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.

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