Prospect Med. Group, Inc. v. Northridge Emergency Med. Group (Summary)

BILLING

Prospect Med. Group, Inc. v. Northridge Emergency Med. Group, No. S142209 (Cal. Jan. 8, 2009)

The California Supreme Court held that in situations where there was a dispute between an emergency physician and an HMO about the appropriate amount to be paid by the HMO for the provision of emergency services, it was not permissible for an emergency room physician or group to “balance bill” the patient for the additional amount in question. The court reasoned that because the state statutory scheme intends to transfer the financial risk of health care from patients to providers, requires emergency care patients to agree to pay for services or to supply insurance information, and requires HMOs to pay physicians for emergency services rendered to their subscribers, balance billing is not permissible. The court also emphasized that there was clear legislative policy against placing patients in the middle of billing disputes between doctors and HMOs.