Gregory Pimstone Stresses On Sensible Legislation For The Paying of Out-of-Network Emergency Care Services


The out-of-network emergency care system in the USA is vague, inefficient, and irrational. A leading healthcare lawyer has made these observations from Los Angeles. He believes there is a solution to the endless litigation linked to the above with legislation and calls out for attention. 

Gregory Pimstone is an esteemed healthcare lawyer and is the head of the healthcare law group at the national law firm Manatt in the USA. He says confusion reigns in the system that deals with the out-of-network ER care payment process. The law sets no formula on how to determine the costs of services rendered during out-of-network ER care. 

How does this system function?

The present system at the beginning of the process is simple and clear. A patient can go to their nearest ER even if his/her healthcare plan is not under a contract with it. The ER is under a legal obligation to treat the patient until he/she is stabilized. The patient’s healthcare plan cannot dictate him/her to visit only those ER providers it has a contract with. Till this step, the system is well-defined and clear. 

The issue arises in the next step. Under the law, managed healthcare plans take care of the out-of-network ER care costs. The regulator oversees the payment method, and the ER is under no legal obligation to accept what is offered. In case of dissatisfaction regarding the payment of the reasonable value for the services rendered, the ER can sue the healthcare carrier. 

The case is taken to court, and an appeal can be made if one of the parties loses in the trial court. 

The problem gets worse 

The above is just an example of one case. Just imagine, daily, patients are coming to ER care units for treatment. Disputes arise, filed cases, and a huge amount of time and money is spent on litigation. Due to the absence of any law regarding how to determine the reasonable value for ER care out-of-network services, the courts offer varied verdicts in cases though most of them are sourced from similar information. The whole system does not make any sense and is just a waste of precious resources and money. 

He says, “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.” 

Gregory Pimstone of Manatt says this grave problem can only be resolved if the California Legislature notes the problem and passes defined legislation to determine a set formula for calculating reasonable costs for out-of-network ER care services. The system can be freed from its flaws and made more streamlined and convenient for everyone if rational legislation is passed on the above matter. 

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