Don’t Pay an Emergency Room Bill Before Talking to a Personal Injury Attorney

When a person in California has insurance through an HMO, they go to their in-network providers for most of their care. That is, unless they are injured in an accident and need emergency care. In those cases, the hospital at which a person is seen may not have a pre-negotiated contract with their HMO. This could result in the HMO’s refusal to pay the full amount they are billed.

When this happens, some doctors have then billed the patient for the balance between what the HMO paid and what the doctor invoiced. This is called “balance billing” and a recent ruling by the Supreme Court of California has fond that it is not allowed. This is just one of the reasons that you need to ensure you have a qualified personal injury attorney on your side if you are injured in an accident.

What the court found about balance billing

The U.S. Supreme Court looked at a case of balance billing and considered how it was affected by the Knox-Keene Act. This Act provides regulations / licensing of managed health care. This law states that HMOs must pay emergency room doctors when said doctors provide care to their customers. If a hospital is a contracted provider, then they must offer care regardless of the patient’s ability to pay. The HMO will then pay for the care that was provided.

The Act further states that if there is a billing dispute that arises, then it is up to the doctors and the HMOs to settle it. The patent is not responsible for billing disputes.

What about cases in which the hospital was not a contracted provider?

The above refers only to hospitals that are contract providers. The legal questions have arisen regarding doctors’ groups and hospitals that are not contracted providers. These are the ones who believed they had a right to balance billing as the Act specifically referred to contracted doctors. The court considered this as well as other facts of the Knox-Keene Act.

The Court’s analysis and conclusion

The court looked at all relevant laws and found that HMOs needed to have procedures in place to resolve potential billing disputes. The reiterated that emergency room providers were required to offer care regardless of the ability of a patient to pay. Finally, they decided that if an emergency room doctor had an issue with billing then they needed to file a lawsuit directly with the HMO – not bill the patient.

All of that said, this does not mean that every emergency room doctor knows this decision or understands the law. They may assume that they can bill a patient if said patient’s HMO does not cover the entirety of their fees. This is just one reason that you should have an attorney on your side if you were injured in an accident and are seeking medical care. You can contact The Law Offices of Larry H. Parker at 800-333-0000 for a free legal consultation.