Source: https://www.scribd.com/document/413297826/Kaiser-Foundation-Health-Plan-v-Queen-s-Health-System
Timestamp: 2019-11-21 04:04:03
Document Index: 235378475

Matched Legal Cases: ['§ 1332', '§ 2202', '§ 1337', '§ 1391', '§ 431', '§ 1395', '§ 431', '§ 431', '§ 431', '§ 1395', '§ 431']

Kaiser Foundation Health Plan v. Queen's Health System | Health Maintenance Organization | Emergency Department
Kaiser Foundation Health Plan v. Queen's Health System
Kaiser, an integrated healthcare system based in Oakland, Calif. that covers individuals at Queen’s four hospitals in Hawaii, disputed Queen’s alleged assertion that it would bill Kaiser members who receive emergency care at Queen’s if Kaiser does not pay all the billed charges, according to a lawsuit Kaiser filed in federal court.
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Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 1 of 18 PageID #: 1
JORDON J. KIMURA #9182-0
JORDAN K. INAFUKU #10392-0
Telephone: 808.529.7300
Facsimile: 808.535.8056
E-Mail: kimura@m4law.com
jinafuku@m4law.com
MOE KESHAVARZI (pro hac vice application pending)
JOHN T. BROOKS (pro hac vice application pending)
Telephone: 213.620.1780
Facsimile: 213.620.1398
E-mail: mkeshavarzi@sheppardmullin.com
jbrooks@sheppardmullin.com
KAISER FOUNDATION HEALTH Case No. ________________________
PLAN, INC. a foreign non-profit
corporation, COMPLAINT FOR
Plaintiff, INJUNCTIVE RELIEF; EXHIBIT A
[Caption continued on next page]
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 2 of 18 PageID #: 2
THE QUEEN’S MEDICAL CENTER,
NORTH HAWAII COMMUNITY
HOSPITAL, INC., MOLOKAI
GENERAL HOSPITAL, and DOES 1-
JUDGMENT AND INJUNCTIVE RELIEF
1. The Queen’s Medical Center, North Hawaii Community Hospital, and
Molokai General Hospital (collectively “Queens Health System Hospitals” or
“QHS”) operate numerous hospitals in the State of Hawaiʻi that provide emergency
medical services to the public. QHS has notified Kaiser Foundation Health Plan,
Inc. (“Kaiser”) that it intends to directly bill Kaiser members who receive
emergency medical services at their facilities for amounts that they are not legally
obligated to pay. Further, QHS disclosed that it intends to bill Kaiser—and then
Kaiser’s commercial members—100 percent of its full billed charges for all
services, including emergency services. QHS’ threatened actions—which it claims
it will retroactively and immediately implement—violate multiple Hawaiʻi and
federal statutes as well as the common law, including laws requiring:
 QHS to hold Kaiser members harmless and refrain from billing them
for any emergency service; and
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 3 of 18 PageID #: 3
 QHS to accept less than full billed charges for emergency services
rendered to Kaiser members.
Kaiser, therefore, seeks a judgment declaring that (1) QHS does not have the legal
right to directly bill Kaiser members for emergency services (except for
deductibles and copayments) and (2) that Kaiser has to pay only the reasonable
value of QHS emergency services rendered to its commercial members, which is
not necessarily 100 percent of QHS’ billed charges. Kaiser also seeks injunctive
relief on the same grounds.
2. Kaiser Foundation Health Plan, Inc. is a nonprofit health plan
incorporated in the state of California. Kaiser’s principal place of business, and the
location of its high level officers, is One Kaiser Plaza, Oakland, California 94612.
Kaiser is authorized to do business in the State of Hawaiʻi, and has operated as one
of the largest health plans in Hawaiʻi for 60 years. Kaiser currently serves more
than 250,000 members in Hawaiʻi, with operations on Oahu, Maui, Hawaiʻi and
Kauai. With the other entities that make up the Kaiser Permanente integrated care
model, Kaiser employs nearly 5,000 people in the State of Hawaiʻi.
3. The Queen’s Medical Center (including The Queen’s Medical Center
– West Oahu) is, and was at all relevant times, two medical care facilities engaged
in the provision of healthcare services on the island of Oahu, State of Hawaiʻi. The
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 4 of 18 PageID #: 4
Queen’s Medical Center operates facilities that provide emergency services at
1301 Punchbowl Street, Honolulu and 91-2141 Fort Weaver Road, Ewa Beach. The
Queen’s Medical Center is a nonprofit corporation incorporated under the laws of
the State of Hawaiʻi, with its principal place of business located in Honolulu,
4. North Hawaii Community Hospital, Inc. is, and was at all relevant
times, a medical care facility engaged in the provision of healthcare services on the
island of Hawaiʻi, State of Hawaiʻi. North Hawaii Community Hospital, Inc. is a
nonprofit corporation incorporated under the laws of and maintains a principal
place of business in the State of Hawaiʻi.
5. Molokai General Hospital is, and was at all relevant times, a medical
care facility engaged in the provision of healthcare services on the island of
Molokai, State of Hawaiʻi. Molokai General Hospital is a nonprofit corporation
incorporated under the laws of and maintains a principal place of business in the
State of Hawaiʻi.
6. Kaiser is informed and believes, and on that ground alleges, that
Queen’s Medical Center, North Hawaii Community Hospital, Inc., and Molokai
General Hospital are under common ownership and control, and collectively refer
to themselves as Queens Health System.
7. DOES 1-10 are sued herein under fictitious names for the reason that
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 5 of 18 PageID #: 5
their true names, identifies and/or responsibilities to Kaiser are currently unknown
except that they were in some manner involved in the conduct alleged herein.
Kaiser prays for leave to amend this Complaint when the true names, capacities,
and/or responsibilities of DOES 1-10 are ascertained.
8. Kaiser brings this action under 28 U.S.C. § 1332 because the parties
are completely diverse in citizenship and the amount in controversy exceeds
$75,000. Further, jurisdiction is proper under 28 U.S.C. § 2202 because this case
presents an actual controversy in which Kaiser seeks a declaratory judgment.
Jurisdiction also exists under 28 U.S.C. § 1337 because this case is a proceeding
“arising under” one or more “Act[s] of Congress regulating commerce.”
9. Venue is proper in this District under 28 U.S.C. § 1391(b) because
each of the entities comprising QHS is a resident of, and maintains its principal
place of business in, the District. Further, the activities giving rise to this action
10. Kaiser is a nonprofit corporation that arranges for the provision of
healthcare services and benefits to its members through the Kaiser Permanente
integrated care delivery model, which includes Kaiser Foundation Hospitals and
Hawaii Permanente Medical Group. In a time of ever-increasing healthcare costs
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 6 of 18 PageID #: 6
and rampant charges for life-saving services, Kaiser Permanente strives to provide
high-quality healthcare at an affordable price. By doing so, Kaiser is able to offer
affordable coverage at a time when more physicians are dropping out of
government programs. It is able to offer healthcare to at-risk and underserved
populations, including seniors, and by offering millions of dollars in free and
discounted care to low-income nonmembers. Kaiser’s model and mission also
allow it to give back millions to support community health, including care for the
housing-insecure population.
11. Integral to Kaiser Permanente’s model of providing health care is
affordability. Kaiser provides many services through direct care, meaning Kaiser
itself hires doctors and offers care in Kaiser facilities. Direct care provides Kaiser
the ability to control and manage the amount its physicians and its facilities charge
for services. Occasionally, Kaiser also contracts with outside physician groups and
hospitals for various services, usually to provide services it cannot offer in a
particular geography, to meet additional needs for high-demand services, and to
protect its members when they require service at a non-Kaiser facility. The
combination of direct services and contracted services make up Kaiser’s network.
Like other Health Maintenance Organizations (“HMOs”) that have a network of
providers, Kaiser typically requires its members seeking health care treatment to
obtain the services at a facility in its network.
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 7 of 18 PageID #: 7
12. Like most states, Hawaiʻi regulates HMOs, including the types of
services HMOs must offer and the adequacy (scope) of the network HMOs set up.1
One key regulation involves the provision of emergency services. While Hawaiʻi
law generally allows HMOs to restrict their members to only seek treatment within
the network the HMO establishes, Hawaiʻi takes the opposite approach for
emergency services. Multiple statutes, including Haw. Rev. Stat. §§ 431:26-
103(a)(2), 432D-1, and 432D-14, require plans like Kaiser to provide coverage for
emergency medical services no matter where the member seeks treatment. This
includes emergency services provided at out-of-network hospitals.
13. The federal government, through the Affordable Care Act, also
requires health plans and insurance carriers to cover emergency services provided
to their members, even if the services are provided by an out-of-network facility.
In fact, three different federal agencies require carriers to provide such services:
the Department of Labor (29 CFR 2590.715-2719A), the Department of Health and
Human Services (45 CFR 147.138) and the Department of the Treasury (26 CFR
54.9815-2719A).
14. Kaiser not only abides by these emergency services regulations, but
advocates for them because its members suffering emergencies need the fastest
Many of these regulations apply not only to HMOs, but all health insurance
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 8 of 18 PageID #: 8
treatment. Kaiser directs all members, including its Hawaiʻi members, undergoing
a medical emergency to “call 911 or go to the nearest hospital.” And when its
members call 911 with emergency symptoms, the question that is asked is “what
facility is closest?” not “what facility is in-network?” Kaiser has no control over
which emergency room its members present at or which emergency services are
provided. Kaiser does not usually even know its members are at an out-of-network
emergency room until after the services are provided. Kaiser is still required,
however, to provide coverage for those emergency services until the member is
QHS is Required to Provide Emergency Services
15. In addition to regulating carriers’ coverage of emergency services,
both state and federal law regulate hospitals. Specifically, both governments
require hospitals to treat all patients suffering emergency medical symptoms
regardless of ability to pay. As this Court pointed out in Arrington v. Wong, 19 F.
Supp. 2d 1151 (1998), hospitals across the country at one time refused to treat
patients suffering from an emergency medical condition, or released them before
stabilization, if they did not have insurance through a company that had a contract
with the hospital. This concept, called patient “dumping,” placed profit over
people and resulted in two-tiered healthcare. Some hospitals exclusively treated
the well-insured while the relatively few public hospitals were overcrowded with
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 9 of 18 PageID #: 9
people unable to afford treatment. Patient dumping was outlawed for any hospital
that decided to accept government insurance (Medicare, Medicaid, etc.) in 1986
through the Emergency Medical Treatment and Active Labor Act (“EMTALA”),
42 U.S.C. § 1395dd. Under EMTALA, hospitals choosing to treat federally
insured patients are required to treat any patient that presents with an emergency
medical condition until that patient is stabilized, regardless of insurance status or
insurance carrier.2
16. QHS has decided to continue to accept government payments, and is
therefore subject to EMTALA and Hawaiʻi regulation. It must provide emergency
medical services to any person who presents at a facility suffering from an
emergency medical condition, including Kaiser members, until the patient is stable
enough to transfer or release. QHS has provided, and continues to provide,
emergency healthcare services to Kaiser members presenting at its facilities.
Kaiser is informed and believes, and on that basis alleges, that each year hundreds
of Kaiser members present at QHS for emergency services resulting in several
millions of dollars in charges.
QHS Is Required to Bill Carriers And Hold Patients Harmless
Hawai‘i has its own version of the anti-dumping statute through Haw. Code R.
11-93-10. (“An appraisal, advice and initial emergency treatment, shall be rendered
to any ill or injured person who requests treatment at a hospital which has an
emergency service department.”)
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 10 of 18 PageID #: 10
17. While the ACA and EMTALA prescribe the services carriers and
hospitals must provide, Hawaiʻi law regulates how such services are paid for
commercial members. Multiple Hawaiʻi statutes require that any hospital that has
a contract for services with a patient’s carrier, including QHS, accept the payment
listed in the contract as payment in full for the services rendered. See, e.g., Haw.
Rev. Stat. §§ 431:206-104 (a)-(e); 432D. These same provisions demand that
hospitals seek that payment directly from the carriers. QHS, like all other Hawaiʻi
hospitals, cannot seek to recover the contract amount directly from the patient,
even if the carrier refuses to or cannot pay.
18. These provisions, called “Hold Harmless” or “No Surprise Billing”
provisions, are common throughout the United States and restrict hospitals from
seeking money from the patients themselves. Hawaii’s approach is very strong;
not only does the State have statutes that require hospitals to hold patients harmless
for bills, but Hawaiʻi Revised Statute § 431:26-104(b) imputes a nonwaivable
provision into every carrier-hospital contract prohibiting hospitals from seeking
payment from the patients under any circumstances, except standard deductibles
and copayments. Importantly, these hold harmless provisions apply regardless of
whether a carrier-hospital contract is written or implied. QHS, as a Hawaiʻi
regulated hospital, is subject to these statutes.
QHS and Kaiser Contracts
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 11 of 18 PageID #: 11
19. At various times before May 30, 2019, Kaiser entered contracts with
the several QHS facilities for, among other things, emergency services. These
contracts terminated on May 30, 2019.
20. As of May 30, 2019, by operation of law, QHS was, and still is,
required to treat Kaiser members suffering emergencies after the written contract’s
termination. Similarly, Kaiser was, and still is, required to provide coverage for all
emergency services rendered at QHS. Kaiser acknowledged to QHS that it was
going to provide payment for those services, and QHS noted that it expects to
receive payment from Kaiser for emergency services rendered to Kaiser members.
Kaiser and QHS, therefore, have an implied contract with respect to the provision
and payment of emergency medical services.
21. The Hawaiʻi legislature understood, and referenced, that implied
healthcare contracts exist between carriers and hospitals. These implied contracts
for health services are regulated the same as express contracts and assume certain
terms. With respect to emergency services, these contracts require payment for
commercial members according to equitable principles of quantum meruit. Kaiser
explained this to QHS and promised to pay according to those principles.
22. On June 3, 2019, however, QHS sent Kaiser a letter regarding how it
would treat both Kaiser and Kaiser members since the written contracts terminated,
a true and correct copy of which is attached as Exhibit A. QHS rejected the
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 12 of 18 PageID #: 12
principles of quantum meruit and informed Kaiser that it would directly bill
Kaiser’s commercial plan members receiving emergency services if Kaiser does
not pay 100 percent of billed charges, even though Kaiser does not owe that
amount under the implied contract.3 QHS also wrote that it would not notify or
seek authorization from Kaiser for services provided to its members, even though
Kaiser is responsible for the payment of some service but not others. Additionally,
QHS told Kaiser the aforementioned policies would be retroactively initiated
beginning May 31, 2019.
23. Kaiser asserts QHS’ threatened actions, which it represents are
already implemented, are contrary to law. Based on these facts, an actual
controversy exists between the parties for which Kaiser desires a declaration of
rights regarding QHS’ (i) intention to directly bill Kaiser members for Kaiser’s
obligations and for amounts exceeding those obligations, and (ii) rejection of
quantum meruit and intention to bill at 100 percent of its full billed charges for
commercial members. A declaratory judgment is necessary in that Kaiser and
QHS have disputes as set forth below.
The QHS letter acknowledged that emergency and non-emergency services would be
provided to Kaiser Medicare members at Original Medicare rates, and to Medicaid
members at Medicaid rates.
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 13 of 18 PageID #: 13
(Declaratory Relief Regarding Kaiser Members’ Obligations)
24. Kaiser re-alleges and incorporates by reference paragraphs 1 through
23 as though fully set forth herein.
25. Under Hawaiʻi law, including Haw. Rev. Stat. §§ 431:26-104 and
432D, hospitals performing services pursuant to contracts, including implied
contracts, must hold the patients harmless for any amount owed by their carrier
and are prohibited from attempting to collect that amount from the patient.
Further, every contract for health services in Hawaiʻi—written or not—has an
imputed, implied, and nonwaivable provision prohibiting providers from billing,
charging, or otherwise seeking reimbursement from a patient except for copays and
deductibles. Hospitals are also prohibited from attempting to collect more than the
26. Federal law, 42 U.S.C. § 1395dd, and Hawaiʻi law, Haw. Code R. 11-
93-10, obligate QHS to provide emergency medical services to Kaiser members.
Further, by accepting government funding and remaining in operation, QHS agreed
to accept these requirements. Pursuant to numerous statutes, including Haw. Rev.
Stat. §§ 431:26-103(a)(2) and 432D, Kaiser is obligated to provide its members
coverage for emergency services rendered by QHS. Thus, as set forth above,
Kaiser and QHS have an implied contract for emergency services.
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 14 of 18 PageID #: 14
27. QHS is therefore prohibited from attempting to collect any money
from Kaiser members receiving emergency medical treatment apart from
deductibles and copayments listed in the member’s policy with Kaiser.
Notwithstanding this requirement, QHS indicates in no uncertain terms that it
intends to seek payments from Kaiser members above and in addition to their
deductibles and copayments. This includes amounts Kaiser is obligated to pay and
amounts above its obligation.
28. Accordingly, an actual controversy of sufficient immediacy exists
between Kaiser and QHS as to whether QHS can attempt to collect payments
beyond deductibles and copayments from Kaiser members for emergency medical
services rendered at its facilities. Kaiser therefore seeks, and this Court should
issue, an order declaring that (1) QHS must hold Kaiser members harmless for any
medical bill related to the provision of emergency services, except deductibles and
copayments as prescribed in the members’ contract with Kaiser, and (2) QHS does
not have the right to collect, bill, or otherwise obtain payment from Kaiser
members for any medical bill related to the provision of emergency services,
except deductibles and copayments as prescribed in the members’ contract with
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 15 of 18 PageID #: 15
(Injunctive Relief Regarding Kaiser Members’ Obligations)
29. Kaiser re-alleges and incorporates by reference paragraphs 1 through
28 as though fully set forth herein.
30. Moreover, if QHS attempts to collect payment from Kaiser members
for emergency medical services rendered at their facilities, then Kaiser will be
irreparably harmed for which there will be no adequate remedy at law.
31. Kaiser is therefore entitled to an order restraining and enjoining QHS
from seeking payments from Kaiser members above and in addition to their
(Declaratory Relief Regarding Kaiser Obligations)
32. Kaiser re-alleges and incorporates by reference paragraphs 1 through
31 as though fully set forth herein.
33. Facilities that provide non-gratuitous emergency medical services are
entitled to recover the reasonable value (i.e. the fair market value) of those
services. The reasonable value of medical services for commercial members,
including emergency medical services, are determined pursuant to equitable
34. As of May 31, 2019, contrary to the law, QHS insists on recovering its
unilaterally set, full billed charges which exceed the reasonable value of its
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 16 of 18 PageID #: 16
services. Given QHS’ high charges, Kaiser is informed and believes, and on that
basis alleges, that requiring Kaiser to pay QHS’ full billed charges instead of the
reasonable value for services provided to commercial members would harm
Kaiser, and by extension its members, by millions of dollars each year. Kaiser is
informed and believes that such amounts already have begun accruing.
35. Accordingly, an actual controversy of sufficient immediacy exists
between Kaiser and QHS as to whether Kaiser, and its members, must pay QHS’
unilaterally set billed charges without proof that they are the services’ reasonable
value. Kaiser therefore seeks, and this Court should issue, an order declaring that
(1) Kaiser is required to pay only the reasonable value of any emergency services
rendered to its commercial members by QHS; (2) the reasonable value of QHS’
services to commercial members is determined under quantum meruit principles
and is not QHS’ unilaterally set billed charges; and (3) QHS does not have the
right to collect more than the reasonable value of emergency services rendered to
Kaiser commercial members during any period for which it and Kaiser do not have
a written, express contract for such services.
(Injunctive Relief Regarding Kaiser Obligations)
36. Kaiser re-alleges and incorporates by reference paragraphs 1 through
35 as though fully set forth herein.
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 17 of 18 PageID #: 17
37. Moreover, if Kaiser was required to pay QHS’ unilaterally set billed
charges without proof that they are the services’ reasonable value, then Kaiser will
be irreparably harmed for which there will be no adequate remedy at law.
38. Kaiser is therefore entitled to an order restraining and enjoining QHS
from (1) demanding Kaiser pay more than the reasonable value for its emergency
medical services under quantum meruit principles and (2) billing Kaiser members
any amount, other than their deductible and copayment obligations, for emergency
WHEREFORE, Kaiser respectfully prays that the Court:
1. Declare that QHS does not have the right to bill Kaiser members for
emergency services, except for copayments and deductibles, and must hold Kaiser
members harmless for bills relating to emergency service; and declare further that
Kaiser is only required to pay the reasonable value, under quantum meruit
principles, for emergency services rendered to its commercial members;
2. Enjoin QHS from billing Kaiser members for emergency services,
except for copayments and deductibles, and from attempting to collect from Kaiser
more than the reasonable value of its emergency services;
3. Award Kaiser all costs and attorneys’ fees incurred herein, to the
Case 1:19-cv-00301-DKW-WRP Document 1 Filed 06/12/19 Page 18 of 18 PageID #: 18
4. Grant such further and additional relief as the Court may deem just
DATED: Honolulu, Hawaiʻi, June 12, 2019.
/s/ Jordon J. Kimura
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