‘Balance Billing’ Lawsuits Emerge After California Supreme Court Ruling
A January California Supreme Court ruling banning so-called "balance billing" has raised the prospect of hospitals and emergency department physicians facing lawsuits from patients seeking refunds for cases in which providers billed patients for charges their health plans did not pay, the Los Angeles Daily Journal reports (George, Los Angeles Daily Journal, 2/11).
Balance billing typically occurs when insured people seek emergency care at facilities that are not included in their HMOs' preferred provider networks.Â Insurers reimburse doctors and hospitals at a lower, out-of-network rate, and the health care providers bill patients for the remainder of the charges (California Healthline, 1/9).
At least two lawsuits have been filed seeking retroactive reimbursements from health care providers, sparking concerns from providers that they could face hundreds of millions of dollars in refunds to patients.
According to the Journal, a central issue in the suits is whether the ruling deeming balance billing illegal applies retroactively.
The Department of Managed Health Care contends that regulations banning balance billing took effect on Oct. 15, but the Journal reports that the state Supreme Court ruling was less clear about when the prohibition on balance billing took effect.
Elena Lopez-Gusman, director of governmental affairs for the California chapter of the American College of Emergency Physicians, said, "Balance billing was legal." She added, "To say that (the law) was retroactive is requiring physicians to have had a crystal ball four years ago."
Francisco Silva, general counsel for the California Medical Association, said ED physicians could file cross complaints against health plans for the low rates they pay (Los Angeles Daily Journal, 2/11).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.