IE: The health plans’ excuse was, “We’ve paid for it once, and in order for you to collect, you would be asking us to pay a second time, and that’s kind of double jeopardy.”
Explore This IssueACEP Now: Vol 36 – No 04 – April 2017
KK: In an analogy, taking the plan’s position, if I decided to subrogate my utility bills to a third party and the third party went out of business, I wouldn’t have to pay my bills anymore. Isn’t that basically what they did?
IE and AS: Yes.
IE: We wrote a series of certified letters to each health plan, both to the CEOs and to the general counsel, alerting them to the fact that we were not being paid, that we had a significant financial shortfall, that level fives that were intubated were being down-coded to level ones, that we were underpaid on many claims, and that we had delays in payments. They wrote back, “Thank you for telling us. We forwarded your letter and your complaint to the plan for processing.” Nothing ever changed, but there was clearly proof that they knew of the abuses and that really the ER doctors were being victimized. We met with Gary Baldwin at the Department of Managed Health Care (DMHC) to complain about them, then spent a day, got on an airplane, and went up to the capitol to talk to them. They took it seriously, but their ultimate decision was La Vida was in trouble. Rather than order the health plans to pay ER claims directly—they felt that would make La Vida more insolvent—they actually worked out an arrangement to pay them additional money, but I don’t believe that they ever monitored that the money flowed to us. So DMHC took the opposite tactic and paid the requested health plan’s increased reimbursement to this troubled IPA, but still not a single increase for emergency physicians occurred.
AS: Along the way, in addition to Irv and his group carrying the torch, California ACEP and the California Medical Association got involved in supporting the cause all the way up through the Supreme Court to show that the house of medicine was in favor of holding the health plans responsible. What was really gratifying, especially for Irv, was in the Supreme Court’s decision. They found the health plan’s conduct morally blameworthy. You don’t get to delegate, walk away, and leave everybody else holding the bag. The Supreme Court was unanimous. Maybe I’m being overly dramatic, but I think lives will be saved because there will be sufficient funds to make sure that appropriate access to care is maintained for patients in need of emergency care.