United States District Court, D. Alaska
ORDER
H.
Russel Holland United States District Judge.
Cross-motions
for Summary Judgment
Plaintiff
moved for partial summary judgment.[1] This motion was opposed, and
defendant cross-moved for summary judgment.[2] Defendant's
cross-motion was opposed.[3]
After
hearing oral argument, the court denied both motions on the
record. What follows is a brief order explaining the
court's denial of the motions.
Facts
Plaintiff
Alaska Native Tribal Health Consortium (ANTHC) is a tribal
organization that provides health care services to Alaska
Natives, American Indians, and other eligible individuals
pursuant to Titles I and V of the Indian Self-Determination
and Education Assistance Act, 25 U.S.C. §§
450f-450n, 458aaa-458aaa-18; the Alaska Tribal Health
Compact; and plaintiff's Funding Agreement with the
Secretary of Health and Human Services. Plaintiff co-manages
the Alaska Native Medical Center (ANMC) in Anchorage, Alaska,
under this authority.[4] Alaska Natives and American Indians who
receive health care services at ANMC are not personally
responsible for paying costs associated with their care,
although plaintiff could choose to charge ANMC patients for a
portion of their care.
Defendant
is Premera Blue Cross. Defendant provides health insurance to
some of the individuals who obtain health care services at
ANMC. From 2001 through 2011, plaintiff and defendant had a
contract which provided the rates which defendant agreed to
pay for the health care services that plaintiff provided to
defendant's insureds. That contract was terminated by
plaintiff on April 15, 2011, as a consequence of a dispute
between the parties over plaintiff's use of Guardian
Flight for air ambulance services.
Unlike
plaintiff, defendant requires its insureds to pay some form
of cost-sharing when they receive health care services
covered by their insurance plan. Defendant's insureds may
be required to pay co-payments or deductibles or some
combination thereof.
Plaintiff
commenced this action on March 27, 2012. Plaintiff alleges
that defendant is not paying it in accordance with Section
206(a) of the Indian Health Care Improvement Act, 25 U.S.C.
§ 1621e. The only remaining claim in this action is
Count 3 of plaintiff's first amended complaint, which
deals with defendant's post-contract payments to
plaintiff. In Count 3, plaintiff seeks to “recover from
Premera the difference between the actual amounts it paid to
ANTHC and ANTHC's reasonable charges billed for health
care and services provided to Premera's
insureds....”[5]
The
court has held that Section 206(a) requires defendant to pay
plaintiff “the higher of its reasonable billed charges
or the Alaska UCR rate.”[6] Plaintiff contends that since
April 16, 2011, defendant has failed to pay it according to
Section 206(a) because defendant is paying plaintiff less
than its billed charges, which plaintiff contends are
reasonable.
Plaintiff
moved for summary judgment that the minimum amount that
defendant owes plaintiff is the difference between
defendant's “allowed amounts” and what
defendant has actually paid plaintiff because defendant has
admitted that its allowed amounts are reasonable charges.
Defendant opposed plaintiff's motion for partial summary
judgment and cross-moved for summary judgment on
plaintiff's remaining claim. Defendant contends that it
has not admitted that its allowed amounts constitute
reasonable payments and that plaintiff cannot prove that its
actual billed charges are reasonable.
Discussion
Summary
judgment is appropriate when there are no genuine issues of
material fact and the moving party is entitled to judgment as
a matter of law. Fed.R.Civ.P. 56(a). The initial burden is on
the moving party to show that there is an absence of genuine
issues of material fact. Celotex Corp. v. Catrett,
477 U.S. 317, 325 (1986). If the moving party meets its
initial burden, then the non-moving party must set forth
specific facts showing that there is a genuine issue for
trial. Anderson v. Liberty Lobby, Inc., 477 U.S.
242, 247-48 (1986). In deciding a motion for summary
judgment, the court views the evidence of the non-movant in
the light most favorable to that party, and all justifiable
inferences are also to be drawn in its favor. Id. at
255.
“Allowed
amounts” are “the maximum amount that an insurer
would consider paying for a medical service or procedure,
including any payments for which the insured individual would
be responsible for (i.e. co-pays, deductibles,
etc.).”[7] Plaintiff argues that defendant has
admitted that its allowed amounts are reasonable and thus
plaintiff contends that defendant should have at least paid
plaintiff the allowed amounts. Plaintiff's argument is
based on two contentions: 1) that defendant contends that it
determines its allowed ...