Hospital billing: emergency services and care.

Existing law provides for the licensure and regulation of health facilities by the State Department of Public Health and requires a licensed facility that maintains and operates an emergency department to provide emergency services and care to any person requesting the services or care for any condition in which the person is in danger of loss of life or serious injury or illness, as specified. Existing law requires hospitals to maintain a written policy regarding discount payments for financially qualified patients as well as a written charity care policy. Existing law requires a hospital to limit the expected payment for services it provides to certain low-income patients to the highest amount the hospital would expect to receive for providing services from a government-sponsored program of health benefits in which the hospital participates. This bill would require a hospital with an out-of-network emergency utilization rate, as defined, of 50% or more to notify payers that its total billed charges for emergency services and care provided to a patient prior to stabilization are subject to adjustment such that the hospital's total expected payment would be 60% of the payer's average in-network payments, as defined, but less than 150% of the payment the hospital reasonably could expect to receive from Medicare for providing similar emergency services and care prior to stabilization. The bill would authorize a payer that receives this notice to reimburse hospitals in accordance with that adjustment. The bill would specify that these provisions do not apply to charges billed by physicians or other licensed professionals who are members of the hospital medical staff or to charges provided as treatment for an injury that is compensable for purposes of workers' compensation. The bill would also specify that its provisions do not apply in specified instances, including if any other law requires the hospital to limit expected payment for the emergency services and care to a lesser amount, if a contract governs the total billed charges for the emergency services and care, or if a government program of health benefits, as specified, is the primary payer for the emergency services and care. The bill would provide for the repeal of its provisions on January 1, 2017.