Los Angeles Business Journal

01/26/2004

HEALTH CARE

by Laurence Darmiento

HMO members who believe they are only responsible for the co-payment on a trip to the emergency room may have a surprise coming to them in the mail.

L.A. Superior Court Judge Linda Lefkowitz has ruled that some emergency room physicians have the right to bill patients if they think they are not getting adequate payment from the insurance company.

The ruling, which has been appealed, involved a pair of lawsuits filed by Prospect Health Source Medical Group, a Culver City independent practice association, against two groups of emergency room doctors at Saint John's Health Center and Northridge Hospital Medical Center.

The case arose when patients of Prospect, which acts as a financial intermediary for insurers, visited the two emergency rooms. The ER doctors then billed Prospect, but after the group refused to pay the full amount they demanded, they began billing patients for the remainder of their bills.

Prospect sought a court judgment that the emergency room doctors should have to take the Medicare rate for such services — about a third of what the ER doctors charged — and not be allowed to bill patients for the rest.

Prior Superior Court decisions have come down on the side of insurers, but in this case Lefkowitz maintained nothing in state law prohibits a practice that's known as "balanced billing."

She further stated that a legal opinion by the Department of Managed Health Care that the practice was illegal was not valid and that state law would need to be changed to stop the practice.

The decision does not affect patients whose medical groups have contracts with emergency room doctors, but that's little comfort to those who generally seek out the closest hospital when in need of emergency care.

"The patient should not be getting that bill. In some cases they were threatened with collection," said Ken Johnson, an attorney representing Prospect. "The decision goes against the grain of the promise of managed care."

Earlier this month Prospect appealed the decision to the California Court of Appeal, but in the meantime, an attorney representing the emergency room doctors said his clients plan to continue balance-billing patients.

"The ER doctors are just looking for a fair and reasonable payment," said attorney Andrew Selesnick, who represents St. John's Emergency Medical Specialist Inc. and the Northridge Emergency Medical Group. Back to top

CAL/ACEP "Lifeline""

01/23/2001

HOW TO COLLECT YOUR MONEY DESPITE KPC'S BANKRUPTCY

By Andrew H. Selesnick, Esq.

In September, 2000, KPC Medical Management, a huge physicians management company, received a 30 million dollar bailout. It promptly burned through the money in less than two months, and declared Chapter 11 Bankruptcy in Riverside, California, in late November, 2000.

KPC'S bankruptcy has left emergency physicians with unpaid claims well in excess of 10 million dollars. The stated intention of KPC officials is to liquidate the company, which most likely will leave little, if any, money for emergency physicians. The pressing issue for emergency physicians is how to get paid, despite the bankruptcy.

For those physicians who did not have a contract with KPC, they can look to the HMO or insurance company to pay them, based on California law. An executive with the Health Care Association of Southern California recently stated that the health insurance companies were responsible for making the payments that KPC did not make. However, given the insurance companies' past positions on the issue and the amount of money at stake, it is unlikely that they will voluntarily pay the KPC claims without legal intervention.

Anticipating this exact scenario, many emergency physician groups have re-submitted their KPC claims directly to the insurance companies. If the insurance companies do not pay the claims within 45 days, the groups have banded together to immediately file a lawsuit.

If you are interested in resolving your KPC problem, please contact Robert B. Scapa, Esq. at (800) 446-5873. Back to top

12/11/2000

KPC Medical Management Owes Emergency Physicians Millions

By Andrew H. Selesnick, Esq.

KPC Medical Management arose from the ashes of the Medpartners financial debacle, and has continued Medpartners' tradition of failing to pay, or underpaying, emergency physicians. KPC, with reportedly over 1 million members in California, is estimated to owe emergency physicians millions of dollars in unpaid, or underpaid claims.

Emergency physicians, who do not have contracts with KPC, have been promised repeatedly for well over one year that they would be paid for the services that they provided to patients. To date, many of those physicians have not been paid anything, with some claims at least two years old.

At least seven emergency physician groups have decided that they have waited long enough for payment from KPC. The California Health & Safety Code requires that emergency physicians be paid, usually within 45 days after presenting a claim. By utilizing California law, these groups are banding together to file a lawsuit against KPC, to force it to pay for services rendered to its members.

If you are interested in resolving your KPC problem, please contact Robert B. Scapa, Esq. at (800) 446-5873. Back to top