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 �"