Podcast Center
Video Center
Webcasts
Resource Center
Events
November 16, 2016 at 02:49 AM
SAN FRANCISCO — In a unanimous decision that could have ripple effects across California’s health care industry, the state Supreme Court has ruled that health plans like Aetna and Blue Shield can be sued over unpaid medical bills even if the plans passed financial responsibility to third parties.
Related: Indemnity health insurers win major ACA court fight
The court’s opinion Monday in Centinela Freeman v. Health Net of California is a blow to health care plans and the so-called “risk bearing organizations,” or RBOs, that they regularly contract with in order to share the financial risk they take on in covering patients’ emergency medical expenses.
Affirming a decision by the Second District Court of Appeal, the state high court sided with doctors in ruling that plans can be sued for negligence if they pass financial risk to RBOs that they know are danger of becoming insolvent. Doing so, it said, leaves medical professionals out to dry after treating emergency room patients that they are required to care for under the law.
“Because the emergency care providers rely exclusively on health care service plans to arrange payment for services received by their enrollees, plans that transfer those responsibilities onto an [RBO] they know or should know will not make those payments have not only shirked their statutory obligations, but have essentially withheld from emergency care providers the fair compensation to which they are entitled,” Chief Justice Tani Cantil-Sakauye wrote in the court’s opinion.
The case stems from the collapse of La Vida, an RBO that shuttered in 2010 after years of financial strain. Defendant health plans including Health Net of California, Anthem Blue Cross, Aetna and Blue Shield contracted with La Vida to pay for plan members’ emergency room visits, in return for a share of their premiums. When La Vida failed to pay, the health plans refused to step in, plaintiffs allege.
See also: Humana and Covered California
An army of Big Law attorneys representing the plans had argued that the law and California state regulations absolve them from liability for medical bills once the responsibility has been assigned to a third party. Putting plans on the hook for those bills later would be an “end run” around their business model and could force them to jack up premiums in order to shoulder more risk, their lawyers contended.
