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An eminent legal healthcare specialist from Los Angeles is speaking out against the paying for out-of-network emergency care prevailing in the USA today. He states significant changes are the need of the hour to create unnecessary, expensive, and irrational processes. The whole system increases financial woes for both parties involved in a lawsuit and benefits no one.

Observations by Gregory Pimstone into the prevailing system

Gregory Pimstone is a highly esteemed lawyer and the head of the healthcare law group of the esteemed national law firm Manatt. When it comes to the system that deals with paying out-of-network emergency care in the USA, he says the process is just clogging the courts of law with needless litigation. The only people who are benefitted from the whole system are lawyers hired to fight the case.

In the USA, when a patient goes to an emergency room care unit and does not have a health plan under contract with that hospital, confusion reigns. This results in several legal and financial problems with a waste of time and precious resources rendering the entire system “irrational” in nature.

What does the law say?

The law of the land lays down that every ER in the nation is under a legal obligation to treat every patient who walks in the hospital even if the healthcare plan him/her is not in contract with the hospital. The patient is taken care of until stabilized. The problem does not arise here but after the patient leaves.

Both the ER and the insurance carrier need to enter into an agreement for the reasonable value of the services. The nation has managed healthcare plans to help. The law states these plans are to release payment with the method that a regulator oversees; however, the ER is not bound to accept this payment offered. If the ER is not happy with the reasonable costs, he/she can sue the insurance carrier in court. The litigation will determine the amount that is to be paid. Again, if one party loses the case in a trial court, the plea is moved forward to an appellate court, entailing further legal and financial hassles.

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The biggest problem here is the law has not fixed formula for calculating this “reasonable value” that is to be determined for such ER out-of-network reimbursement and administration cases.

So, what is the solution?

He says there is a solution to the above problem if the state legislature steps in to determine the rate of reasonable costs to be paid in such cases. The Legislature of California has taken no step so far to look into the matter. The result is every case heard in court is unique. The payment and rate data used in one dispute differs from one case to another. Therefore, the jury, arbitrator, or the judge hearing the case will come in with varied determinations of the reasonable costs to be paid in the case despite using exactly the same information as other cases.

Gregory Pimstone of Manatt says this is where the whole system is deemed inefficient and unnecessary. Unless the state legislature does not intervene, the problem will prevail and only result in endless litigation clogging the courts in the land.

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