The Ever Outrageous Outlier

This one (lawsuit) appears to be all about outlier provisions, and what happens when a really high dollar claim hits a plan………………………………..

Editor: Hospital managed care contracts typically include the biggest GOTCHA CLAUSE ever created by mankind, the ever outrageous OUTLIER. Yet plan sponsors blindly accept these contracts of adhesion through PPO networks, in essence committing financial suicide through guaranteed higher health care costs…..

By Scott Bennett on Linkedin

Pomona Valley Hospital and MGM (and United Healthcare) are in a battle over about 1.5 million dollars in a contract dispute.  Sections of the “kitchen sink” complaint are in the image.

This one appears to be all about outlier provisions, and what happens when a really high dollar claim hits a plan.  While it is unlikely, I’d like to see this one get to a jury on the issue of good faith and fair dealing in contracting – and bring in all of the parties.

Pomona Valley has a cost to charge ratio of around 10%, so it would be interesting as to what some solid legal advocacy (by all those involved) would say about an agreement (or more likely web of conflicting agreements) to pay 66% of the “Entire Claim” on the outlier claims.  This is a docket to watch (potentially) for some stellar expert work, audits, memos, primary sources, and reports.  Or it settles…

Scott Bennett

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