Judge grants ER doctors right to bill patients above co-pays.

HMO members who believe they are only responsible for the co-payment on a trip to the emergency room may have a surprise coming to them in the mail.

L.A. Superior Court Judge Linda Lefkowitz has ruled that some emergency room physicians have the right to bill patients if they think they are not getting adequate payment from the insurance company.

The ruling, which has been appealed, involved a pair of lawsuits filed by Prospect Health Source Medical Group, a Culver City independent practice association, against two groups of emergency room doctors at Saint John's Health Center and Northridge Hospital Medical Center.

The case arose when patients of Prospect, which acts as a financial intermediary for insurers, visited the two emergency rooms. The ER doctors then billed Prospect, but after the group refused to pay the full amount they demanded, they began billing patients for the remainder of their bills.

Prospect sought a court judgment that the emergency room doctors should have to take the Medicare rate for such services--about a third of what the ER doctors charged--and not be allowed to bill patients for the rest.

Prior Superior Court decisions have come down on the side of insurers, but in this case Lefkowitz maintained nothing in state law prohibits a practice that's known as "balanced billing."

She further stated that a legal opinion by the Department of Managed Health Care that the practice was illegal was not valid and that state law would need to be changed to stop the practice.

The decision does not affect patients whose medical groups have contracts with emergency room doctors, but that's little comfort to those who generally seek out the closest hospital when in need of emergency care.

"The patient should not be getting that bill. In some cases they were threatened with collection," said Ken Johnson, an attorney representing Prospect. "The decision goes against the grain of the promise of managed care."

Earlier this month Prospect appealed the decision to the California Court of Appeal, but in the meantime, an attorney representing the emergency room doctors said his clients plan to continue balance-billing patients.

"The ER doctors are just looking for a fair and reasonable payment," said attorney Andrew Selesnick, who represents St. John's Emergency Medical Specialist Inc. and the Northridge Emergency Medical Group.

Lose Weight Now

Blue Shield of California has responded to the growing waistlines of its patients with a test program that will pay $75 to $200 to members who shed pounds and adopt other lifestyle changes, such as quitting smoking and increasing physical activity.

The company's initiative takes health promotion programs, often limited to discounts on health club memberships, to a new level, in a bid to reduce rising prevalence of diabetes and other chronic diseases.

The pilot program is being tested on 25,000 subscribers in California. To earn the money, members sign up on the program's Web page, which offers a variety of health tips, and then record their weekly activities, such as how many times they exercised.

"The root of many chronic diseases has to do with lifestyle and the choices people make, and we wanted to do something to address this," said Deborah Schwab, the company's director of new product development.

While there are no checks on people's activities, the company expects only a small percentage to cheat, Schwab said. However, the program must still pay for itself, so Stanford University researchers will study if participation indeed lowers medical claims, a factor in determining if the program moves beyond the pilot stage.

Staff reporter Laurence Darmiento can be reached at [phone] ext. 237 or at [e-mail].