PacifiCare Wins Ruling Over Costs of ER Care
PacifiCare Health Systems Inc. won a decision against emergency room doctors over who is responsible for covering costs when medical groups collapse.
The 4th Appellate District panel in Santa Ana sided with PacifiCare last month, upholding a lower court’s decision throwing out a case brought by the California Emergency Physicians Medical Group.
The San Diego doctors sued the Cypress health plan last year in Superior Court, alleging that it was responsible for more than $100,000 in unpaid bills after the Family Health Networks medical group closed down.
Emergency room doctors in California are often paid by medical groups that contract with a patient’s insurer to provide primary, specialist and hospital care.
The physicians claimed PacifiCare had to pay once Family Health failed, since doctors aren’t allowed to turn away a patient needing emergency care. The health maintenance organization contended it already had discharged that obligation to the medical group under a contract that paid the medical group to take care of the patient.
The appellate panel said state laws allow HMOs to transfer risk to intermediaries like Family Health.
“If the decision stands, a health plan can delegate payment of emergency services to a drunken sailor and walk away,” said Ian Guthrie, an attorney for the doctors’ group, which is considering an appeal to the state Supreme Court.
However, insurers said any other decision by the appeals court would have undermined the underlying structure of managed care.
“Providers should be paid, but to require the plans to pay twice turns the statute on its head,” said Peter Roan, an attorney representing PacifiCare.
,Laurence Darmiento, staff reporter with the Los Angeles Business Journal.
