given the regulations and oversight of the Department of Manage Health Care ("DMHC") concerning these payments, NorthBay's UCL claim must be predicated *984on an incorrect reimbursement amount that causes it injury rather than the methodology that led to it. Accordingly, I GRANT Blue Shield's motion for partial summary judgment.

BACKGROUND

I. FACTUAL AND LEGAL BACKGROUND

NorthBay is a nonprofit healthcare organization that owns and operates two hospitals in Solano County, California. See First Amended Compl. ¶ 3. The hospitals provide comprehensive care, including emergency care. Id. Blue Shield is a health care service plan in which members receive care from in-network hospitals for more favorable reimbursement terms than if they were out-of-network. See Crawford Decl. ¶¶ 3-5 (Dkt. No. 47-3). The health plan implements a two-tiered benefit structure to control costs and offer lower monthly dues to its members. Id. ¶ 6.

When health plan members visit hospitals that are outside the network, such as Blue Shield members who receive emergency care from NorthBay, hospitals are required to provide treatment. See Cal. Health & Safety Code § 1317 ; 42 U.S.C. § 1395dd(a). In California, health plans must promptly pay a reasonable amount for the emergency services, called the "reasonable and customary value." Cal. Code Regs. tit. 28, § 1300.71(a)(3)(B), Cal. Health & Saf. Code § 1371.4(b). These "prompt-pay" laws, embodied in the Knox-Keene Health Care Service Plan Act of 1975, ("Knox-Keene Act" or the "Act") require health plans to reimburse hospitals within thirty working days after it receives a complete claim. See id. § 1371.35(a).

California's "prompt-pay" laws also task the Department of Managed Health Care ("DMHC") with regulating the state's health care policy. See id. § 1371.38. In turn, DMHC directs health plans like Blue Shield to adopt their own reasonable and customary value methodology ("R & C methodology") for reimbursing non-contracted hospitals according to its guidance and regulations. See Cal. Code Regs. tit. 28, § 1300.71(a)(3)(B). Health plans then submit their R & C methodologies to the DMHC consistent with this regulatory scheme.

In Section 1300.71(a)(3)(B), the DMHC adopted what are termed the Gould factors (named after Gould v. Workers' Comp. Appeals Bd. , 4 Cal. App. 4th 1059, 1071, 6 Cal.Rptr.2d 228 (1992) ) to determine whether a given reimbursement amount is of "reasonable and customary value." The Gould factors include six non-exclusive considerations related to medical provider qualifications, the nature of the service provided, fees charged by geography, and other considerations. Id. Health plans must consider these factors when they develop their R & C methodology, but there is no regulation dictating the appropriate way to consider them or requiring a specific reimbursement value. As amicus curiae in other law suits, the DMHC has represented before that it "does not specifically approve or disapprove filings purporting to establish a methodology, pursuant to Title 28 Cal. Code Regs. § 1300.71(a)(3)(B), for reimbursement of non-contracted providers." Tooch Decl. Ex. D. ¶ 7 (Dkt. No. 52-1). But the DMHC has the authority to take disciplinary actions like civil, criminal, or administrative penalties if it does find an R & C methodology is non-compliant with Section 1300.71. See Cal. Code Regs. tit. 28, § 1300.71(s)(2).

Blue Shield submitted its R & C methodology to the DMHC around March 2015. See Vojta Decl. ¶ 5 (Dkt. No. 47-1). Its R & C methodology considers reasonable and customary value of non-contracted services by what other hospitals in the region charge or receive for payment of similar services, the hospital's own reported costs *985of operation, and other considerations. Id. ¶ 4. Consistent with the DMHC's request, Blue Shield detailed how it considered the Gould factors in compliance with Section 1300.71(a)(3)(B). See Tooch Decl. Ex. A at BSC002648. The DMHC has not required Blue Shield to change its R & C methodology. Id.

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342 F. Supp. 3d 980, Counsel Stack Legal Research, https://law.counselstack.com/opinion/northbay-healthcare-grp-hosp-div-v-blue-shield-of-cal-life-health-cand-2018.