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Beverly Hills Surgery Center LLC v. Operating Engineers Health and

July 14, 2011

BEVERLY HILLS SURGERY CENTER LLC
v.
OPERATING ENGINEERS HEALTH AND WELFARE FUND ET AL



The opinion of the court was delivered by: The Honorable Jacqueline H. Nguyen

JS-6

CIVIL MINUTES - GENERAL

Present: The Honorable JACQUELINE H. NGUYEN

Alicia Mamer Not Reported N/A Deputy Clerk Court Reporter / Recorder Tape No.

Attorneys Present for Plaintiffs: Attorneys Present for Defendants: Not present Not present

Proceedings: ORDER GRANTING PLAINTIFF'S MOTION TO REMAND [8] (In Chambers)

Before the Court is Plaintiff's Motion to Remand pursuant to 28 U.S.C. § 1447(c). (Docket No. 8.) The Court deems the matter appropriate for decision without oral argument. Fed. R. Civ. P. 78; L.R. 7--15. Accordingly, the hearing scheduled for July 18, 2011 is removed from the Court's calendar. For the reasons discussed below, the Court GRANTS Plaintiff's Motion and REMANDS the action to the Los Angeles County Superior Court.*fn1

I. BACKGROUND

This case stems from a dispute over reimbursement between a medical provider, Beverly Hills Surgery Center, LCC ("Plaintiff" or "Beverly Hills"), and three entities tied to an ERISA-qualifying health plan ("the Plan"). These entities-the Defendants in this action-are Operating Engineers Health & Welfare Fund ("OEHW"), the health plan itself; Anthem Blue Cross Life & Health Insurance Co. ("Anthem"), the health plan administrator; and Qmedrix Systems ("Qmedrix"), a medical data consultancy.

In its Complaint, Plaintiff alleges the following:

Beverly Hills operates as a non-preferred provider of outpatient medical services.

(Compl. ¶ 7.) As a non-preferred provider, Beverly Hills does not enter into written agreements with health plans for reimbursement. Instead, Beverly Hills is reimbursed at the Usual and Customary Rate ("UCR"), an industry measure of standard local medical charges, as determined by an outside vendor. (Id. ¶¶ 8, 12.)

Before providing coverage to members of the health plan, Beverly Hills contacted OEHW or Anthem (collectively, "Plan Defendants") to verify that the patients were entitled to benefits. (Id. ¶ 22.) During this process, Plan Defendants indicated that Beverly Hills would be reimbursed for 90% of the first $1,000 in charges; any additional charges would be reimbursed at 60% of the UCR. (Id. ¶ 23.)

After Beverly Hills submitted bills, Plan Defendants employed Qmedtrix to determine the UCR for the services rendered. (Id. ΒΆ 27.) Plan Defendants then notified Beverly Hills that payment would not ...


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