A widely respected and esteemed healthcare lawyer from Los Angeles is crying out against the current system that deals with ER administration and reimbursement in the USA. When a patient visits an ER provider that does not have a healthcare plan contracted with the hospital, every ER in the nation is obligated by law to treat the patient until he/she is stabilized. However, the problem arises after the healthcare services have been given to the patient. The process for reimbursement of the costs incurred for these services is cumbersome and only gives birth to legal and financial woes to both parties of the dispute.
Gregory Pimstone and the correct solution to resolve the problem
Gregory Pimstone is the head of the healthcare law group at National law firm Manatt in the USA. When it comes to the current system of ER care in the nation, he says, “The process for determining how to pay for emergency medical care at an ‘out-of-network emergency room is expensive, inefficient, and unnecessary.”
The whole process is confusing, and it is here that the legislature in California should intervene to establish fair rates that wipe out the need for endless lawsuits on the matter. However, to date, the state Legislature has displayed no willingness to resolve the issue. Unless it eventually does, the courts of the land will continue to be filled with litigation that offers no benefits to anyone except attorneys and legal experts hired for the case.
How expensive are these cases?
He goes on to add these cases pertaining to ER care reimbursement are very expensive. Both the hospitals and the healthcare carrier plans need to exchange large volumes of electronic data about their respective claims. In addition to the above, they need to share details of their contracts with other carriers or providers.
Both parties require the presence of expert witnesses to crunch all of this data. Besides this, there are legal fees involved in the litigation process. The amount sought by hospitals in these cases can even run into tens or hundreds of US million dollars. This is not the end of the ordeal- when one party loses their plea in a trial court, they move forward with appeals, again costing them a lot of time and money.
Gregory Pimstone of Manatt asks, “How does this make any sense?” and adds A rational system would set prices for emergency care based on defined benchmarks.”. The ideal solution for combating the issue would be the California Legislature stepping in to establish a benchmark for setting a reasonable value for ER care. The legislature could hear the testimony of the stakeholders in the case and come to a final conclusion as to the right benchmark for reasonable value on the matter. In this way, the issue will be eradicated, and the endless cycle of litigation will finally come to a close.
He concludes by adding, ‘The problem is not going away: patients show up every day in ERs around the state that are not in their insurer’s network. We can either have a system that requires providers and carriers to lawyer up and duke it out each time in court, arguing vague standards. Or we can decide to address the issue with something definite and conclusive and put our resources to better use.”