Fair payment and balance billing in the ER: What’s the solution?

As health care reform drives more insured patients into the system, access to care is more critical than ever. And in protecting patient access to care, fair payment is one of the most pressing issues facing emergency physicians today.

Emergency medicine providers are in a unique position when it comes to providing patient care. Unlike physicians in private practice who can screen patients to make sure they’ll be paid for care, or elect not to care for a plan’s enrollees, emergency physicians do not have that choice under the EMTALA mandate, which requires hospital emergency departments to see everyone, regardless of insurance status or ability to pay.

In addition, physicians in most other specialties have incentive to contract with payers because it gives them access to more patients. Essentially, they’re trading a rate for more people. In our business, patients don’t usually choose where and when they’ll need emergency services, so we don’t necessarily gain any volume for exchanging to a lower reimbursement rate.

When health plans set unfair rates rather than paying for emergency services based on usual and customary charges, it puts emergency medicine providers in a tough position. Some physicians drop out of health plan networks when plan reimbursements don’t cover the costs of providing services. This means that some patients may have larger “out-of-network” bills. And when health plans do not pay fairly, emergency providers are forced to bill patients for the unpaid balances.

Consequences of a balance billing ban

In 2009, the California Supreme Court ruled emergency physicians who are outside certain health insurance networks could not bill patients in those networks for the balances of their bills. The ruling calls it an unfair billing practice. Consequently, patients are now using the court’s ruling to file lawsuits in an effort to make physicians pay the money back.

While we don’t want patients to be stuck in the middle of a financial dispute over care that has been provided, preventing the option of balance billing tips the scales in favor of payers’ rights. Banning balanced billing allows insurance companies to arbitrarily set very low reimbursement rates for out-of-network emergency visits when emergency providers have no choice but to take care of every patient who walks through the door.

In addition, when emergency care providers can’t get fair reimbursement from insurance providers, it harms the call panels — the anesthesiologists, orthopedists, radiologists and other emergency care consultants who provide specialty care to emergency patients. These providers typically have their own practices and provide voluntary ED call coverage on top of that. But without a fair payment standard, more and more specialists are unwilling to take calls, and suddenly hospitals lack access to critical specialists. As a result, patients often must be transferred long distances to receive care they used to receive at their local hospital.

Decreasing reimbursements for emergency care and providing uncompensated care to millions of uninsured patients have contributed to the closure of hundreds of emergency departments across the country and a lack of emergency resources, which threatens everyone’s access to lifesaving emergency care.

Devising a fair payment approach

So, what is the answer? Clearly, balance billing is not our objective. Surprise medical bills are an expensive burden for patients and their families after a health emergency. However, it’s what emergency physicians have been forced to do to be adequately compensated for their services.

As the American College of Emergency Physicians (ACEP) and other organizations agree, a better approach is for state regulators, legislators, insurers and emergency medicine providers to develop fair payment methodologies and rates, while including assurances for all parties that there are reasonable ways to obtain a balanced review of disputed claims.

Patients do not choose where and when they will need our services and should not face post-care financial burdens for seeking emergency care. Likewise, emergency physicians are required to see every patient, and to meet that mission need to be fairly compensated. And only with diligent efforts to ensure fair payment for our services will we continue to attract the best and brightest new physicians to our specialty.

There is much work to be done to find the right mix of fair payment standards and billing philosophies. Fair payment methodologies exist that have been independently and objectively developed and tested. Now is the time to create a win-win situation for payers, physicians and, most importantly, patients.

Martin Ogle is an emergency physician and vice president, CEP America.

Image credit: Shutterstock.com

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