Doctors Seek More Insurer Transparency

(CN) — A new federal rule covering payment for emergency room services must include a demand for transparency from insurers, a doctors' group claims in court.

Doctors are required by federal law to treat patients who come to the emergency room regardless of the patient's ability to pay for treatment.

Even when patients have insurance, they frequently go to the emergency room without determining whether the hospital is in- or out-of-network.

President Barack Obama's health care law required the Department of Health and Human Services and Department of Labor to establish new guidelines for calculating how much of an emergency medical bill is an insurer's responsibility when the hospital is out-of-network.

But in a federal lawsuit filed in Washington on Thursday, the American College of Emergency Physicians says it worried the rules proposed by the departments will lead to dramatic underpayments for emergency care services rendered.

"When a person is in a car accident, suffers a heart attack, or is otherwise seriously ill or injured, he or she is usually transported to the nearest emergency department and treated by an emergency physician," the May 12 complaint says.

"When the patient has health insurance, the emergency physician is often not a member of the insurer's contracted network of providers. The nation's critically important network of emergency room services cannot be maintained unless emergency physicians receive adequate payment for these 'out-of-network' emergency medical services."

The final rule, issued in November 2015, requires insurers to pay the "greatest of three" calculations for emergency services: 1.) the insurer's in-network amount; 2.) the "usual, customary, and reasonable" (UCR) amount; or 3.) the Medicare amount.

"In almost all instances, the highest of these three amounts will be the UCR amount," the complaint says. "However, insurers have historically understated and prevented public verification of the UCR amounts."

In a comment letter sent after the rule was published, the doctors' group asked the government to add transparency requirements to force insurers to determine a UCR figure using publicly available data.

Insurers have, in the past, allegedly manipulated UCR figures to reduce their financial obligation.

In some states, this practice leaves patients with a larger bill, because they must pay for the part of a physician's bill not paid by insurance.

Other states require the doctor to accept an insurer's payment for out-of-network services, even if it is far lower than the doctor's fee.

"The Final Rule leaves ACEP's members who are out-of-network emergency physicians with no minimum payment protection in states that prohibit balance billing. The viability of the practice of emergency medicine is at risk because many physicians will have no choice but to leave the practice of emergency medicine if they cannot receive fair payment for out-of-network services," the association claims.

The doctors seek an injunction halting the implementation of the new rule.

The Department of Health and Human Services did not immediately respond to a request for comment.The association is represented by Ronald Connelly with Powers, Pyles, Sutter & Verville in Washington.

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