In December 2017, RPC filed a Post-Submission Brief on “Reasonable Charge” Law in the case In re North Cypress Medical Center Operating Co., LTD. Relator, v. Crystal Ann Roberts, Real Party in Interest. The case concerns the amount Ms. Roberts owes North Cypress as an out of network provider for medical services and whether North Cypress must disclose its negotiated rates with health plans.
In its brief, RPC argues that the law of unjust enrichment applies. To prevent unjust enrichment of the patient, he or she owes the provider “reasonable charges.” For this purpose, “reasonable charges” are the “reasonable value” of the services, and the “reasonable value” of the services is measured by the lesser of their cost or their market value. In-network contract payments are direct evidence of the market value of hospital services. They have been held “pertinent” in the unjust enrichment context to the determination of a “reasonable rate” to be paid by an insurer for emergency hospital services.
In network contract prices are often among the best measures of the market value of hospital services – they are set in advance of services by voluntary agreement between willing sellers and willing buyers. They are not, however, publicly available. As the hospital is seeking payment, it should disclose this information.
Other ways to estimate the value or the costs of particular hospital services exist and may be appropriate for use in certain circumstances. In some circumstances data on usual, customary, and reasonable (“UCR”) charges may be relevant to determining the amount a medical provider is due.
Read the full brief here. RPC’s brief adopts the Statements of the Case and Issues Presented in a brief of the Real Party in Interest and a brief filed by another Amicus Curiae, the Fuentes Firm.