Part of a continuing use of this blog to educate citizens about rights they have.
One of the crimes being committed on consumers who are lucky enough to have insurance coverage is the "balance billing" game (where you have a medical bill from an ER room visit, your HMO pays a portion of the bill which the hospital does not like and the hospital balance bills you for the gap between what your HMO paid and the hospital's original billing).
General rule: The hospital cannot balance bill emergency room charges unless the contract with the health plan specifically allows it.See Parnell v Adventist Health (2005)35 Cal.4th 595 & Prospect Medical Group, Inc. v Northridge Emergency Group(2009)45 Cal.4th 497 [opinion at http://www.lifehealthdisabilityinsurancelaw.com/uploads/file/S142209%20Prospect%20v%20Northridge%281%29.pdf] See also http://www.abanet.org/health/esource/Volume5/06/Lai.html
From an old letter (which is only a basic model; you should consult with counsel to get the language and issues all included/addressed that should be and then send the letter via certified mail return receipt requested):
Since my last letter, as I am sure you know, the California Department of Managed Health has implemented regulations that expressly prohibit the type of balance billing you are attempting in the above referenced matter. I have attached a copy of the regulation, and the press release from DMHC director, Cindy Ehens, announcing this new rule.
As you are no doubt aware, the California Supreme Court recently issued its decision in Prospect Medical Group, Inc. v Northridge Emergency Group(2009)45 Cal.4th 497. In Prospect the court clearly held that hospitals may not balance bill bill a patient when the patient's HMO pays less than the hospital is willing to accept for emergency treatment rendered to patients of an HMO, with which the hospital did not have a contract.
FYI: The documents to attach to this letter are available from the California Department of Managed Health.
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