CMA Opposes Effort to Allow Health Plans to Continue Dodging Payment for ER Services

CAL/AAEM News Service calaaem_news@yahoo.com
Thu, 22 Apr 2004 18:12:48 -0700 (PDT)


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CMA Opposes Effort to Allow Health Plans to Continue Dodging Payment for ER Services

April 15, 2004


CMA filed a brief with the California Supreme Court this week, urging the justices to deny a request to limit the reach of a recent appellate court ruling that would prevent health plans' from shirking their payment responsibilities when they contract with intermediaries they know to be financially unstable.

Earlier this year, the Sixth District Court of Appeal had ruled that health plans in certain circumstances must pay for emergency services provided to its enrollees by noncontracting physicians, even though the plan has delegated its payment responsibilities to a contracting intermediary. In the ruling, Appellate Judge J. Coffee concluded that even though a health plan can legally contract its payment responsibilities to a third party, the plan can be held liable for payment if it negligently contracted with that intermediary when it knew-or should have known-that the intermediary was financially unstable. 

PacifiCare, the defendant in this case, has requested that the state Supreme Court "depublish" or limit the reach of the appellate court's ruling, saying the opinion is "confusing" and "makes no significant contribution to legal literature." Only published opinions serve as precedents for future legal cases.

In its brief, CMA noted that while health plans "may not like the court's decision," the ruling establishes a "significant new rule of law and makes a substantial contribution to legal literature by providing physicians with some relief." The brief also pointed out that the case, Ochs v. PacifiCare, is "the first time that a court has recognized" negligence by an insurer who knew or should have known that "serious problems existed" with a subcontractor that resulted in the subcontractor being unable "to make payments to physicians for medically necessary services" to health plan patients. 

Click here for more information, including a copy of CMA's brief. 

Source: CMA Alert




Cyrus Shahpar & Brian Potts 
Managing Editors, CAL/AAEM News Service 
UC-Irvine

		
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<P><FONT size=3><B><SPAN style="FONT-FAMILY: Arial">CMA Opposes Effort to Allow Health Plans to Continue Dodging Payment for ER Services</SPAN></B><SPAN style="FONT-FAMILY: Arial"><o:p></o:p></SPAN></FONT></P>
<P class=MsoNormal style="MARGIN: 0in 0in 0pt"><FONT size=3><?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:date Month="4" Day="15" Year="2004"><SPAN style="FONT-FAMILY: Arial">April 15, 2004</SPAN></st1:date><SPAN style="FONT-FAMILY: Arial"><o:p></o:p></SPAN></FONT></P>
<P><SPAN style="FONT-FAMILY: Arial"><BR><FONT size=3>CMA filed a brief with the California Supreme Court this week, urging the justices to deny a request to limit the reach of a recent appellate court ruling that would prevent health plans' from shirking their payment responsibilities when they contract with intermediaries they know to be financially unstable.<o:p></o:p></FONT></SPAN></P>
<P><SPAN style="FONT-FAMILY: Arial"><FONT size=3>Earlier this year, the Sixth District Court of Appeal had ruled that health plans in certain circumstances must pay for emergency services provided to its enrollees by noncontracting physicians, even though the plan has delegated its payment responsibilities to a contracting intermediary. In the ruling, Appellate Judge J. Coffee concluded that even though a health plan can legally contract its payment responsibilities to a third party, the plan can be held liable for payment if it negligently contracted with that intermediary when it knew-or should have known-that the intermediary was financially unstable. <o:p></o:p></FONT></SPAN></P>
<P><SPAN style="FONT-FAMILY: Arial"><FONT size=3>PacifiCare, the defendant in this case, has requested that the state Supreme Court "depublish" or limit the reach of the appellate court's ruling, saying the opinion is "confusing" and "makes no significant contribution to legal literature." Only published opinions serve as precedents for future legal cases.<o:p></o:p></FONT></SPAN></P>
<P><SPAN style="FONT-FAMILY: Arial"><FONT size=3>In its brief, CMA noted that while health plans "may not like the court's decision," the ruling establishes a "significant new rule of law and makes a substantial contribution to legal literature by providing physicians with some relief." The brief also pointed out that the case, <I>Ochs v. PacifiCare</I>, is "the first time that a court has recognized" negligence by an insurer who knew or should have known that "serious problems existed" with a subcontractor that resulted in the subcontractor being unable "to make payments to physicians for medically necessary services" to health plan patients. <o:p></o:p></FONT></SPAN></P>
<P><SPAN style="COLOR: blue; FONT-FAMILY: Arial"><A href="http://www.calphys.org/html/bb547.asp"><FONT size=3>Click here</FONT></A></SPAN><SPAN style="FONT-FAMILY: Arial"><FONT size=3> for more information, including a copy of CMA's brief. <o:p></o:p></FONT></SPAN></P>
<P><SPAN style="FONT-FAMILY: Arial"><FONT size=3>Source: CMA Alert</FONT></SPAN></P></DIV></o:p></SPAN></DIV><BR><BR><DIV><FONT face=arial><FONT size=3><STRONG>Cyrus Shahpar &amp; Brian Potts</STRONG> <BR>Managing Editors, CAL/AAEM News Service <BR>UC-Irvine</FONT></FONT></DIV><p>
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