Medical Group Admits Balance Billing
A San Diego-area group of emergency room physicians has reached a settlement with the Department of Managed Health Care regarding the balance billing of hundreds of patients they treated.
Under the terms of the agreement with the agency, the Emergency Services Medical Corp. (ESMC) of Solana Beach has agreed to stop balance billing patients, and has also filed a plan of correction with the agency.
ESMC, which provides emergency services primarily to Sharp Healthcare in San Diego, balance billed 324 patients, apparently after a 2009 California Supreme Court ruled the practice was illegal. It did not admit any wrongoing as part of the settlement, which the DMHC said was reached in lieu of litigation. No fine was assessed, records show.
ESMC has agreed to retain a new agent to conduct its billing and revised its internal policies for billing patients and briefed staff. Among the changes is an assumption that a remaining balance after an insurer has paid its obligation does not mean it is not owed by the patient. It also agreed to refund sums that were balance billed. According to the DMHC, the amount totaled $24,711.14.
Arthur Gruen, M.D., ESMC's chief executive officer, did not respond to a request seeking comment.
In other actions taken by the DMHC, it levied $30,000 fines against Aetna and Dental Choice of California. The Aetna fine stemmed from a 2013 incident where an enrollee sought emergency care at an urgent care center that was listed in Aetna's provider network. The health plan then denied payment, and the patient was charged a $150 co-payment, instead of the $50 required under her contract. Aetna deemed the emergency treatment medically unnecessary when the enrollee filed a grievance. The DMHC determined that Aetna violated the Knox-Keene Act by not taking the necessary actions to determine if the care was medically necessary.
The Dental Choice of California fine was connected to a unfair pattern of payments to providers. According to a DMHC audit, the plan did not pay full interest on claims; did not provide clear determination letters regarding disputed claims; and did not appropriately report provider disputes to the agency.
The DMHC also fined Human Affairs International of California, a subsidiary of Magellen Health Services, $15,000 for engaging in an unfair practice pattern. The agency determined during an audit that the health plan paid 94% of its claims in a timely manner, below the minimum threshold of 95% timely payments.
