California Spine & Neurosurgery Institute v. Blue Shield of California

Analysis Group assisted Blue Shield of California in a suit alleging that Blue Shield’s payment for an out-of-network neurosurgery claim was below the provider’s usual, reasonable, and customary charges. An Analysis Group team led by Managing Principal Mark Gustafson and Vice President Phil Hall-Partyka supported Managing Principal Bruce Deal, who provided deposition and trial testimony on behalf of Blue Shield on the reasonable value of the services provided and explained how full billed charges is not a measure of reasonable value. The team also supported the preparation of testimony by a neurosurgeon, who testified that the at-issue patient was misdiagnosed and the surgery did not meet the criteria of an emergency. The jury found that Blue Shield’s original reimbursement was, in fact, in excess of the reasonable market value of the services.