Unihealth v. U.S. Healthcare, Inc.

14 F. Supp. 2d 623, 1998 U.S. Dist. LEXIS 10296, 1998 WL 385456
CourtDistrict Court, D. New Jersey
DecidedJuly 10, 1998
DocketCivil Action 95-6037(WHW)
StatusPublished
Cited by8 cases

This text of 14 F. Supp. 2d 623 (Unihealth v. U.S. Healthcare, Inc.) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Unihealth v. U.S. Healthcare, Inc., 14 F. Supp. 2d 623, 1998 U.S. Dist. LEXIS 10296, 1998 WL 385456 (D.N.J. 1998).

Opinion

OPINION

PISANO, United States Magistrate Judge.

This case concerns a contract dispute between plaintiff, Unihealth, and defendants, U.S. Healthcare, Inc. and The Health Maintenance Organization of New Jersey, Inc. Unihealth represents the Meadowlands Hospital Medical Center, which entered into a “Hospital Services Agreement” with the defendants in 1991. Pursuant to this agreement, Meadowlands Hospital was to provide hospital services to enrollees in U.S. Healthcare’s health maintenance organization in exchange for U.S. Healthcare’s payment for said services. On November 28, 1995, Uni-health brought this suit against defendants, alleging that defendants breached their contract by failing to make proper reimbursements according to the terms of the contract. A non-jury trial was held before the Court on February 10 and February 11,1998.

For the reasons discussed herein, the Court finds that: (1) the repeal of the former governmental hospital billing system (the “DRG system”) frustrated the Hospital Services Agreement; (2) a modification of this agreement is necessary to provide an equitable remedy for the parties; and (3) the amounts billed for normal newborn babies are to be included in the 1992 and 1993 reconciliations required under the discount clause of this agreement.

With reference to plaintiffs claim for 1992 services, the Court orders defendants to pay plaintiff $39,374.54, which constitutes payment for hospital services and prejudgment interest. With reference to plaintiffs claim for 1993 services, the Court is not satisfied that either party has provided an appropriate method of reconciliation of their respective *626 positions. Accordingly, the Court refers the case to a Special Master. The Special Master shall assist the parties, through mediation, to arrive at a charging formula that is comparable to the DRG system for the purpose of modifying the discount clause in the parties’ agreement. In the event the parties are unable to agree upon a suitable charging mechanism, the Special Master shall receive evidentiary submissions from the parties and shall file a Report and Recommendation as to the appropriate standard for plaintiffs billings. The Court assigns the Special Master to subsequently reconcile the amount, including prejudgment interest, that the defendants owe plaintiff for 1993 hospital services pursuant to this formulated rating system.

FACTUAL BACKGROUND

Unihealth, a nonprofit public benefit corporation organized under the laws of the state of California, was the sole corporate member of Meadowlands Hospital Medical Center (“Meadowlands”), which operated a health care facility until March 29, 1994, when operations were ceased. Unihealth then sold certain of its asserts to Liberty Riverside Health Care, Inc. According to the terms of the sale agreement, Meadowlands retained the rights to any claims against the defendant, among others. On August 3, 1995, Meadowlands was dissolved and all of its claims, including the one against defendants, were distributed to Unihealth.

On April 1, 1991, Meadowlands entered into a “Hospital Services Agreement”, (“the Agreement”), with U.S. Healthcare, Inc. and The Health Maintenance Organization of New Jersey, Inc. (“HMO”). 1 This agreement provided for the terms by which U.S. Healthcare would pay Meadowlands for services rendered to its members. See Ex. P-1 (the Agreement). Schedule A of the contract describes the services covered under the contract. See id. at pp. 1-2 of Schedule A. According to this schedule, “Maternity Care” service includes “semi-private accommodations in a regular maternity bed for the purpose of delivering a baby; inclusive of daily service and all ancillary services for both mother and child.” Id. at p. 1 of Schedule A.

The Agreement also provides that “fees to be charged by Hospital for Hospital Services rendered to Members shall be as described in Schedule B, attached hereto and by reference made a part of this Agreement.” Id. at p. 1. Schedule B provides a table of rates that Meadowlands could charge for various services. See id. at Schedule B. U.S. Healthcare agreed to pay “per diem” rates, for all inpatient medical procedures aside from vaginal and caesarean (C-section) deliveries, which were to be paid through a flat-fee “case” rate system. 2 See id. Schedule B states that ease rates for both vaginal deliveries and C-seetions “include[ ] normal newborn.” Id.

Under the “per diem” rate system, defendants were to "pay Meadowlands a fixed daily amount when a patient was in the hospital for that particular procedure. See id. According to calculations made during the negotiation of the Agreement, these per diem rates resulted in significantly lower hospital billings than the billings accrued from the rates that Meadowlands ordinarily charged other patients. See Transcript of February 10, 1998 Proceedings, Volume I (“TI”):50-52. To compensate plaintiff for its potential loss in revenue under such terms, the parties incorporated the following clause, which the Court refers to as “the discount clause,” at the bottom of Schedule B:

If the overall discount for all Inpatients exceeds 40% during a calendar year, U.S. Healthcare will reimburse Meadowlands Hospital and Medical Center monies beyond the 40% discount. A reconciliation will be completed by HMO within 180 days of the end of the calendar year.

Id.

Although the discount clause applies where “the overall discount ... exceeds 40%,” the *627 term “discount,” specifically, the lodestar from which the discount should be assessed, is not referred to or defined anywhere in the Agreement. The correct interpretation of this clause is one of the primary issues in this case. The resolution of this issue determines the amount of payment that the defendants owe under the Agreement for the year of 1993. The second issue is whether amounts billed for normal newborn babies are to be included in the reconciliation required under the discount clause. The resolution of this issue determines the amount of payment the defendants owe for the years of 1992 and 1993. 3

After the parties executed the Agreement in 1991, they began to perform under it. Plaintiff provided services to U.S. Healthcare members, and submitted bills to U.S. Healthcare for those services. See Exs. P-4, and P-5 (Meadowlands Hospital U.S. Healthcare “Patient Account Inquiry Screens” for the Calender Years of 1992, 1993, respectively). 4 U.S. Healthcare, in turn, paid for those services in accordance with the rates contained in Schedule B to the Agreement. See id.

Although the Agreement required the defendants to calculate the reimbursement due under the discount clause within 180 days of the end of the calendar year, the parties never agreed upon a reconciliation for any year. See Ex. P-1 at Schedule B; Plaintiffs Proposed Conclusions of Law and Findings of Fact (“PF”) at p. 19.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

JB Pool Mgmt., LLC v. Four Seasons
67 A.3d 702 (New Jersey Superior Court App Division, 2013)
Nye v. Ingersoll-Rand Co.
783 F. Supp. 2d 751 (D. New Jersey, 2011)
Chase Manhattan Bank v. Iridium Africa Corp.
474 F. Supp. 2d 613 (D. Delaware, 2007)

Cite This Page — Counsel Stack

Bluebook (online)
14 F. Supp. 2d 623, 1998 U.S. Dist. LEXIS 10296, 1998 WL 385456, Counsel Stack Legal Research, https://law.counselstack.com/opinion/unihealth-v-us-healthcare-inc-njd-1998.