Health care Lawyer Greg Pimstone Points Out the Out-of-Network Emergency Care Reimbursement System Is Inefficient


In America, every emergency room care provider isobligated to treat an injured person under the law. No person can be refused treatment, and no Insurance carrier can force any insured to visit the emergency care room with whom it has a contract. The healthcare plan of the patient will take care of the costs. However, it is here that the problem starts. Managed health plans calculate the treatment costs via a method overseen by the regulator, and the ER provider is under no obligation to accept what is offered. This is where the dispute starts, and the matter is taken to court. A leading healthcare lawyer from Los Angeles is now speaking out against the system, citing it to be inefficient, unnecessary, and expensive.

Greg Pimstone– Changes are needed to save time and costs

Greg Pimstone is an eminent lawyer from Los Angeles and currently is the head of the healthcare law group firm Manatt in the USA. When dissatisfied, the ER provider files a case against the insurance carrier to determine the amount of reasonable value for the services rendered. This problem gets worse as many patients are landing up at non-contracted hospitals on a regular basis.

Huge expenses are involved in needless litigation

He says that every one of these cases is expensive. The plans and hospitals have to exchange a lot of electronic data about their claims and contracts with other carriers and providers. Both sides need expert witnesses for crunching the data and offering opinions when it comes to the reasonable value of these services. On top of this, there are legal fees that are incurred when it comes to litigating these lawsuits. Here, the hospitals seek tens or hundreds of millions in what they believe to be underpayments. When one party loses in a trial court, there are appeals, and the litigation again resumes.

He adds this whole system of determining the reasonable value of out-of-network emergency room care is highly complex, chaotic, and financially expensive for the state. Though the law lays down many provisions pertaining to the litigation, it fails to define a fixed benchmark via which the courts in the state can determine the reasonable value for the healthcare services rendered,

The state legislature needs to step in for help

The state courts are clogged with cases. However, he says there is a fix to this problem. The state legislature of California should define a clear benchmark on how to determine the reasonable value of such out-of-network emergency services to help courts accelerate cases faster. It should show an interest and hear the views of the stakeholders involved to finally conclude that defines a clear benchmark for curbing the number of cases piling up in the state.

The system is so irrational that it makes no sense. He adds that this process actually serves no purpose and only benefits the lawyers that have been hired to battle out the case in the courts of law.