LACMA Physician Spotlight:
Dr. Jonathan Nissanoff
I T W A S N ’ T T H A T L O N G A G O that orthopedic surgeon Jonathan Nissanoff, MD, found himself in the frustrating position of taking calls in the emergency room for which he wasn’t paid properly because of dealing with non-contracted insurance companies. Today, Dr. Nissanoff said, thanks to ECURE, or Emergency Claims Underpayment Recovery Experts, a Los Angeles-based company he co-founded in 2011, the situation has much improved for him as well as for many other physicians dealing with non-contracted insurers. ECURE’s mission, according to its website, is to ensure that providers are reimbursed “usual customary and reasonable fees” by insurance carriers for emergency services they provide. The company uses federal and state laws that have been put in place to recover these funds and to protect the financial interests of physicians of any specialty who take emergency room calls as well as those of ambulance companies and hospitals. Dr. Nissanoff said he took it upon himself to learn the laws associated with emergency medical claims after having written off significant monies year after year. He also learned that California ER doctors or on-call specialists who don’t have a pre-existing contract with a patient’s insurance company may not “balance bill” the patient — bill the patient for the difference between what the patient’s health insurance chooses to reimburse and what the provider chooses to charge — for emergency services rendered. In 2009, the California Supreme Court declared the practice of socalled “balance billing” in the context of emergency care unlawful. Doctors must resolve billing disputes solely with the health plans; only the health plans are responsible for reimbursing out-of-network providers for emergency care services. And California law limits recovery of non-network providers for ER services rendered to only “reasonable and customary” amounts, not the amount charged by the ER physician, Dr. Nissanoff said. What constitutes “reasonable and customary,” however, is often disputed, since there is no prior agreement in place. In any given case, the “reasonable amount” may be the amount a doctor bills, the amount the HMO chooses to pay or anything in between, according to an article written by attorneys from the California Department of Managed Health Care. The problem, as Dr. Nissanoff sees it, is that health insurers often underpay doctors because they believe that many doctors 8 P H Y S I C I A N M A G A Z I N E | O C TO B ER 2016
are afraid to take legal action. “Even with these laws, the insurance companies realize that it takes a lot of money to litigate them and that providers won’t do anything because they know it would cost more to sue the insurance companies than the value of the underpayments,” Dr. Nissanoff said. “That’s what happens every day.” Dr. Nissanoff said ECURE was formed strictly to take on health insurance firms that underpay clients, who today include California healthcare providers, California urgent care centers, California hospitals and California Emergency Medical Services. This is how the process works, Dr. Nissanoff said. “ECURE essentially buys small amounts of underpayments from many providers and consolidates them, and then goes after the carrier that has been shortchanging providers,” he said. “We litigate as one entity under the Emergency Claims Underpayment Recovery Experts. It’s almost like a mini class action lawsuit.” According to Dr. Nissanoff, the service is essentially risk-free to clients because ECURE absorbs all attorney and court fees. The client gets final closure on all accounts receivable once the case is settled, won or lost. There doesn’t have to be continued appeals and rebillings hoping for additional payment. The judge and jury make it final. “We spend a lot of money fighting the insurance companies,” Dr. Nissanoff said. “We have won or settled 95% of our cases against the insurance companies.” He said since 2011, ECURE has dealt with “hundreds of cases” and currently has 39 cases in the court system. He said because of ECURE’s history, claims are getting settled faster these days, in as short as 30 days. However, on average it takes ECURE 18 to 24 months to settle a case in or out of the courtroom, he said. The company now has 30 employees and six attorneys and opened offices in San Diego and San Francisco. “We are hopeful to get the word out that providers don’t have to accept whatever they get because they have no other choice,” Dr. Nissanoff said. “Our hope is that insurance companies will start paying correctly, and we’re happy to work ourselves out of business by turning the tables on insurance companies.”