New Calif. Provider Playing Field Benefits Patients

New Calif. Provider Playing Field Benefits Patients

Aug 12, 2014


Co-Author, Law360, August 12, 2014

Two recently published cases from California Courts of Appeal are changing the landscape for litigation between noncontracted (i.e., “nonpar”) providers and health care payors.

In Children’s Hospital Central California v. Blue Cross of California, 226 Cal.App.4th 1260, 172 Cal.Rptr.3d 861 (Cal. App. 5 Dist., 2014), the appellate court took on the issue of whether the six-part test set out in California Code of Regulations, title 28, Section 1300.71(a)(3)(B)[1] provides the “exclusive standard for determining the reasonable and customary value” for reimbursing noncontracted providers of emergency services. The court determined that the six-part test does not limit what evidence may be introduced when a provider pursues a quantum meruit theory against a health plan, nor does it restrict the scope of discovery. In fact, the court found that rates paid by all payors, including the government, are evidence that must be considered in determining the market value for emergency medical services and poststabilization care.

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