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admitted to Non Panel-Utah hospitals during 1997, 1998, and 1999
was attributable to emergency medical care.
The following schedule, reflecting petitioner’s experience
for the years 1997, 1998, and 1999, presents the total amounts
(by percentage) that petitioner was billed for outpatient
hospital visits by: (1) Health Services’ hospitals (HS); (2)
independent hospitals on petitioner’s panel (Panel-Not Owned);
(3) independent Utah hospitals not on petitioner’s panel (Non
Panel-Utah); and (4) independent hospitals outside of Utah and
not on petitioner’s panel (Non Panel-Non Utah).
Year HS Panel-Not Owned Non Panel-Utah Non Panel-Non Utah
1997 92.1% 3.6% 3.1% 1.3%
1998 90.4% 4.8% 3.7% 1.2%
1999 89.7% 4.8% 4.2% 1.3%
Petitioner generally compensated its contractor hospitals
pursuant to a modified diagnosis related group (DRG) payment
system under which an enrollee admitted to a hospital on either
an inpatient or outpatient basis would be assigned a DRG and the
hospital would be paid a fixed fee consistent with the DRG
schedule.
D. Point-of-Service Options
Petitioner offered several plans (described below) that
included a “Plus” or a point-of-service option. Enrollees in
such plans were permitted to use the services of physicians
and/or hospitals outside of petitioner’s network with the
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