2. Court Rules in Favor of Noncontracting Physicians (CMA Alert)

Thu, 8 Jan 2004 22:31:50 -0800

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Indeed, this is a MAJOR victory which was most dangerous and one that will
be likely be followed by an HMO-DHS counter-attack. We must be ready, more
ready for this challenge and predict it will come stronger ahead of us...

So, join the CMA... 

Yes, Join the CMA... 

Join the CMA...

And of course, please make sure that, irrespective of who you belong to in
EM, whether you are a member of AAEM, ACEP, SAEM, all or none, please most
of all make sure that you contribute to the EMPAC, the one (unified/united)
California fund for political action committee... Email me for details on
how to contribute to EMPAC>

My two cents...

Antoine Kazzi

A. Antoine Kazzi, MD, FAAEM 

Vice-President, the American Academy of Emergency Medicine 

Vice-Chair, Department of Emergency Medicine 

University of California, Irvine 

-----Original Message-----
From: cma_alert@cmanews.org [mailto:cma_alert@cmanews.org] 
Sent: Thursday, January 08, 2004 2:50 PM

2. Court Rules in Favor of Non-Contracting Physicians

In a significant victory for physicians, a Los Angeles trial court ruled
that non-contracting physicians who provide emergency services to health
plan enrollees are not prohibited from balance billing those patients if an
HMO fails to reimburse them for the entire amount billed. 

In this case, Prospect Health Service Medical Group v. St. Johns Emergency
Medical Group, the plaintiff (a capitated IPA) argued that when a physician
bills and is paid by an HMO or its contracting intermediary, an "implied
contract" has been created whereby the physician is prohibited from balance
billing the patient under the Knox-Keene Act. 

In her decision, Judge Linda Lefkowitz ruled that non-contracting physicians
are not precluded from balance billing patients and that an opinion
published by the Department of Managed Health Care to that effect wrongly
relied on unpublished, distinguishable cases, which have no precedential
value. 

Judge Lefkowitz also rejected the plaintiff's request to set Medicare rates
as the defined "reasonable" rate for emergency medical services. 

Click here <http://www.calphys.org/html/bb467.asp> to download a copy of
the court's opinion in this case. For more information, see CMA ON-CALL
document #0130, "Non-contracting Physicians/Implied Contracts." ON-CALL
documents are available free to CMA members at CMA's members-only website
<http://www.cmanet.org/logon> . Nonmembers can purchase ON-CALL documents
for $2 per page at the CMA Bookstore <http://www.cmanet.org/bookstore> .

Contact: CMA's legal information line, 415/882-5144 or legalinfo@cmanet.org
<mailto:legalinfo@cmanet.org> 

This e-mail/fax message, including any attachments, is for the sole use of
the intended recipient(s) and may contain confidential and privileged
information.  Any unauthorized review, use, disclosure or distribution is
prohibited.  If you are not the intended recipient, please contact the
sender by reply e-mail/fax and destroy all copies of the original message. 

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<div class=Section1>

Indeed, this is a MAJOR victory which was most dangerous and one
that will be likely be followed by an HMO-DHS counter-attack. We must be ready,
more ready for this challenge and predict it will come stronger ahead of us...

<p class=MsoNormal style='text-autospace:none'><font size=3 color=blue
face="Trebuchet MS"><span style='font-size:12.0pt;font-family:"Trebuchet MS";
color:blue'>&nbsp;</span></font></p>

So, join the CMA...

Yes, Join the CMA...

<p class=MsoNormal style='text-autospace:none'><font size=3 color=blue
face="Trebuchet MS"><span style='font-size:12.0pt;font-family:"Trebuchet MS";
color:blue'>Join the CMA...</span></font></p>

<p class=MsoNormal style='text-autospace:none'><font size=3 color=blue
face="Trebuchet MS"><span style='font-size:12.0pt;font-family:"Trebuchet MS";
color:blue'>&nbsp;</span></font></p>

And of course, please make sure that, irrespective of who you
belong to in EM, whether you are a member of AAEM, ACEP, SAEM, all or none,
please most of all make sure that you contribute to the EMPAC, the one
(unified/united) California fund for political action committee... Email me for details on
how to contribute to EMPAC&gt;

<p class=MsoNormal style='text-autospace:none'><font size=3 color=blue
face="Trebuchet MS"><span style='font-size:12.0pt;font-family:"Trebuchet MS";
color:blue'>&nbsp;</span></font></p>

<p class=MsoNormal style='text-autospace:none'><font size=3 color=blue
face="Trebuchet MS"><span style='font-size:12.0pt;font-family:"Trebuchet MS";
color:blue'>My two cents...</span></font></p>

<p class=MsoNormal style='text-autospace:none'><font size=3 color=blue
face="Trebuchet MS"><span style='font-size:12.0pt;font-family:"Trebuchet MS";
color:blue'>&nbsp;</span></font></p>

<p class=MsoNormal style='text-autospace:none'><i><font size=3
 face="Times New Roman"><span style='font-size:12.0pt;font-style:italic'>Antoine
 Kazzi</span></font></i></p>

<p class=MsoNormal style='text-autospace:none'><font size=3
face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p>

A. Antoine Kazzi, MD, FAAEM

<p class=MsoNormal><font size=3 face=Verdana><span style='font-size:12.0pt;
font-family:Verdana'>Vice-President, the </span></font><font face=Verdana><span
  style='font-family:Verdana'>American</span></font><font face=Verdana><span
 style='font-family:Verdana'> </span></font><font face=Verdana><span
  style='font-family:Verdana'>Academy</span></font><font face=Verdana><span
style='font-family:Verdana'> of Emergency Medicine </span></font></p>

<p class=MsoNormal><font size=3 face=Verdana><span style='font-size:12.0pt;
font-family:Verdana'>Vice-Chair, Department of Emergency Medicine </span></font></p>

<p class=MsoNormal><font size=3 face=Verdana><span style='font-size:12.0pt;
  font-family:Verdana'>University</span></font><font face=Verdana><span
 style='font-family:Verdana'> of </span></font><font face=Verdana><span
  style='font-family:Verdana'>California</span></font><font face=Verdana><span
style='font-family:Verdana'>, </span></font><font face=Verdana><span
  style='font-family:Verdana'>Irvine</span></font><font face=Verdana><span
style='font-family:Verdana'> </span></font></p>

<p class=MsoNormal style='text-autospace:none'><font size=3
face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p>

<p><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p>

<p><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>-----Original
Message-----<br>
<b><span style='font-weight:bold'>From:</span></b> cma_alert@cmanews.org
[mailto:cma_alert@cmanews.org] <br>
<b><span style='font-weight:bold'>Sent:</span></b> </span></font>Thursday, January 08, 2004 2:50 PM</p>

2. Court Rules in Favor of
Non-Contracting Physicians

In a significant victory for physicians, a Los Angeles trial court
ruled that non-contracting physicians who provide emergency services to health
plan enrollees are not prohibited from balance billing those patients if an HMO
fails to reimburse them for the entire amount billed.

In
this case, Prospect Health Service Medical
Group v. St. Johns Emergency Medical Group, the plaintiff (a
capitated IPA) argued that when a physician bills and is paid by an HMO or its
contracting intermediary, an "implied contract" has been created
whereby the physician is prohibited from balance billing the patient under the
Knox-Keene Act.

In
her decision, Judge Linda Lefkowitz ruled that non-contracting physicians are
not precluded from balance billing patients and that an opinion published by
the Department of Managed Health Care to that effect wrongly relied on
unpublished, distinguishable cases, which have no precedential value.

Judge
Lefkowitz also rejected the plaintiff's request to set Medicare rates as
the defined "reasonable" rate for emergency medical services.

<a
href="http://www.calphys.org/html/bb467.asp">Click here</a> to download a copy
of the court's opinion in this case. For more information, see CMA
ON-CALL document #0130, "Non-contracting Physicians/Implied
Contracts." ON-CALL documents are available free to CMA members at
CMA's <a href="http://www.cmanet.org/logon">members-only website</a>.&nbsp;Nonmembers
can purchase ON-CALL documents for $2 per page at the <a
href="http://www.cmanet.org/bookstore">CMA Bookstore</a>.

<p><font size=2 face=Arial><span style='font-size:10.0pt;font-family:Arial'>Contact:
CMA's legal information line, 415/882-5144 or <a
href="mailto:legalinfo@cmanet.org">legalinfo@cmanet.org</a></span></font></p>

<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'>&nbsp;</span></font></p>

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