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Southern California Hospital System Sues Kaiser Permanente for Managing Bills Rather Than Managing Care
Date:2/13/2008

that HMOs like Kaiser fairly and properly reimburse providers of emergency medical services because otherwise more hospitals may be forced to close". Mr. Krissman commented further that "Prime Healthcare had no choice but to file lawsuits against Kaiser in order to ensure continued access to healthcare for the members of the communities in which its hospitals are located."

In contrast to financially distressed hospitals, Kaiser reported profits of $1.3 Billion in 2006 and $2.5 Billion in 2007. This is not surprising given that although insurance premiums have increased; the amount of revenue spent on patient care has remained the same or decreased. Rather than spending the increased premiums on patient care, HMOs are using the money on increased layers of bureaucracy and middle management whose job it is to refuse necessary patient care, deny provider claims or find other ways to not pay provider claims properly. According to Dr. Prem Reddy, a board certified Cardiologist and Chairman of Prime Healthcare Services, "HMOs, including Kaiser, ought to be focused on effectively managing patients' care; but unfortunately, they are focused on managing bills". Also, in order to implement a process of working efficiently with Kaiser, Dr. Hassan Alkhouli, Medical Director of Prime Healthcare's Orange County Hospitals, attempted numerous times to arrange for a meeting with Kaiser's utilization managers to address utilization issues but his telephone calls went unanswered.

According to Prime Healthcare, Kaiser's tactics to avoid properly paying claims include making repeated and unnecessary demands for medical records, denying reimbursement for emergency medical services under the guise that the care was not medically necessary even though the Prudent Layperson Standard is met on every occasion, retrospectively reviewing claims for emergency care, and demanding the transfer of Kaiser members to Kaiser's hospitals with no regard to the patients' medical condition
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SOURCE Prime Healthcare Services
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