June 20, 2024

The Irrational and Chaotic System of Paying For Out-of-Network Emergency Care Needs An Immediate Solution Says Gregory Pimstone


Legal disputes regarding out-of-network emergency care payments are rising in California due to a faulty reimbursement and administration system. The whole process for reimbursement for such claims lacks clear-cut directions when it comes to determining the amount of reasonable value that should be paid to the ER provider by the healthcare carrier. The courts in the state are clogged with legal disputes that show no signs of stopping. The system is chaotic and confusing. It serves no purpose and only benefits the lawyers who have been hired to fight the case.

Gregory Pimstone says the state legislation should step in with a solution

Healthcare expert Gregory Pimstone from Los Angeles and head of the healthcare law group at national law firm Manatt says the whole process for determining the payment for out-of-network care is unnecessary, expensive, and inefficient.

The root of the problem lies in the fact that there is no defined benchmark under the law to determine the reasonable value for such services rendered to a patient. The process is confusing and chaotic; costing both parties to dispute lots of money that can even run into millions of dollars. The system is so inefficient that it makes no sense to remain in the state at all.

A general overview of the problems this system brings

If a person is injured in the USA, they can go to the nearest ER provider even if that hospital does not have a contract with their health insurance plan. No medical professional at the hospital can deny the person treatment, and no health insurance carrier can direct an insured to only visit those ER providers with whom they have a contract. The patient is treated until they are stabilized to be discharged.

Dispute between the ER provider and the healthcare carrier

When it comes to the payment of this treatment, it will be done by the health insurance plan the patient is under. In a non-contracted health insurance plan, the matter is taken care of by managed healthcare plans that determine the reasonable value to be paid to the ER provider via a method supervised by the regulator.

Under the law, the ER provider is not obligated to accept the amount of reasonable value offered. If dissatisfaction with the amount, a legal case can be filed in court to determine the same. If one of the parties to the above suit loses in the trial court, an appeal to determine the number of fair prices can be made to a higher court.

Gregory Pimstone of Manatt says this whole cycle of litigation clogging the courts of law today can be stopped with the intervention of the State Legislature. They should take the onus of establishing fair prices when it comes to determining the payment for out-of-network emergency care. This step will help the courts of law and parties involved in the case to resolve issues quickly, and the payment system for ER care will become more defined and streamlined.

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