Pac. Bay Recovery, Inc. v. Cal. Physicians' Servs., Inc.

218 Cal. Rptr. 3d 562, 12 Cal. App. 5th 200, 2017 WL 2200162, 2017 Cal. App. LEXIS 496
CourtCalifornia Court of Appeal, 5th District
DecidedMay 19, 2017
DocketD070561
StatusPublished
Cited by42 cases

This text of 218 Cal. Rptr. 3d 562 (Pac. Bay Recovery, Inc. v. Cal. Physicians' Servs., Inc.) is published on Counsel Stack Legal Research, covering California Court of Appeal, 5th District primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Pac. Bay Recovery, Inc. v. Cal. Physicians' Servs., Inc., 218 Cal. Rptr. 3d 562, 12 Cal. App. 5th 200, 2017 WL 2200162, 2017 Cal. App. LEXIS 496 (Cal. Ct. App. 2017).

Opinion

HUFFMAN, Acting P.J.

*203California Physicians' Services dba Blue Shield of California (Blue Shield) is a health care service plan subject to the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act), Health and Safety Code section 1340 et seq.1 Pacific Bay Recovery, Inc. (Pacific Bay) is a medical provider that treats substance abuse and narcotic addiction. Blue Shield contracts with certain medical groups and providers to provide medical care at reduced costs through a network of provider *565contracts. (§ 1342.6.) Pacific Bay had no provider contract with Blue Shield during the time at issue in this matter. Thus, Pacific Bay was an out-of-network provider.

Pacific Bay treated an individual who was a subscriber to a Blue Shield health plan. It submitted invoices to Blue Shield for payment for the services rendered to the subscriber in the amount of $3,500 each of the 31 days of treatment. Blue Shield paid Pacific Bay for six days of treatment at the billed rate of $3,500 per day. Pacific Bay contends it was underpaid and brought suit against Blue Shield to recover the additional amount it claimed to be owed. The court sustained Blue Shield's demurrer to the first amended complaint (FAC) without leave to amend, finding that Pacific Bay had not shown that it was entitled to any payment from Blue Shield.

Here, Pacific Bay argues the court erred in sustaining the demurrer without leave to amend. It frames the issue before this court as follows: Is Blue Shield obligated to pay Pacific Bay, an out-of-network nonemergency provider, a usual, customary, and reasonable rate for services Pacific Bay provided to a Blue Shield subscriber? On the record before us, we answer this question in the negative. As such, we affirm the judgment in this matter, which followed the superior court sustaining Blue Shield's demurrer to the FAC.

FACTUAL AND PROCEDURAL BACKGROUND

Allegations in the FAC

Blue Shield is a health care service plan under the Knox-Keene Act. The Department of Managed Health Care (DMHC) regulates Blue Shield.

Pacific Bay specializes in treating substance abuse and narcotic addiction and has treated numerous patients, including patients who are subscribers and/or members of a Blue Shield health care plan. Pacific Bay has a *204reputation of providing high quality care, treatment, and procedures. It provides intensive inpatient and outpatient services to patients struggling with addiction.

A Blue Shield subscriber was admitted to Pacific Bay's program on December 1, 2014. At that time, the subscriber belonged to a Blue Shield PPO plan and was covered under a policy or certificate of insurance that was issued and underwritten by Blue Shield. This plan ensured the subscriber's access to medically necessary treatments, care, procedures, and surgeries by medical providers. However, Pacific Bay was an "out-of-network provider" that had no preferred provider contracts or other contracts with Blue Shield at the time it rendered services for the subscriber.

Pacific Bay contacted Blue Shield to obtain prior authorization, precertification, and consent to render treatment and perform procedures on the subscriber. Blue Shield advised Pacific Bay that the subscriber was insured, covered, and eligible for coverage under Blue Shield's PPO plan for the services to be rendered by Pacific Bay at facilities operated by Pacific Bay. In addition, Pacific Bay believed Blue Shield would pay for the services it provided the subscriber. Blue Shield did not advise Pacific Bay that the applicable plan or policy was subject to certain exclusions, limitations, or qualifications, which might result in denial of coverage of the services provided to the subscriber. Also, Blue Shield did not offer Pacific Bay copies of the relevant policies or certificate of insurance coverage applicable to the subscriber. Pacific Bay was led to believe that it would be paid a portion or percentage of its total billed charges.

*566During the course of its treatment of the subscriber, Pacific Bay submitted five invoices to Blue Shield for its services at its usual and customary rate of $3,500 per day. In response, Blue Shield provided Pacific Bay with an explanation of benefits (EOB) in relation to the subscriber's plan. Blue Shield paid Pacific Bay for six of the 31 days of service at a rate of $3,500 per day. It paid nothing for the additional 25 days.

Pacific Bay appealed Blue Shield's payment for the services, but did not receive a satisfactory answer. The majority of Pacific Bay's invoices remained unpaid.

Pacific Bay's Suit

Believing it had been underpaid by Blue Shield, Pacific Bay filed a complaint in San Diego Superior Court, alleging six causes of action (recovery on payment for services rendered, quantum meruit, breach of implied contract, declaratory relief, estoppel, and violation of regulations). The thrust *205of Pacific Bay's complaint was that it contacted Blue Shield to obtain prior authorization, precertification, and consent to render treatment to the subscriber and was led to believe it would be "paid a portion or percentage of its total billed charges, which charges correlated with usual, reasonable and customary charges." In the complaint, Pacific Bay claimed that the DMHC had adopted regulations that "define the amount that health care service plans [,] such as Blue Shield[,] are obligated to pay non-contracted providers such as" Pacific Bay. In support of its allegations, Pacific Bay cited to section 1300.71, subdivision (a)(3)(B) of title 28 of the California Code of Regulations. Specifically, Pacific Bay alleged that this portion of the regulation provided the "same criteria used by California Courts to determine the quantum meruit amounts that should be paid for services rendered by non-contracted providers by insurers in California." Based on its six causes of action, Pacific Bay averred that it was "owed reimbursement, compensation, and payment of the cost of the services, treatment, care and pharmaceuticals [,] which it rendered and provided to the [subscriber] at [its] billed rates or at rates equivalent to the usual, customary and reasonable value of [its] services, in conformance with the commitments, contracts, promises and agreements made by Blue Shield."

Blue Shield demurred to the original complaint, arguing that it could not be liable to Pacific Bay, an out-of-network provider without any contract with Blue Shield, for any amount beyond what the terms of the governing evidence of coverage (EOC)2 allowed. Blue Shield also explained that Pacific Bay did not plead any facts that would entitle it to receive additional payment from Blue Shield. Specifically, Blue Shield noted that Pacific Bay simply offered conclusory allegations that it rendered services at Blue Shield's request without concrete details explaining the arrangement.

In opposing the demurrer, Pacific Bay argued it was a provider under section 1300.71, subdivision (a)(3)(B) of title 28 of the California Code of Regulations, and thus, was entitled to the reasonable and customary value of the services rendered.

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218 Cal. Rptr. 3d 562, 12 Cal. App. 5th 200, 2017 WL 2200162, 2017 Cal. App. LEXIS 496, Counsel Stack Legal Research, https://law.counselstack.com/opinion/pac-bay-recovery-inc-v-cal-physicians-servs-inc-calctapp5d-2017.