ACEP sues feds over out-of-network emergency patients

The American College of Emergency Physicians (ACEP) has filed a lawsuit against the Department of Health and Human Services over emergency reimbursement rules it says run the risk of insufficient payments.

The rule, ACEP claims, will lead to underpayments to member hospitals for out-of-network emergency care, citing a history of such payments by insurers left to define "usual, customary and reasonable" (UCR) amounts. A 2010 federal final rule on out-of-network emergency care ruled that insurers must pay whichever is highest: the in-network, the Medicare amount or the UCR amount, which is usually the highest.

However, the lawsuit alleges that historically, payers have understated that figure and stonewalled public records of it. Insurers often use private databases that the public and emergency providers have no means of checking, according to the suit. Prior to the Affordable Care Act, doctors simply billed patients for whatever was the difference between the total billed amount and the insurer reimbursement; however, the government's interpretation of the ACA frees insurers from any obligation to pay any amount billed by out-of-network providers before shifting responsibility to the patient.

Federal officials have declined ACEP's request to modify the final rule, issued last November, to require payers to be transparent on UCR amounts. Without this intervention, ACEP said, emergency doctors may be forced out of the practice without appropriate compensation for out-of-network care. Emergency doctors have warned this "balance billing" practice hurts healthcare consumers as well, FierceHealthFinance previously reported.

"The stakes are extremely high for the nation's emergency physicians, including ACEP's members, and the patients that they serve," the lawsuit states.

To learn more:
- here's the lawsuit (.pdf)