The Irrational System of Paying for Out-of-Network Emergency Care Increases Legal Woes - Gregory Pimstone Explains Why


A reputed lawyer in Los Angeles is asking for significant changes to be made to the irrational system of emergency room care reimbursement and administration prevailing in the system. He believes this system is inefficient and expensive. It brings a host of financial and legal woes both to the E.R. provider and the health insurance company. It serves no good purpose and only clogs the courts with unnecessary litigation and benefits legal experts and professionals hired to fight the case.

Gregory Pimstone digging deeper into the issue

Gregory Pimstone is an esteemed and respected legal expert in Los Angeles and Head of the healthcare law group at national law firm Manatt. 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."

Every ER in America is under a legal obligation to treat a patient, even if he/she is not covered any a contract with the hospital. The problem does not surface while the treatment process is on. It arises when it is over, and the E.R. provider and carrier need to agree on the amount of reasonable costs that should be paid for the services. Confusion reigns in the above cases as the laws of the land have not determined a fixed parameter via which this reasonable value is to be set. As a result, there is a surge in legal disputes, and both parties are aggressively battling it out in courts.

A solution is possible with legislation

He believes the above never-ending cycle of legal disputes can be eradicated with state legislation in California. In this way, a reasonable value can be established and mitigate litigation in the land. The state has exercised the above in some cases, for example, when a person visits a hospital contracted with his/her healthcare plan and the surgical team is joined by an anesthesiologist not contracted by the carrier, a factor used in this doctor gets 125% of what Medicare would have paid for a similar service.

It is tough for one to imagine that a sensible legislature will not seek to establish such a simple benchmark for emergency care. This benchmark does not have to be 125% of what Medicare would have paid. The legislature of the state could hear the testimony on the matter as to what this benchmark should be.

When a benchmark has been set after hearing the opinions of stakeholders, this will actually resolve the issue to a large extent and swiftly end the cycle of legal disputes on the matter. Gregory Pimstone of Manatt says,"The process for determining how to pay for emergency medical care at an 'out-of-network emergency room is expensive, inefficient, and unnecessary," Every American E.R. is under a legal obligation to treat a patient; however, the current process for getting reimbursed for the above is only increasing legal and financial problems for both the parties. Only a legislative fix will resolve and eradicate the issue over time.


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