1 Sep 2021

Gregory Pimstone On Paying For Out-Of-Network Emergency Care

Post by Jordan Toplen

The out-of-network care

Every American patient is entitled to treatment by any nearby emergency room care in case of a medical emergency. However, the administration and reimbursement of emergency room care have had many conflicts between service providers and insurance companies.  Most disputes arises when patients are admitted to medical institutions that are not in contract with the patient’s insurance company. According to the head of the healthcare law group at national law firm Manatt, Gregory Pimstone, handling payments regarding out-of-network emergency rooms has become an inefficient and expensive process.

Whose responsibility is it?

According to the law, an individual in need of emergency services is entitled to these services in the closest Emergency room care. Moreover, it requires hospitals to offer these services even when they are not in contract with the patient’s emergency services. The insurance company is obligated to pay for the services rendered. The law directs a regulator to oversee payments made by an insurance company. Nonetheless, hospitals are not mandated to accept the payments made if they are dissatisfied. This is because every case is different. Therefore, the data used on one dispute may differ from one hospital to another. It rests on the objectivity of a jury, judge, or arbitrator to determine a reasonable amount for payment.

The blame games

There are different cases every year. These processes require an exchange of electronic data on the claims and their contracts with other providers and carriers. The litigation of each of these cases is expensive as professional expertise is needed to analyze the data, legal fees to be paid, and there can also be appeals if one side loses. There are many cases, so doctors and non-contracted carriers continue litigating case after case even after completing a time-consuming and expensive case in relation to earlier patients.

Amassing money for selfish gains,

There are reports that indicates that Doctors and medical personnel have found a loophole in the Affordable Care Act and attempt to manipulate it. In some cases, individuals are run into getting private insurance covers. These private insurance companies offer cost-sharing benefits to their clients. This makes it accessible for patients to use out-of-network. When using out-of-network services, private insurers pay for inpatient premiums; however, the insurance lapses when the provider is billing a lot of money to the insurance company leaving all the additional costs to fall on the patient. This has resulted in healthcare consumers catering for all the additional costs demanded. The challenge is, some states lack adequate professional personnel to monitor, audit, regulate and take action against individual(s) taking advantage of the loophole in the Affordable Care Act.

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