A health care lawyer named Gregory Pimstone records the experiences of the emergency healthcare system of the USA just to realize how hollow it is and calls for a change. In this healthcare system, if a person with insurance takes emergency health care facilities from an out-of-network hospital, he will experience a tedious process to pay the bills. The reimbursing process takes a toll on the time and resources of the patient, hospital, and insurance company. This dilemma occurs because no laws are available to fix a medical fee rate for such a situation.
If a person is injured, the law permits them to seek medical assistance from the nearest ER irrespective of the contracted list. Once the patient is stable, the healthcare plan is to pay the charges, regardless of the contracted list. But the emergency provider deems the value offered by healthcare plans unreasonable. Here, the law becomes problematic because it does not define reasonable.
The case of Children’s Hospital Central California v Blue Cross of California. 4th 1260 (2014) is a clear example. Both parties, upon disagreement on reasonable value, went to court. The court calls for determining the scope of rates regarding the series, including all previous rates, even by government payors. But each case is different.
The rates data for each hospital were different. The lack of an equation to determine reasonable value leads to such arbitrary decisions. There are thousands of cases like this. All cases result in court arbitration, and the court has to consider rates that change each year, making year-old claims inappropriate to determine reasonable value.
Hence, Hospitals and Health Insurances companies are constantly engaged in costly litigation for the same case with a different patient. Both exchange records, hire lawyers, present witnesses to collect opinions to determine one single value. These sessions cost millions of dollars. If one side loses, it goes for an appeal initiating the cycle again.
This irrational system calls for the need to reinstate procedures and define set values. Another loophole is if a person goes to a contracted hospital with a non-contracted doctor, then that one person receives 125 percent of Medicare would pay.
This huge flaw is what Gregory Pimstone wants to point out. The Biden Administration has presented the “No Surprise Act” 2022 regarding this matter, but it is also ineffective. The Act only proposes a list of factors to take into consideration for determining value. There is still no definite method to determine the costs and decide who gets what—still no way to direct the courts and aid the decision-making process.
The Californian legislature has not taken up the issue. Thousands of patients in need of health care arrive in non-contracted hospitals every day. There are only two ways to go about the subject. Either legislate a decisive way to determine the value and end the waste of resources. Or let the two parties continue their legal battles forever.