Gregory Pimstone Gives an Insight on The Irrational System of Paying for Out-of-Network Emergency Care Process

Every emergency room of a hospital in America is under a legal obligation to treat a patient; however, the reimbursement and administration process currently involved only complicates matters leading to unnecessary litigation and financial woes. There is a fix possible with the right legislation to practically deal with the problem. The only people getting benefited are legal professionals who have been hired to fight such cases that are currently clogging courts in the state.

Gregory Pimstone is an eminent lawyer from 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.”

He goes on to elaborate that whenever a patient visits an emergency room in a hospital that does not have a contract under the patient’s insurance company, the process for reimbursement of expenses becomes confusing. The method only leads to chaos and unnecessary litigation.

He says a fix is possible

Unfortunately, no one in California has displayed interest nor willingness to resolve the above issue. Unless the problem is not resolved, the courts in the state will remain clogged with excessive litigation that serves no benefits except to the lawyers hired to fight cases. In order to curb this confusion and lessen the burden on the courts of law in California, the state needs to pass legislation to establish reasonable and fair rates for emergency room healthcare services, he says.

Understanding how the process works

When people get injured and require emergency services, the laws allow them to be treated at the nearest ER even if it is not contracted with the patient’s health insurance plan. The law mandates medical practitioners to take care of the patient till he/she is stabilized. The law also states that the patient’s health plan will pay for the treatment rendered.

The health plan cannot direct the insured to only visit contracted ERs or reject to cover healthcare services by the emergency provider who is not under a contract with the company. The above makes complete sense and, from the public standpoint, is very defined and clear.

The problem

The problem surfaces after the treatment have been served to the patient. Here, the carrier and the emergency provider cannot come to a consensus on the reasonable amount to pay for the healthcare service. The law mandates managed care plans to make the payment with a method that a regulator oversees. However, the provider is under no obligation to accept it. If the emergency provider is not satisfied with the amount, litigation can be filed to determine the reasonable value of these services.

This is where the process becomes intensely inefficient and needs resolution at the earliest with the right legislation. Gregory Pimstone Of Manatt says the problem arises here as the law does not establish a fixed formula to determine what is reasonable when it comes to emergency room healthcare services in the state. This, in turn, gives rise to innumerable financial and legal woes for both parties to a suit.