Arnold Schwarzenegger Helps Providers & Medical Reimbursement Attorneys

When a patient receives emergency room services, and the patient’s managed health care plan subsequently refuses to pay the entire bill, can the emergency service provider fight back for the unpaid balance? One thing in California is now clear, you can.

In 2005, the California Supreme Court interpreted the Knox-Keene Act to permit emergency care providers in California to sue HMO and PPOs directly over billing disputes. Bell v. Blue Cross of California, 131 Cal.App.4th 211, 220 (2005)

Providers (specifically emergency physicians and hospitals) no longer have to bear the brunt of this burden as billing disputes with health plans continue.

“Balance billing” is a term coined by the health care industry in which a physician bills a patient directly for costs of medical services that a health insurance company is unwilling to pay. On January 8, 2009, the California Supreme Court determined that it is unlawful for emergency room physicians or hospitals to balance bill patients for the cost of emergency

services. This landmark decision, rendered in Prospect Medical Group, Inc. v. Northridge Medical Group, specifically affects physicians who do not have a contractual relationship with the patient’s insurance company, guaranteeing reimbursement for emergency care provided.

In 2006, California Governor Arnold Schwarzenegger, who was balance billed himself, ordered the state Department of Managed Health Care (DMHC) to promulgate regulations to protect Californians from ‘balance billing.’ He simultaneously enacted Health and Safety code section 1371.4 which gives you the right to sue for unpaid bills.

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