BM_55. CMA Defends Physicians' Rights to Payment for Emergency Services

Fri, 2 May 2003 00:03:11 -0700 (PDT)

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-----Original Message-----

From: cma_alert@cmanews.org [mailto:cma_alert@cmanews.org] 

Sent: Thursday, April 24, 2003 1:37 PM

CMA recently filed a friend-of-the-court brief with the California Court of Appeals in Ochs v. PacifiCare, defending physicians' rights to recover payment from health plans for emergency services provided to their enrollees. In this case, physicians from a professional emergency medical corporation provided emergency care to a PacifiCare patient in a hospital emergency department. PacifiCare, however, denied any obligation to reimburse the physicians for their services, as the health plan had contracted its payment responsibilities to an intermediary. The intermediary had since, however, closed due to financial insolvency.

The trial court ruled in favor of PacifiCare, suggesting that health plans are not obligated to pay for emergency services provided by noncontracting physicians. If the ruling is allowed to stand, this would mean that a treating physician could not look directly to a health plan for payment, even if its contracting intermediary has gone out of buisness. The trial court's ruling has been appealed.

By law, hospitals that maintain an emergency department must provide emergency medical services to all those who need them, regardless of the patient's ability to pay and regardless of whether the patient's health plan contracts with the particular facility where the patient presented or with the particular physicians providing the care. CMA's brief to the appellate court emphasized that the law also requires health plans to pay for emergency medical services and reimburse those who actually provided such care.

CMA's brief argued that if, as the trial court ruled, health plans can evade their common law responsibilities, as well as their extensive statutory obligations under the Knox-Keene Act, the state's already fragile emergency care system will be destroyed . The brief stated that it is both unfair and illegal for health plans, companies that have been paid premiums to pay for medically necessary care and that are specifically obligated under the law to pay for such care, to contribute to the further destabilization of California's health care system by refusing to pay for emergency services provided by physicians to their enrollees. 

<http://www.calphys.org/html/bb240.asp> Click here for more information, including a copy of CMA's brief.

Brian Potts 
Managing Editor, CAL/AAEM News Service 
MS-IV, UC-Irvine

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<DIV><FONT size=2>
<P>-----Original Message-----</P>
<P>From: cma_alert@cmanews.org [</FONT><A href="mailto:cma_alert@cmanews.org"><U><FONT color=#0000ff size=2>mailto:cma_alert@cmanews.org</U></FONT></A><FONT size=2>] </P>
<P>Sent: Thursday, April 24, 2003 1:37 PM</P>
<P></P>
<P>BM_55. CMA Defends Physicians' Rights to Payment for Emergency Services </P>
<P></P>
<P>CMA recently filed a friend-of-the-court brief with the California Court of Appeals in Ochs v. PacifiCare, defending physicians' rights to recover payment from health plans for emergency services provided to their enrollees. In this case, physicians from a professional emergency medical corporation provided emergency care to a PacifiCare patient in a hospital emergency department. PacifiCare, however, denied any obligation to reimburse the physicians for their services, as the health plan had contracted its payment responsibilities to an intermediary. The intermediary had since, however, closed due to financial insolvency.</P>
<P>The trial court ruled in favor of PacifiCare, suggesting that health plans are not obligated to pay for emergency services provided by noncontracting physicians. If the ruling is allowed to stand, this would mean that a treating physician could not look directly to a health plan for payment, even if its contracting intermediary has gone out of buisness. The trial court's ruling has been appealed.</P>
<P>By law, hospitals that maintain an emergency department must provide emergency medical services to all those who need them, regardless of the patient's ability to pay and regardless of whether the patient's health plan contracts with the particular facility where the patient presented or with the particular physicians providing the care. CMA's brief to the appellate court emphasized that the law also requires health plans to pay for emergency medical services and reimburse those who actually provided such care.</P>
<P>CMA's brief argued that if, as the trial court ruled, health plans can evade their common law responsibilities, as well as their extensive statutory obligations under the Knox-Keene Act, the state's already fragile emergency care system will be destroyed . The brief stated that it is both unfair and illegal for health plans, companies that have been paid premiums to pay for medically necessary care and that are specifically obligated under the law to pay for such care, to contribute to the further destabilization of California's health care system by refusing to pay for emergency services provided by physicians to their enrollees. </P>
<P>&lt;</FONT><A href="http://www.calphys.org/html/bb240.asp"><U><FONT color=#0000ff size=2>http://www.calphys.org/html/bb240.asp</U></FONT></A><FONT size=2>&gt; Click here for more information, including a copy of CMA's brief.</P></FONT></DIV><BR><BR><STRONG>Brian Potts <BR>Managing Editor, CAL/AAEM News Service</STRONG> <BR>MS-IV, UC-Irvine<p><hr SIZE=1>
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