CMA files amicus brief before the California Supreme Court in La Vida IPA nonpayment case The California Medical Association (CMA) recently filed an amicus brief in the California Supreme Court in Centinela Freeman Emergency Medical Assocs. v. Health Net et al. to urge a fair and just interpretation of provisions within the Knox-Keene Act that permit health plans to delegate payment responsibility to risk-bearing organizations (RBO). CMA filed the brief to support the plaintiffs in the case, out-of-network health care providers who were left unpaid for emergency medical care when La Vida Independent Practice Association went bankrupt in 2010. Most of the major Knox-Keene health plans in California contracted with La Vida on a capitation basis to pay for and manage the health care of hundreds of thousands of patients in Southern California. Existing law insulates health plans from payment responsibility for medical claims once they enter into a delegation arrangement with an RBO. Notwithstanding such law, the providers in Centinela are seeking reimbursement from the health plans on the theory that they negligently delegated to La Vida, because they continued to send patients to La Vida when they knew or should have known of La Vida’s financial distress and impending insolvency. In a 2014 published opinion, a California Court of Appeal upheld the viability of a negligent delegation claim. The court held that fairness and justice dictate health plans must be held responsible for unpaid claims for emergency medical care where: (1) a physician is obligated by statute to provide emergency care to the health plans’ enrollee, even if the physician is not contracted with the health plan or its delegated RBO; (2) the health plan, which has a statutory duty to reimburse the physician, chose to delegate that duty to an RBO it knew, or had reason to know, would be unable to fulfill the delegated obligation; and (3) the RBO in fact fails to make the necessary reimbursement. In such circumstances, the court held, the resulting loss should be borne by the health plan and not the physician. The health plans are appealing that opinion in the Supreme Court. CMA's amicus brief implicitly acknowledges the viability of the delegation model and accepts that, generally, health plans are absolved of liability after they delegate to an RBO. When health plans delegate negligently, however, the brief argues that they must be held accountable for their own misconduct. The brief provides historical and practical rationale for a negligent delegation claim. It draws on the lessons from widespread RBO bankruptcies in the late 1990s and considers the superior position of health plans in a delegation arrangement. The defendant health plans in this lawsuit are Health Net of California, Inc.; Blue Cross of California; Anthem Blue Cross; PacifiCare of California; California Physicians’ Service Blue Shield of California; Cigna HealthCare of California, Inc.; Aetna Health of California, Inc.; and SCAN Health Plan. For a copy of the brief click here. Contact: CMA Center for Legal Affairs, (800) 786-4262(800) 786-4262 FREE FREE or legalinfo@cmanet.org. Call Send SMS Call from mobile Add to Skype You'll need Skype CreditFree via Skype June 2, 2015 General Legal Advocacy, Emergency Physicians 0 0 Comment Read More »
Study finds that ACA Medi-Cal expansion could fuel ER use A retrospective study conducted by researchers at the University of California, San Francisco (UCSF) found that the number of visits to California emergency rooms (ERs) rose by 13.2 percent between 2005 and 2010, from 5.4 million to 6.1 million annually, with a significant 35 percent increase in the number of ER patients insured through Medi-Cal. The authors suggest that the Medi-Cal expansion under the Affordable Care Act (ACA) could further increase these numbers, as millions of additional patients become eligible for Medi-Cal in 2014. Researchers also found that Medi-Cal patients had the highest ER usage burden for ambulatory-care-sensitive conditions (54.76 per 1,000 patients on average) compared with those who had private insurance (10.93 per 1,000 patients) or no insurance at all (16.6 per 1,000 patients). This study comes on top of the announcement this month that the California Department of Health Services intends to begin to implement a 10 percent Medi-Cal physician payment rate reduction on October 1, 2013, for Medi-Cal managed care and on January 9, 2014, for fee for service. This reduction is the result of legislation that was passed in March of 2011, when California’s budget was in dire straits. Even though California's fiscal outlook is much brighter now than it was in 2011 when the legislature first passed the 10 percent cut, the state has moved forward with the cuts and will retroactively collect payment back to July 2011. The cuts had been held up in court while the California Medical Association (CMA) pursued legal action to stop the state from decimating California's already tattered safety net. Unfortunately, the Ninth Circuit Court of Appeals recently overturned the injunction, clearing the way for the state to begin implementation. CMA has submitted a petition to the U.S. Supreme Court, asking them to review the case. (See, "CMA files a petition with the Supreme Court to block the 10 percent physician reimbursement cut" for more information.) These cuts will assuredly force physicians out the Medi-Cal program, which is expected to assume care for more than 2 million new patients in 2014 under the ACA Medicaid expansion. Even before the cuts, California's Medi-Cal provider payment rates were the lowest in the nation. Low reimbursement rates have driven many of California’s providers from the program. As a result, 56 percent of Medi-Cal patients report difficulty finding a doctor. When they are unable to find a provider, many Medi-Cal patients seek preventive and other non-urgent care in hospital ERs. Others may simply go without preventive and primary care altogether and end up in the ER only after their condition has become severe. The inability to find a provider adds to pervasive ER overcrowding, which increases wait times, decreases quality and threatens access to emergency care for everyone. If these cuts are not stopped, Medi-Cal will become nothing more than a broken promise of access to care. The UCSF study was supported by the California HealthCare Foundation, the National Center for Advancing Translational Sciences, the National Institutes of Health and the Robert Wood Johnson Foundation Physician Faculty Scholars Program. View the research letter, recently published in the Journal of the American Medical Association. September 20, 2013 Medi-Cal Emergency Physicians, Emergency Rooms, Insurance/Reimbursement, Medi-Cal, Medi-Cal Cuts, Access to Care 0 0 Comment Read More »
