San Jose’s Good Samaritan Hospital — owned by for-profit hospital chain HCA Healthcare — is suing Santa Clara County and its medical health insurance plan over their reimbursements for emergency look after greater than 5,000 sufferers.
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Regional Medical Heart, which can be named as a plaintiff within the lawsuit, was owned by HCA till the county bought it three months in the past. The county’s acquisition was pushed by HCA’s plans to shut the hospital’s Degree II trauma heart — a transfer that may have left East San Jose residents with out close by entry to trauma care.
Based on the lawsuit, which was filed on July 17 in Santa Clara County Superior Court docket, sufferers coated by the county’s Valley Well being Plan routinely visited Good Samaritan Hospital and Regional Medical Heart, that are required by legislation to offer emergency care to anybody no matter their insurance coverage or capability to pay.
After a Valley Well being Plan affected person has been handled, the hospital then sends the invoice to the insurance coverage firm. Usually, if a hospital has a contract with an insurance coverage supplier and is “in-network,” insurance coverage pays the agreed-upon price. If the hospital is “out-of-network,” the insurance coverage supplier has to pay an affordable value for the providers.
However makes an attempt at negotiating a contract between Good Samaritan Hospital and Valley Well being Plan have been “wholly unsuccessful,” in response to the lawsuit. The 2 events have additionally disagreed over the price of providers for sufferers insured by Valley Well being Plan, with the lawsuit alleging the county-sponsored insurance coverage supplier “has paid amounts that are substantially less than the billed amounts.”
Vally Well being Plan “repeatedly has refused to pay the reasonable and customary value of the services” for its sufferers, the lawsuit mentioned. “VHP instead ‘self-determined’ amounts to pay to the hospitals. These amounts are less than reasonable and customary value for the services. VHP has thus put the hospitals in an untenable position — they cannot refuse to provide emergency medical services to VHP patients, but they also cannot accept VHP’s self-determined and insufficient amounts for those services.”
Good Samaritan is in search of to recuperate the distinction between what Valley Well being Plan has paid in these instances and what it believes is the “reasonable and customary value of the hospitals’ services,” in response to the lawsuit.
A spokesperson for Good Samaritan Hospital declined to reply particular questions on how a lot the hospital believed it’s owed and the way the dispute has impacted total operations.
The lawsuit additionally accused the county of utilizing a “flawed methodology that does not comply with California laws to determine the amount it pays for such services.”
In a press release, Santa Clara County Counsel Tony LoPresti mentioned the county “uses well-established and widely accepted methodologies for developing reasonable and customary reimbursement rates for medical services, and we look forward to presenting those methodologies to the court in this litigation.”
The lawsuit comes at a time when the county is bracing for impacts to its well being care system because of President Donald Trump’s “Big, Beautiful Bill,” which is able to reduce Medicaid — a federally funded public medical health insurance program often called Medi-Cal in California — by $1 trillion over the following decade. Revenues from Medicaid are the most important income for the county-operated Santa Clara Valley Healthcare system, and the county is anticipating $1 billion in misplaced federal revenues domestically over the following few years.
