Posted in three other forum threads but no quite answered. I was hoping to reach non par docs operating in California....
What happens when an HMO plan member must obtain medical care in an emergency? The hospital he goes to for service and the doctors on duty there are obligated by law to provide the care needed to stabilize the patient. The HMO is also obligated by law to pay for its members' emergency care. A dilemma arises when the provider and the plan have not already agreed on how payment for services will be handled: how much must the plan pay, and is the provider obligated to accept the amount paid by the HMO as payment in full? Providers claim that plans are setting reimbursement rates unfairly, at sums too low to adequately pay for the services. Plans claim that providers are charging rates that are not fair, that are beyond the usual and customary charges for the location.
The California Supreme Court, in Prospect Medical Group vs. Northridge Emergency Medical Group (2009) 45 Cal.4th 497, ruled that California law requires that the dispute about payment for the out of network provider cannot involve the patient, but is between the provider who must render the care and the plan which is obligated to pay for the care. The provider cannot use balance billing to try to force the plan to pay more by putting economic demands on the patient, and plans cannot pay too little thereby forcing its members to pay the rest of a fair compensation to the provider. As a result, when a plan member in an emergency must get medical treatment from an out of network hospital or physician, his financial obligations are the exact same as they would be under the plan terms for in-network providers. The provider cannot bill the patient but must work out payment with the health plan.