Legal Newsline

Monday, March 30, 2020

Emergency physicians organization fights for fair payment from insurance companies

By Dawn Geske | Aug 12, 2016

Medical malpractice 06

WASHINGTON (Legal Newsline) – An emergency physicians' organization is taking aim at a ruling that decides how much insurance companies compensate emergency physicians for their services.

The American College of Emergency Physicians (ACEP) has challenged the final rule issued by the U.S. Department of Health and Human Services, the U.S. Department of Labor, and the U.S. Department of the Treasury. The case, American College of Emergency Physicians v. Burwell et al., was filed in the U.S. District Court for the District of Columbia.

Under the rule, a standard was created that required insurance companies to compensate out-of-network emergency care providers the higher dollar figure for one of three amounts: pay the plan’s in-network amount; the Medicare amount; or the usual, customary and reasonable amount, referred to as the UCR.

There is no standard in place for the rate of UCR, resulting in different payment amounts. The suit alleges that the UCR is unreliable and subject to interpretation by insurance companies. ACEP also claims that insurance companies are forcing emergency physicians to leave their networks because they are using very low rates of reimbursement for their services.

“Emergency physicians are in a pretty unique situation among physicians and that is that they’re required according to EMTLA (Emergency Medical Treatment and Labor Act) to see any patient that comes through the door regardless of that patient’s ability to pay, regardless if they have insurance or not,” Damaris Medina, senior associate at Michelman & Robinson, told Legal Newsline.

“What happens is that requirement leaves physicians, at times, providing free care for those people that can’t pay. The concern is that insurance companies have decreased their reimbursement in recent years and by decreasing their reimbursement; they’re not properly compensating physicians for their services."

The low reimbursements also make it more of a challenge to retain emergency physicians.

“Recruiting for emergency physicians is becoming harder every day,” Medina said. “Emergency care is really the safety net of the health care system, and it's becoming harder and harder every day to keep it alive.”

Whether the challenge to the regulation will make a difference remains to be seen, Medina maintains confidence in the outcome.

“I think that’s the hope," Medina said. "They’re attacking the regulation directly. They’ve tried through a number of different ways to affect both the language and the effect of the regulation.

"They’ve been unsuccessful and I think that’s the crux of their complaint. The department hasn’t really taken that into consideration and just kind of adopted the final rule anyway."

Opponents of UCR hope the lawsuit will stir up change and help draw, not deter, more physicians to emergency medicine.

“The problem with the regulation is it doesn’t define UCR,” Medina said. “It completely leaves it up to the health plans to define it, and there’s absolutely no transparency. As emergency physicians that are getting paid UCR, they can’t figure out how that amount was derived.”

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Organizations in this Story

U.S. Department of Health and Human ServicesU.S. Department of LaborU.S. Department of the TreasuryAmerican College of Emergency Physicians