Alaska Native Tribal Health Consortium v. Cross

          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 ...