The current process of ER care administration and reimbursement is filled with flaws and needs significant changes.  A leading healthcare law expert in Los Angeles is speaking out against the system and is calling out for state legislative intervention to resolve the issue and end the cycle of endless litigation in the state. 

Gregory Pimstone is a widely-respected lawyer based in Los Angeles and is the Head of the healthcare law group at national law firm Manatt. He explains that the current out-of-network payment system for ER care in the USA is filled with confusion, financial and legal woes. 

The law of the land does not lay down a set formula to determine how reasonable costs for ER care out-of-the-network services should be determined. The present system makes no sense, and he says a rational system will eliminate unnecessary litigation clogging the courts of the land today.

How will a rational system help? 

He says, “A rational system would set prices for emergency care based on defined benchmarks.” He goes on to explain that California has done the above in a few cases. He cites the following example saying that if a person has surgery in a hospital that is contracted with his/her healthcare plan, but an anesthesiologist who is not contracted with the healthcare carrier of the person is brought in to join the surgical team, one factor used is this doctor gets 125 percent of what Medicare would generally pay for similar services. It is difficult to imagine that a rational legislature will not seek to establish a simple benchmark for emergency care. 

The amount does not have to be 125 percent like Medicare. The legislature can fix the amount after hearing testimony on whether this benchmark ought to be 125 percent or any other sum. When such a benchmark is set after determining and hearing the view of the stakeholders about the correct sum, this will end the endless cycle of unnecessary litigation prevailing in the nation today. 

New regulations of the Biden administration 

This is a problem that needs sensible legislation, and the nation is not getting it at all. The Biden administration is currently promulgating regulations to incorporate the No Surprises Act, which is going to be effective in some states of America from 2022. However, these regulations will not solve the issue. The new legislature lists the wide range of factors that any trier of fact can take into account to determine the reasonable costs of emergency services. However, it will not solve the issue as there are no defined or clear-cut parameters to determine the reasonable value that should be paid. 

Gregory Pimstone of Manatt sums up by saying, ‘The problem is not going away: patients show up every day in ERs around the state that are not in their insurer’s network.  We can either have a system that requires providers and carriers to lawyer up and duke it out each time in court, arguing vague standards.  Or we can decide to address the issue with something definite and conclusive and put our resources to better use.”