Desert Healthcare Dist. v. PacifiCare, FHP, Inc

In Desert Healthcare Dist. v. PacifiCare, FHP, Inc. (2001) 94 Cal.App.4th 781, a hospital sued a health care service plan for the cost of services provided to enrollees of the plan. The insurer, PacifiCare, had contracted with an intermediary, Desert Physician's Association (DPA). This was a capitation agreement for which PacifiCare paid a flat fee per person to DPA to provide physicians and obtain hospital services for PacifiCare's subscribers. The intermediary, DPA, contracted with a provider, Desert Healthcare, to obtain hospital services for PacifiCare's subscribers. Under this arrangement, Desert Healthcare billed DPA rather than PacifiCare for the services it provided to PacifiCare subscribers. DPA filed for bankruptcy, extinguishing its debt to Desert Healthcare for millions of dollars. Desert Healthcare sued PacifiCare to recover payment for the services it rendered to PacifiCare's subscribers under the contract with DPA. The court rejected Desert Healthcare's argument that the nonwaiver clause of section 1371 of the Knox-Keene Act required PacifiCare to bear the ultimate responsibility for the services provided despite its capitation agreement with DPA. (Desert Healthcare, supra, 94 Cal.App.4th at p. 786.) Like the Aetna court, it held that whether read in isolation or as a part of the whole statute, the nonwaiver clause did not impose an obligation on the insurer to pay the provider directly. (Id. at p. 788.) It merely "imposes certain procedural requirements on the processing of claims; it does not create a new, independent basis for liability." (Ibid.) The Desert Healthcare court also held that Desert Healthcare's interpretation would destroy capitation agreements allowed under other provisions of the Knox-Keene Act. (Id. at p. 789.) In Desert Healthcare Dist. v. PacifiCare FHP, Inc. (2001) 94 Cal.App.4th 781, the Court held: "The instant case is a perfect example of when a court of equity should abstain. Desert Healthcare essentially argues that PacifiCare abused the capitation system by transferring too much risk to its intermediary without adequate oversight. In order to fashion an appropriate remedy for such a claim, be it injunctive or restitutionary, the trial court would have to determine the appropriate levels of capitation and oversight. Such an inquiry would pull the court deep into the thicket of the health care finance industry, an economic arena that courts are ill-equipped to meddle in. As such, there is no proper role for the court of equity to play in the instant dispute." (Desert Healthcare, supra, 94 Cal.App.4th at pp. 795-796.) In Desert Healthcare, the owner of a hospital sued PacifiCare, a health care service plan licensed under the Knox-Keene Act. Similar to the arrangement alleged here, PacifiCare contracted with Desert Physicians Association (DPA) to provide medical services to subscribers of PacifiCare. Pursuant to their "capitation agreement," "PacifiCare paid DPA a flat fee per person to provide physicians and obtain hospital services for PacifiCare's subscribers." (Desert Healthcare, supra, 94 Cal.App.4th at p. 785.) DPA, in turn, contracted with Desert Healthcare to obtain hospital services for PacifiCare's subscribers. (Ibid.) After DPA filed for bankruptcy and extinguished its debts, Desert Healthcare sought to recover millions of dollars it had spent for hospital services provided to subscribers of PacifiCare. (Ibid.) Desert Healthcare asserted UCL claims based on the Knox-Keene Act against PacifiCare based on "PacifiCare's practice of requiring waivers from its providers and refusing to pay claims for which it had received premiums." (Id. at pp. 785-786.)