The System for Paying for Out-of-Network Emergency Care Is Unnecessary and Irrational – An Insight by Gregory Pimstone 

The System for Paying for Out-of-Network Emergency Care Is Unnecessary and Irrational – An Insight by Gregory Pimstone 

August 31, 2021 Off By takiayabalmone

The payment process for emergency room care reimbursement and administration for “out-of-network services is irrational in the USA, and a leading Los Angeles based lawyer is calling out for the right legislation to address this problem. The whole process results in never-ending legal and financial woes. The courts of law are clogged with litigation, and only lawyers hired to fight such cases are benefited under the prevalent system. 

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 says that under the present system, for every person who goes to ER care in any hospital that does not have a contract with the healthcare company of the patient, confusion takes over the entire situation. Every ER in the USA is obligated to treat a patient; however, the method for getting reimbursement results in financial and legal chaos. It is here that he asserts, a solution is possible. 

Though managed care plans look after the above reimbursement process, the ER provider is not obligated under law to accept the amount offered. If the ER provider is not satisfied with the amount, a case can be filed in a competent court of law. 

Establishing fair and reasonable rates in California 

There is no fixed 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.   

Relevant evidence includes “the scope of rates accepted by or paid to” the hospital or similar hospitals in the area, and 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 states the only solution to the above problem is to have legislation that sets fair rates for paying out-of-network ER care costs. This will help resolve the issue to a large extent and organize the ER care reimbursement system better. The present ER care reimbursement system in the state makes no sense at all, and he says, “A rational system would set prices for emergency care based on defined benchmarks.” It is the need of the hour to resolve the problem and streamline the process to become a hassle-free one with success.