CMA files amicus brief before the California Supreme Court in La Vida IPA nonpayment case June 2, 2015 General Legal Advocacy, Emergency Physicians 0 The California Medical Association (CMA) recently filed an amicus brief in the California Supreme Court in Centinela Freeman Emergency Medical Assocs. v. Health Net et al. to urge a fair and just interpretation of provisions within the Knox-Keene Act that permit health plans to delegate payment responsibility to risk-bearing organizations (RBO). CMA filed the brief to support the plaintiffs in the case, out-of-network health care providers who were left unpaid for emergency medical care when La Vida Independent Practice Association went bankrupt in 2010. Most of the major Knox-Keene health plans in California contracted with La Vida on a capitation basis to pay for and manage the health care of hundreds of thousands of patients in Southern California. Existing law insulates health plans from payment responsibility for medical claims once they enter into a delegation arrangement with an RBO. Notwithstanding such law, the providers in Centinela are seeking reimbursement from the health plans on the theory that they negligently delegated to La Vida, because they continued to send patients to La Vida when they knew or should have known of La Vida’s financial distress and impending insolvency. In a 2014 published opinion, a California Court of Appeal upheld the viability of a negligent delegation claim. The court held that fairness and justice dictate health plans must be held responsible for unpaid claims for emergency medical care where: (1) a physician is obligated by statute to provide emergency care to the health plans’ enrollee, even if the physician is not contracted with the health plan or its delegated RBO; (2) the health plan, which has a statutory duty to reimburse the physician, chose to delegate that duty to an RBO it knew, or had reason to know, would be unable to fulfill the delegated obligation; and (3) the RBO in fact fails to make the necessary reimbursement. In such circumstances, the court held, the resulting loss should be borne by the health plan and not the physician. The health plans are appealing that opinion in the Supreme Court. CMA's amicus brief implicitly acknowledges the viability of the delegation model and accepts that, generally, health plans are absolved of liability after they delegate to an RBO. When health plans delegate negligently, however, the brief argues that they must be held accountable for their own misconduct. The brief provides historical and practical rationale for a negligent delegation claim. It draws on the lessons from widespread RBO bankruptcies in the late 1990s and considers the superior position of health plans in a delegation arrangement. The defendant health plans in this lawsuit are Health Net of California, Inc.; Blue Cross of California; Anthem Blue Cross; PacifiCare of California; California Physicians’ Service Blue Shield of California; Cigna HealthCare of California, Inc.; Aetna Health of California, Inc.; and SCAN Health Plan. For a copy of the brief click here. Contact: CMA Center for Legal Affairs, (800) 786-4262(800) 786-4262 FREE FREE or legalinfo@cmanet.org. Call Send SMS Call from mobile Add to Skype You'll need Skype CreditFree via Skype Comments are closed.
