An esteemed healthcare lawyer from Los Angeles is speaking out against the USA’s prevailing system of paying out-of-network emergency care. He stresses the need for legislative intervention to immediately change the process that he considers to be irrational, expensive, and unnecessary. 

Gregory Pimstone speaks on the flaws of this system 

Gregory Pimstone is a widely respected healthcare legal expert and head of the healthcare law group at national law firm Manatt. He firmly believes the system for the reimbursement and administration of ER care in the USA is filled with flaws, especially when it comes to determining the reasonable costs for healthcare services in an emergency care room.

After a patient is discharged from ER care, the payment issue arises between ERs and the healthcare carrier. Though managed healthcare plan carriers look after the payment method using a process set down by the regulator, the ER is under no obligation to accept the payment offered. This leads to litigation, and if one party loses in a trial court, appeals are made. 

The problem gets worse as patients walk into ER units daily, and disputes are regular. Multiple lawsuits are filed, and parties are wasting their own time and financial resources in the battle. The entire process is wasting time and valuable resources. 

No law has been set for determining the amount of reasonable costs

 The law of the land does not set out a set formula when it comes to the determination of these costs. The result leads to multiple litigation suits being filed in courts of law, giving rise to legal and financial woes. The current system serves no purpose and only benefits the legal professionals hired to fight such cases. 

Sensible legislation is the only solution 

Since the law lays down no set formula for determining the reasonable costs for ER care out-of-network payments, the legislature must step in and take note of the issue in California. If it continues to overlook the problem, the cycle of litigation will never cease. 

The Biden administration has promulgated regulations to implement the No Surprises Act, which is scheduled to come into effect from 2022 in some American states. However, he adds this promulgation is still not a solution. 

Why? 

It lays down that a list should be made on the wide range of factors that a trier of fact should take into account with discretion for determining the reasonable value of ER care services. However, litigation will continue in the absence of a clear and defined formula for determining this fair rate. Unfortunately, the legislature of California is not doing anything about the issue and shows no interest in intervening in it either. 

Gregory Pimstone of Manatt concludes 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.”