Emergency room care is administered and reimbursed in California is irrational and gives birth to endless financial and legal complications. A leading specialist of healthcare law in Los Angeles is speaking out against the system and is calling for substantial change to curb the unnecessary confusion and litigation entailed in the process.
Gregory Pimstone calls out for sensible legislature to fix this issue
Gregory Pimstone is a widely-respected legal expert based in Los Angeles and is the Head of the healthcare law group at national law firm Manatt. He says that the current ER care administration and reimbursement system is total confusion, leading to tremendous financial woes and legal disputes.
The problem is not going away soon
A lack of consensus between the ER care provider and health insurance carrier with regard to the reasonable amount to be paid for healthcare services rendered to a patient is the root cause of this problem. Legal disputes on the subject have clogged courts of law, and there is a huge waste of time and money.
Cases are expensive
Every case is highly expensive. Both the hospital as well as the healthcare insurance carriers need to exchange large volumes of electronic data about their individual claims. They also need to share information about their providers, carriers, and contracts. Both of these parties should have expert witnesses to help crunch this data and give them opinions on the reasonable value of services. The costs do not end here. There are legal fees of the lawyers and procedures included for litigating these disputes. Hospitals might seek millions of dollars in the case of underpayments. If one party loses the case in a trial court, they will file appeals and spend more money and time for the settlement of these legal disputes. The above obviously makes no sense, and the state lacks sensible legislation to resolve the problem.
Sensible legislation will solve the problem
He says the Biden administration is promulgating healthcare regulations for incorporating the No Surprises Act scheduled to come into effect in 2022 for some states. However, this will not resolve the current problem pertaining to ER care reimbursement.
This legislature will list a wide range of factors that the trier of fact will take into consideration while using discretion to determine the fair value of ER care. He asks how this promulgation will end legal disputes related to the above issue. It does not set out any sort of definite direction to carriers, courts, or ER providers. Moreover, California has not even stepped in to deal with the issue either.
The issue will prevail as patients come to ER care rooms daily across the state that does not fall in their insurer’s network. Gregory Pimstone of Manatt says that the state can either have a system that allows regulators and carriers to lawyer up and fight the case in court with something that is both conclusive and definite, or they can put their current resources to better use.