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HomeMy Public PortalAbout081-2016 - BOW-Reid Hospital agreement for healthcare service claimsw AGREEMENT FOR PAYMENT OF HEALTH CARE SERVICES CLAIMS This Agreement, effective July 22, 2016 is by and between Reid Hospital & Health Care Services, Inc ("Reid Health") and the City of Richmond, Indiana ("City") WHEREAS, the City of Richmond is a governmental entity which offers to its employees, health insurance benefits through the City's Health Care Plan ("Plan"); WHEREAS, Reid Health is a not for profit Indiana corporation providing quality health care to the residents and citizens of Richmond and Wayne County, Indiana and surrounding areas; WHEREAS, on or about January 1, 2015, the City entered into an agreement with ELAP whereby ELAP (and/or its related entities and agents) acted to re -price claims for services submitted to the Plan, including claims submitted by Reid Health; WHEREAS, prior to this Agreement, no contract existed between Reid Health and the City or Plan concerning or related to the pricing of health care services provided by Reid Health to Plan beneficiaries. Reid asserts there were contracts between Reid Health and the individuals receiving health care services at Reid Health; WHEREAS, starting on January 1, 2015, ELAP (and/or its related entities and agents) "re -priced" Reid Health claims submitted for services provided to Plan beneficiaries, and paid Reid Health less than the amount charged by Reid Health without an agreement by the parties to accept the re -priced claim methodology; WHEREAS, Reid Health's Board of Directors has adopted a "Fairness in Pricing" policy based on its belief that it is inherently unfair to selectively offer certain payment terms to some patients or third party payors but not others, and therefore the Board has directed that Reid Health offer its pricing terms and conditions equally to all.; WHEREAS, Reid Health objected to the reduction in payment of its claims for services provided to Plan beneficiaries and asserted that Plan beneficiaries were liable for the amount deducted from payment by ELAP's re -pricing of the claims, because the beneficiaries had signed contracts agreeing to pay for services received from Reid Health; WHEREAS, Reid Health and the City both desire to resolve their differences and to work to improve the health and wellness of Plan beneficiaries while helping the City and Plan control costs and expenses for beneficiary health care. NOW THEREFORE, in consideration for the mutual promises contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows: 1. Definitions. Contract No. 81-2016 a. "Claim" means a invoice or statement for hospital healthcare services rendered to a Beneficiary by Reid Health. b. "Beneficiary" or "beneficiaries" means a person(s) considered to be "covered individuals" under the Plan c. "Date of Service" means (i) for an outpatient or emergency department service, the day on which the service was actually provided; and (ii) for an inpatient service, the day on which the patient was discharged from the hospital. d. "Patient's Portion" means the authorized copayments, deductibles, coinsurance amounts and amounts for non -covered services that are allocated to the Beneficiary upon the Plan's Explanation of Benefits ("EOB") statement. Payment of Claims. The City will pay to Reid Health the sum of One Million Three Hundred Thousand Dollars ($1,300,000.00) in full and complete satisfaction of all currently outstanding Claims with a date of service between January 1, 2015 and May 31, 2016. This includes (i) claims on which a partial payment has been made by the Plan and (ii) claims on which no payment has been made by the Plan. This payment by the City does not discharge the Patient Portion of any Claim with a date of service between January 1, 2015 and May 31, 2016 as set forth in section 3 below. Payment will be made by the City within eight (8) days of the date on which this Agreement is signed by the City. 3. Liability of Beneficiaries. Reid Health agrees that for Claims with a Date of Service between January 1, 2015 and May 31, 2016, it shall not collect, or attempt to collect, from any Beneficiary, more than the amount set forth as the Patient's Portion on the EOB provided by the Plan under the City's "re -pricing" plan. All claims with a Date of Service May 31, 2016 or earlier will be processed using the same methodology, regardless of when the Claim is processed or when the EOB is issued. 4. Health Care Services Agreement. Contemporaneously with the execution of this Agreement, the parties have entered into the attached Health Care Services Agreement. During the effective term of the Health Care Services Agreement, which is June 1, 2016 through December 31, 2016, the Plan will not engage in any "re -pricing" or discounting of Reid Health Claims with a Date of Service June 1, 2016 or after. Any Claims with a Date of Service June 1, 2016 or after which have already been processed by the Plan will be reprocessed pursuant to the terms of the Health Care Services Agreement. This provision does not prevent any Beneficiary from disputing whether services were actually provided to him or her or from exercising any rights the Beneficiary may have in relation to Reid Health. 5. 2017 Health Care Services Agreement. The parties will immediately begin discussions to negotiate an Agreement for Health Care Services for 2017 and the future. This provision does not obligate the parties to enter into any future agreement. 1 � V 6. Application of this Agreement. This agreement applies only to Claims submitted by Reid Health for hospital services, and not to claims for services by any other entity. 7. Cooperation on claims processing. For all Claims, regardless of the Date of Service,the City and Reid Health and their agents will reasonably cooperate with each other and share necessary information in order to process or reprocess any Claims or to resolve Beneficiary questions about balances owed as the Patient Portion of a Claim as well as any Claim balances owed by the Plan 8. Warranties and Representations. Each party to this Agreement, hereby represents and warrants to the other parties as follows: (a) the person executing this Agreement on behalf of the party has full power and authority to enter into this Agreement and to perform all of that party's obligations; (b) prior to the execution of this Agreement, the party has fully informed itself as to the terms, contents, provisions and effects of this Agreement, and all facts and conditions sufficient and necessary to the decision to execute this Agreement; (c) prior to the execution of this agreement, the party has had the benefit of the advice of an attorney chosen and employed by that party concerning this Agreement; (d) no promise or representation of any kind has been made to the party by the other party except as expressly set forth in this Agreement and the attached exhibit; (e) the party is not relying on any oral understandings, oral representations, or oral agreement of any kind or on any other matter not expressly stated in this Agreement and any such reliance would be unintended by the other parties and unreasonable and unjustifiable; and (f) this Agreement constitutes a valid, binding and enforceable obligation of that party, its terms are lawful and fair. 9. Governing law. This Agreement shall be governed by and construed in accordance with the laws of the State of Indiana without regard to choice of law rules. Each party has caused this Agreement to be executed by its authorized representative, effective July 22, 2016. REID HOSPITAL & HEALTH CARE SERVICES, INC By: Title: President/CEO Date: Z ZA- CITY OF RICHMOND, INDIANA BOARD OF PUBLIC WORKS AND SAFETY By: �JG14 /(!�' Vicki Robinson Title: President�j / Date: ! —� ! � Approved: David M. Snow Title: Mayor Date: Z �"