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Month: August 2021

Healthcare Lawyer Gregory Pimstone Highlights the Problems of the Irrational Out-of-Network ER Care System in the USA

Healthcare Lawyer Gregory Pimstone Highlights the Problems of the Irrational Out-of-Network ER Care System in the USA

The reimbursement system for out-of-network payments for emergency room care in the USA is highly irrational and expensive. The number of legal disputes is increasing and clogging the courts of laws hearing such cases. A prominent and widely respected healthcare legal expert from Los Angeles is calling out for significant changes to eradicate the financial and litigation woes associated with the process.

Gregory Pimstone stresses a legislative fix to the problem

Gregory Pimstone is an esteemed healthcare lawyer from Los Angeles and is the head of the healthcare law group at national law firm Manatt in the USA. He firmly believes that only legislative intervention can fix the above issue. The problem starts when a patient walks into an ER care unit under a healthcare plan that is not under the contract of the hospital.

Courts are clogged with legal suits

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Though no ER can refuse treatment of the patient, and no healthcare plan can force the patient to visit only those hospitals with whom it has a contract. The patient is treated until stabilized, and the patient’s healthcare plan is obligated to pay for the services rendered. This again is governed under the law by managed healthcare plans that use a method overseen by the regulator for payment. The ER is under no legal obligation to accept this payment if dissatisfied and has the right to file a case in court to sue the carrier.

There is no set formula set out by law, and so the problem prevails, making the whole system irrational. He cites the examples of the following case.

In the case of the Children’s Hospital Central California v Blue Cross of California, 226 Cal. App. 4th 1260 (2014), it has been laid down that reasonable value is “the going rate” for the services, what “a willing buyer would pay a willing seller.” Id., at 1274.

The court stated that in making this determination, “courts accept a wide variety of evidence” and that “the facts and circumstances of the particular case dictate what evidence is relevant to show the reasonable market value of the services at issue.”  Id., at 1275.

The court further laid down that in making the above determination, “the facts and circumstances of the particular case dictate what evidence is relevant to show the reasonable market value of the services at issue.”  Id., at 1275.

Relevant evidence includes “the scope of rates accepted by or paid to” the hospital or similar hospitals in the area. From that evidence “along with evidence of any other factors that are relevant to the situation,” a court can make its determination of reasonable market value.   Id.  “All rates that are the result of contract or negotiation, including rates paid by government payors, are relevant to the determination of reasonable value.”  Id., at 1278.

Gregory Pimstone of Manatt concludes the sole solution to this problem is to have defined legislation to set the fair rates for paying out-of-network ER care costs to curb litigation. This will help resolve the issue to a large extent and organize the ER care reimbursement system in a better way.

Insights By Ileana Hernandez of Manatt On Healthcare Fraud And Its Rising Urgency For Speedy Prosecution

Insights By Ileana Hernandez of Manatt On Healthcare Fraud And Its Rising Urgency For Speedy Prosecution

Healthcare fraud is intensely on the rise in the USA, and the Government and political parties have joined hands to combat this mounting problem with reinforced vigor. Changes have been made to the US healthcare sector by US Presidents Trump and Biden, respectively; however, with these new processes and developments, the problem still prevails. The advent of the Pandemic saw a huge increase in regulatory violations and legal disputes in the nation due to new infections caused by the surfacing of mutant strains of the coronavirus in the nation.

Ileana Hernandez of Manatt gives an insight into massive false billing claims worth millions

Ileana Hernandez, a partner with Manatt, Phelps & Phillips Law Firm and a proactive member of the firm’s healthcare litigation practice, says, “Recent activities demonstrate the government’s fierce determination to monitor and prosecute healthcare fraud cases.”

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The US government has the determination to prosecute people actively involved in healthcare fraud. There have been massive nationwide sweeps conducted by the Department of Justice or the DOJ in the USA. They were conducted across 36 and 41 districts in 2016 and 2017, respectively. In the first sweep, more than 300 healthcare professionals were charged with false billing claims worth $900M: the guilty included doctors, nurses, and other licensed healthcare professionals.

In the second nationwide sweep conducted in 2017, more than 115 professionals, including doctors, nurses, and licensed medical practitioners, were charged with false billing claims. However, the amount of healthcare fraud here was $1.3B, the biggest in US history to date.

Ileana Hernandez of Manatt says, In addition to the large government sweeps, nearly 500 lawsuits related to healthcare fraud were filed by private citizens on behalf of the federal government,” said Ileana Hernandez of Manatt. “Many of these lawsuits were based on alleged off-label marketing, kickbacks, Stark violations, upcoding, double billing and lack of medical necessity claims.”

Recovering lost money due to false billing claims

New healthcare programs in the nation have been launched to battle this problem, for instance, with the CARES act Provider Relief Fund, the government of the USA is now placing a high priority on monitoring cases of potential healthcare fraud in federal programs to recover lost money due to false billing claims. Measures have been taken to weed out healthcare fraud from the system aggressively. There is a focus on companies dealing with medical drugs and devices, small groups of individuals and physicians (in some areas), and other professionals linked to the healthcare sector.

She says in the past year, the Federal Government in the USA has stepped up actions to focus beyond manufacturers to target healthcare providers who have submitted false billing claims for opioid prescriptions under its healthcare system programs. These actions include FCA investigations, administrative acts, and traditional criminal actions as well.

Ileana Hernandez of Manatt sums up by saying, “In the current healthcare climate, nobody is immune to the government’s efforts to stomp out cases of healthcare fraud and abuse, and they will go to any length to recoup monies and prosecute entities.”