Part B Insider (Multispecialty) Coding Alert

Court rules that 'balance billing' isn't illegal in the ER

It's not illegal for emergency room physicians to "balance bill" patients who belong to managed-care organizations (MCOs), a court ruled.

When a managed-care patient comes into the ER, sometimes an emergency physician who belongs to that patients' MCO isn't available. In that case, a non-participating ER doc is legally required to treat the patient, and the MCO must pay the doctor.

But the doctor doesn't have to accept the MCO's payment rate as payment in full, the Court of Appeals for the Second District of California ruled in Prospect Medical Group v. Northridge Emergency Medical Group (B172737). Instead, the doctor can bill the patient for the difference between the MCO's rate and the doctor's fee.

If the patient belongs to a Medicare managed-care plan, the physician can still "balance bill" the patient, the court added.

However, the health plan has standing to sue the physician if it decides the physician's fee is unreasonable, the court said. Thus, the plaintiff in this case, Prospect Medical Group, can sue based on the idea that the physicians were charging an unreasonable amount.

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