ER docs warn balance billing hurts consumers

Emergency doctors say federal regulations could create big bills for consumers seeking emergency care outside their provider networks, but health policy experts and consumer advocates warn their proposed solution doesn't take care of the problem, according to Kaiser Health News.

While the Affordable Care Act bars plans from charging higher copays or coinsurance for out-of-network ED visits, KHN reports that a loophole allows providers to "balance bill" patients to take care of any costs that insurers don't cover, which consumer advocates say is the real threat to consumers. Federal law requires insurers pay a "reasonable amount" before an organization can balance bill, which it defines as whichever is the greatest amount among:

  • Medicare reimbursement for the service
  • A number based on the same methodology the plan generally uses to determine payment for out-of-network services
  • The median amount negotiated with in-network providers

Under the second and third options, insurers are able to pay whatever they want, according to the Emergency Department Practice Management Association and the American College of Emergency Physicians, necessitating an objective standard to prevent exploitation of consumers, the publication reports. This standard, the organizations say, should be the "usual and customary charges" based on an independent claims database.

But insurers argue the problem is on emergency providers' end, pointing to data that show the average Medicare payment was $176, while the average out-of-network charge was $971, according to the article. "It comes down to the prices emergency doctors are charging, which are often far higher than what Medicare pays," Clare Krusing, an America's Health Insurance Plans spokeswoman, told KHN. "So the question really is, 'Are these fair prices in the first place?'"

To better protect consumers, policymakers must consider doing away with balance billing for emergency care, according to the article. New York, for example, passed a law that took effect in April that bans providers from  billing insured patients for out-of-network emergency care in most cases. This law could be a model for other states, because it removes the consumer from the position of a bargaining chip between payers and providers, Kevin Lucia, a senior research fellow at Georgetown University's Center on Health Insurance Reforms, told KHN. The debate over the practice is heating up in other states as well, such as California, where the practice is on the rise for Medicaid patients, FierceHealthPayer recently reported.

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