Eminent Lawyer Gregory Pimstone Speaks on The Irrational Paying for Out-of-Network Emergency Care System 

The American courts are clogged with cases pertaining to ER out-of-network payments for reasonable costs as no law in the land sets out a clear formula for it. The whole system for administration and reimbursement for ER care is inefficient, irrational, and expensive. The parties to litigation are just wasting their valuable time and money. The only people who benefited from the system are lawyers who are hired to fight these cases. 

Gregory Pimstone says significant changes are the need of the day

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.”

ERs in the USA is obligated under law to treat every patient that walks in. The patient needs to be treated until he/she can be discharged from the unit. The problem starts here. He says confusion reigns when one walks into an ER care unit, especially when the person does not have a healthcare plan under a contract with the hospital. No ER can refuse treatment, nor can any healthcare plan carrier direct the person to only visit ER care units with whom it has a contract. 

The root cause for legal disputes in the USA

The patient is treated until stabilized, and the healthcare carrier needs to pay for the services rendered as per the law of the land. The managed healthcare plans have provisions for the above, and the payment is determined via a method overseen by its regulator. However, the ER is under no legal obligation to accept the payment rendered. If the ER is not satisfied with the payment amount, a legal suit can be filed in court against the carrier. The parties fight it out in court, and if one of them loses in the trial court, an appeal can be made for justice. 

There is no clear-cut law in the land 

He says in the absence of a defined law to set out a formula for determining this reasonable amount for out-of-network ER care; the courts are clogged with suits. This only results in financial and legal woes. Imagine the amount of valuable time and resources wasted in the process. The State Legislature has done nothing to resolve the problem, and it is the need of the hour for it to step in with a solution. The formula for reasonable value can be determined after a hearing by stakeholders with their opinions on the subject.  Only then can this cycle of endless litigation can stop, and the ER out-of-network reimbursement and administration process is streamlined, he says. 

Gregory Pimstone of Manatt says though the Biden Administration is introducing some prominent changes in promulgation that will come into effect in 2022, it will not resolve this issue. The California Legislature needs to intervene with a clear and defined formula for defining the reasonable value of ER care out-of-network payments.