St. Agnes Med. Center v. Sante Community Physicians IPA Med. Group CA5

FACTS AND PROCEDURAL HISTORY

Key Terms and Structures We begin by noting the terminology used in our discussion to describe some of the basic relationships in the health care insurance system. Insurance companies such as Blue Shield, Aetna, Anthem Blue Cross, Health Net, and others, offer health maintenance organization (HMO) plans for health insurance coverage to consumers in the Fresno area. With this type of coverage, most medical services are provided by or coordinated through a member’s primary care physician who is normally part of a physicians’ association or

Unless otherwise indicated, all further statutory references are to the Business and Professions Code.

2. group under contract with the HMO. (See, e.g., Zembsch v. Superior Court (2006) 146 Cal.App.4th 153, 157.) We refer to such plans in a generic way as simply HMO’s or HMO plans, unless there is need to mention a particular company by name. We refer to the persons insured under such plans as the HMO members. An independent practice association (or IPA) is an association of physicians in a geographic area. A physician joins an IPA by signing a contract with that IPA. As a distinct legal entity, an IPA…