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California Consumers Off The Hook In ER Fee Disputes

Posted by Jane Akre
Friday, January 09, 2009 11:14 AM EST
Category: Major Medical, Protecting Your Family
Tags: HMOs, Managed Care, Hospitals, Emergency Rooms, Emergency Care

Emergency room fee disputes will be between doctors and HMO and not patients in California.


IMAGE SOURCE: iStockphoto/ emergency sign/ author: © BradenGunem


A medical emergency forces you to go to a California emergency room

Problem taken care of, you later receive a bill for fees that your HMO did not cover. Do you pay?

California’s Supreme Court ruled Thursday that doctors and hospitals who believe they have been underpaid by the HMO cannot go after consumers for the remainder.

The unanimous ruling is winning praise from consumer group. 

The director of the California Department of Managed Health Care, which regulates HMOs in the state, believes the decision lifts a burden off consumer’s backs. Cindy Ehnes, director says in a statement, “We’ve never retreated from protecting patients caught in the middle of billing disputes and, just as vigorously, we won’t retreat from efforts to make sure that doctors are paid fairly.”

The remaining cost will have to be picked up by the HMO or the doctor, cautions the California Medical Association.  The association believes as a result, some doctors will quit ER care or greedy HMOs will intentionally underpay.

“California emergency rooms are really in bad shape, and this will make the situation significantly worse,” says trauma surgeon, Dev GnanaDev, to the San Francisco Chronicle. 

In California, more than 21 million consumers fall under HMO or health maintenance organization coverage.  In some cases, the patient’s HMO does not have a fee contract with that hospital.

“Balanced billing” occurs when the physicians and hospitals submit charges. HMOs say those charges are often inflated.  But hospitals and doctors say without balanced billing, or minimal fee requirements they are often underpaid.

Often HMO coverage does not specify coverage limits of emergency care other than the doctors and hospitals are supposed to receive “reasonable fees” for their services.

Typically the cost of an ER visit is about $100 and up to $1,000 for surgery.

California hospitals and doctors say they are already due about $200 million in unpaid bills.  Collection agencies frequently pressure patients to pay such bills.

Thursday’s ruling is intended to take the patient out of the dispute.

Gov. Arnold Schwarzenegger praised the ruling because it "reaffirms that patients should not be put in the middle of billing disputes between providers and health plans."

But Dr. Ramon Johnson, an ER physician from Orange County, tells the Los Angeles Times, “This is really bad for emergency medicine.  This is going to shift a lot of money to HMOs and away from people who actually provide the care." #

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