Now non-participating providers providing emergency services have standing to directly sue health insurance companies to resolve reimbursement disputes over services rendered.

 

Emergency room physicians have been particularly hard hit by the ban on ‘balance billing.’  Due to this ban you can now take advantage of California Health and Safety Code section 1371.4(b). 

 

Two California appellate decisions have held that medical providers could bring private actions for violations of the Knox-Keene Act under the Unfair Competition Law (UCL) and common law theories. Coast Plaza Doctors Hosp. v. Blue Cross of California, (2009) 173 Cal. App. 4th 1179; Bell v. Blue Cross of California. 

 

In Bell v. Blue Cross, a non-participating emergency room physician sued a health insurance plan, seeking reimbursement for the reasonable value of the emergency medical services he rendered to the plan’s enrollees. State law requires health plans to reimburse emergency physicians for care provided to the plan’s enrollees. The trial court agreed with the insurance plan that the doctor did not have standing to enforce the Knox-Keene Act. The California Court of Appeal disagreed, finding that the Act’s jurisdiction was not exclusive to the Department of Managed Health Care and that the doctor did have standing to pursue his claim. The court also noted that the legislative history of the Act did not intend to give health plans unfettered discretion to unilaterally determine the amount it would reimburse a non-participating provider, without regard to the reasonableness of the fee.

 

Clients include out-of-network physicians across California.

 

Call today for a free consultation (888) 570-1288 and examples of case results.