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  January 12, 2009
  Source:  WorkInjury.com
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Sup.Ct:   Supreme Court Nixes Emergency Room 'Balance Billing' for HMO Members

"Balance billing" is when a health provider bills a patient directly for the part of the bill not covered by insurance. In this case, the patient was a member of an HMO but had required emergency treatment outside the plan.

Under all HMO plans, when - due to the nature of the ailment - an HMO member is forced to seek emergency treatment outside the HMO, the HMO must cover the treatment.

But what happens when the HMO makes payment for an amount less than what the emergency treater bills (as was the case here)?  Can the emergency provider seek the difference directly from the patient?

The California Supreme Court has now said NO. The emergency provider must resolve the billing dispute with the HMO only and leave the patient out of it.

"Interpreting the applicable statutory scheme as a whole - primarily the Knox-Keene Health Care Service Plan Act of 1975, Health and Safety Code section 1340 et seq. - we conclude that billing disputes over emergency medical care must be resolved solely between the emergency room doctors, who are entitled to a reasonable payment for their services, and the HMO, which is obligated to make that payment.

"A patient who is a member of an HMO may not be injected into the dispute. Emergency room doctors may not bill the patient for the disputed amount."

The case is Prospect Medical v. Northridge Emergency.

To read the full opinion,

      PLEASE CLICK HERE.