Californians won a major health care victory on Wednesday.
Now, patients who end up in an emergency room cannot be billed for services that are covered by their health insurance – care they already paid for through insurance premiums, deductibles and co-pays.
Sacramento Superior Court Judge Michael P. Kenny on Wednesday upheld a new state regulation, which took effect Oct. 15, that makes that indisputably clear.
As a result, patients no longer will be caught in the middle of billing disputes between emergency-room doctors and insurers.
Here's how that happens: Say you end up at the nearest emergency room with a life-threatening illness or injury. It's out of your health insurance network, which is no fault of yours. The doctor charges $1,200; the insurer wants to pay $900.
Too often in these cases, when doctors and insurers don't agree on a payment, patients have ended up getting billed for the difference (called "balance billing").
The reality is that if there's a difference between what the doctor charges and what the insurer pays, one of two things is happening:
• The insurer is failing to pay the "reasonable and customary" value of the services, as the law requires; or
• The doctor is billing more than the "reasonable and customary" value.
This has nothing to do with the patient, who should be left out of the dispute. California, the judge noted, has "multiple mechanisms" for doctors and insurers "to obtain timely and meaningful resolution of the disputed claim."
The new regulation and the court ruling are steps in the right direction, ensuring that patients don't get stuck with paying twice when doctors and insurers can't agree on a payment.
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