March 6, 2020
Technicalities Don’t Defeat Provider Claims for Emergency Services
Last week, the Court of Appeal gave a victory to non-contracted providers of emergency medical services. In San Jose Neurospine v. Aetna Health of California, the court rejected Aetna’s position that because the provider “did not use the correct [billing] codes, [the provider] was not entitled to payment for emergency services and all its causes of action had to be dismissed.” Instead, the court found that the “law abhors” what the judges called technicalities that “ignore legislation, common sense, and fairness.”
The court explained that there are only limited opportunities for health plans to deny claims for emergency services-which occur “only if the health care service plan reasonably determines that the emergency services and care were never performed.” Even though the provider initially used non-emergency billing codes, the court found that the provider’s resubmission of the claim referencing “ER” and later statements from the doctor that emergency services were performed was enough to reverse a judgment in favor of the health plan.
The case explains that because the underlying statutes are meant to liberally provide payment for emergency services, which providers must perform by law, health plans are not excused by mere billing mistakes. “Where the health care service plan knows that emergency services were in fact provided, a coding mistake on a billing claim does not automatically excuse or terminate its duty to pay for the services under section 1371.4, subdivision (c).”
If you have any questions regarding payment disputes or contract issues between or concerning health care providers and plans, please let your Payne & Fears lawyer know.