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California hospital system underpaid by Blue Shield for ER services, jury finds

Fairfield, Calif.-based NorthBay Healthcare may recover $16 million-plus from Blue Shield of California after a federal jury in San Francisco found the health insurer underpaid the hospital system for emergency care.

On Feb. 13, after a six-day trial, the jury found Blue Shield owed NorthBay 67 percent of its billed charges, according to law firm King & Spalding, which represented NorthBay. The exact amount of damages has yet to be determined, but is currently estimated at more than $16 million. The case stems from December 2016, when Blue Shield and NorthBay ended their contract for in-network care. Blue Shield then allegedly paid NorthBay low rates for emergency services provided to Blue Shield members, which prompted NorthBay to sue the health insurer.

NorthBay operates NorthBay Medical Center in Fairfield and NorthBay VacaValley Hospital in Vacaville.

In an emailed statement to Becker's Hospital Review, Blue Shield said it is "a nonprofit health plan whose goal is to give people access to quality care that's sustainably affordable. This case went to trial because the amounts NorthBay Healthcare Group charged for emergency services for our members ran counter to that goal. The jury determined that the value for these services was far lower than what NorthBay had billed Blue Shield, and far lower than the amounts that NorthBay had argued to the jury as the reasonable value of its services. Neither the jury nor the court have determined what additional amounts may be owed, and the jury portion of this case is just the first phase of the lawsuit. While NorthBay's hospitals currently are not in our provider network, we remain open to working with any provider who shares in our quality and affordability goals."

via Becker's

#blueshield #emergencyroom #physicianreimbursement

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