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I Don’t Think a Doctor Should Be Doing This and Neither Does the California Department of Managed Health Care

Written by : Patricia I. James **

Summary: You have medical insurance. You go to the emergency room because you need immediate medical care. It is your understanding that the doctor will accept whatever your insurance pays. Well, in somewhere between ten and fifty cases, Dr. Jeannette Martello did not and instead went after the patients for the full amount.

The source of today’s Post is an article entitled “State Suing Doctor Over Billing Tactics” published by Anna Gorman, Los Angeles Times. It states that Jeannette Martello is a plastic surgeon who worked under contract to provide on-call emergency services at Huntington Memorial Hospital’s (“HMH”) emergency room.

Case in point is Bill Buck who accidentally cut off the tip of his finger at his cabinet workshop two years ago. He went to HMH’s ER for medical care. Unfortunately, Dr. Martello was the doctor on call. When the insurance company reimbursement was $3,500 for a $12,630 bill, she returned the check to the insurance company and filed a lawsuit against Mr. Buck, his wife and his business for the full amount. She also started proceedings to force the sale of the Buck’s home to collect the money.

Me: Granted, $3,500 is a far cry from $12,630. However, if she didn’t want to accept a lesser amount, she should have dealt with the health plan to try to get more money. As a matter of fact, the California Supreme Court ruled in 2009 that, if there was a dispute over payments for patients with certain plans, such as managed care plans (of which Mr. Buck was a member), the issue was supposed to be resolved between the doctor and the health plan.

Now, get this: According to Dr. Martello’s attorney, Andrew Selesnick, since the patients were in stable condition at the time they received treatment from Dr. Martello, she was not providing emergency services. Therefore, she was allowed to bill them for what the insurance companies would not cover.

Me: First, if the Buck case is any example, she did not bill the patients for what the insurance companies would not cover. She did not accept the amounts sent to her by the insurance companies and, instead, sent the checks back and went after the patients for the full amount.

Second, since the patients were stable, the treatment was not considered to be an emergency? What the? If I went to an emergency room, I would never make the distinction that, now that I am stable, all bets are off and I have to pay the full amount. Would you?

So, according to this article, her attorney said, “The question is, “Were these emergencies or not?”…We don’t believe that they were emergencies. The issue is not black and white. It is very gray.”

Me: Huh? Scenario one: I am having a heart attack. I am brought to the emergency room. I am “stabilized” at some point which, according to this attorney, means it is no longer an emergency.  Unless they immediately whisk me off to a room, which I guess is a different billing question, I am responsible for paying for everything the medical staff does from that point on?

Her attorney goes on to say that the patients did not want an emergency room doctor to stitch them up, so they waited for a plastic surgeon. “They wanted a professional,” he said. He added, “No one is complaining that Dr. Martello did a bad job.”

Me: Scenario two: If I am in a restaurant and my server informs me that they have two lovely specials this evening, one a boneless chicken breast and the other a filet mignon, I think I can figure out that the filet is going to be more expensive. However, if I am sitting in the ER and one of the staff says, “Would you like your hand reattached by the regular emergency room doctor or by the on-call plastic surgeon,” I think the answer is obvious and I am not going to think that I am going to be charged more.

In 2010, after investigating complaints against Dr. Martello about her collection practices, California managed healthcare regulators issued a cease-and-desist order against her. Now, I think us mere mortals would have taken heed and knocked it off. However, Dr. Martello, being the feisty number she is, apparently ignored it since it did not stop her.

Since the cease-and-desist order didn’t work, the CDMHC filed an unprecedented lawsuit against Dr. Martello alleging that her actions posed a “substantial, irreparable, and unjustified threat to the financial livelihood” of the patients and that she collected or attempted to collect more from patients than the insurance companies paid. This is known as balance billing. The article states, “[p]rotections against balance billing are strongest in emergency room cases because patients have less control over who treats them.” The judge in that case issued a preliminary injunction ordering her to stop collecting or trying to collect bills from patients. Guess what? She ignored that too.

There are at least 10 court cases brought by Dr. Martello in which she allegedly violated the law by suing for payments from patients covered by managed care. Of course, there may be many more since she has been listed as a plaintiff in more than 50 civil cases since 2010, many of which allege breach of contract.

The state is hoping that the judge will dismiss all of the cases filed by Dr. Martello against her patients and award restitution. In the meantime, those cases have been stayed pending the outcome of the state’s lawsuit against her.

The California Medical Board has since gotten wind of the situation and has filed a separate accusation against Dr. Martello regarding the balance billing. According to the article, “[i]n its petition to revoke her medical license, the board also accuses her of engaging in unprofessional conduct by requiring patients visiting emergency rooms to sign agreements to pay her costs if their insurance firms didn’t.”

Me: Doesn’t this just keep getting better and better? Scenario three: I am sitting in the ER with blood dripping from the stump where my hand used to be. I am given a form that I am really not in any condition to read or understand that says I have to pay Dr. Martello’s costs if my insurance company does not. Let’s pretend that I am lucid enough to think, “Well, of course my insurance company is going to pay.” However, if the article is quoting what the form says, it says that the patient agrees to pay her costs if the insurance company does not pay; it does not say that the patient agrees to pay Dr. Martello’s costs if the insurance company does not pay the full amount.

Thankfully, what I gleaned from the article is that this is the only doctor (at least of which the CDMHC is aware) who has been accused of balance billing. However, since there is an actual term for it, balance billing, where else is this taking place?

For those of you who are wondering, Dr. Martello is no longer under contract with HMH and Mr. and Mrs. Buck are still fighting the case against them. Stay tuned.

**No portion of this Post is intended to constitute legal advice The views expressed are solely those of the author.

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4 responses to “I Don’t Think a Doctor Should Be Doing This and Neither Does the California Department of Managed Health Care”

  1. Just another reason to go socialized medicine.

    • It could be another reason but there are many arguments for and against socialized medicine. I am not saying that this is the final word on the subject but you might read the following article entitled, “The Ugly Realities Of Socialized Medicine Are Not Going Away,” found at http://www.forbes.com/sites/sallypipes/2011/12/19/the-ugly-realities-of-socialized-medicine-are-not-going-away-3/. And thank you for your comment.

      • I clicked on the link and it said it couldn’t find the page requested. Yes there will always be pros and cons about socialized medicine. All I know is that I’ve seen families where people worked all their lives only to be wiped out by huge medical bills. That’s just not right.

        • Sorry. I corrected the link and you should be able to find the article now.

          I agree that it is not right that people should have their entire life savings depleted and everything they have worked for lost because of huge medical bills.

          However, I do not know if socialized medicine is the answer. And what I mean by that is that I do not know one way or the other. There are many sides to this issue (how many, I do not know) but I do know that it is complicated.

          I will address the article, “The Ugly Realities Of Socialized Medicine Are Not Going Away,” by Sally Pipes, as well as another I just came across regarding insurance coverage in my next post.