YDM Management Co., Inc. v. Sharp Community Med. etc.

Plaintiff YDM Management Company, Inc. (YDM) appeals from a judgment of the trial court in favor of defendant Sharp Community Medical Group, Inc. (Sharp), after Sharp successfully moved for summary judgment of YDM's operative complaint. YDM purchased accounts receivable from Doctors Express, a company that operated urgent care facilities in San Diego, for services rendered to Sharp managed care members. In its role as an Independent Practice Association (IPA), Sharp provided health insurance to its managed care members, and paid claims for services provided to its members. At the time that it provided the services at issue to Sharp members, Doctors Express did not have a preferred provider contract with Sharp. Providers without a contract with an IPA were reimbursed for nonemergency medical services provided to the IPA's members at amounts significantly less than the "reasonable and customary value for the health care services rendered." However, an IPA such as Sharp was required by regulation to reimburse out of network providers for the full "reasonable and customary value" for any emergency medical services provided to its members. As the assignee of Doctors Express, YDM filed this lawsuit seeking additional reimbursement from Sharp for services provided by Doctors Express to members of Sharp's health plan, beyond the amount that Sharp had already reimbursed Doctors Express for those services. The trial court granted summary judgment in favor of Sharp. On appeal, YDM contended the trial court erred in granting summary judgment in Sharp's favor based on the declaration of a Sharp employee, and that the court erred in failing to give adequate consideration to the declaration of YDM's expert in concluding that there was no triable issue of material fact. The Court of Appeal concluded the trial court did not err in granting summary judgment in favor of Sharp. View "YDM Management Co., Inc. v. Sharp Community Med. etc." on Justia Law