Letter to the editor: President of ACEP responds to '20 things to know about balance billing'

It's important to remember — just because you have a health insurance card does not mean you have coverage for medical care. Read the details and know what your health plan covers.


As president of the American College of Emergency Physicians (ACEP), I am writing on behalf of more than 35,000 emergency physicians in response to "20 things to know about balance billing" by Brooke Murphy.

First, health insurance companies have been adept at portraying physicians as the cause of the problem when in fact they have created this situation. They are misleading patients by offering "affordable" premiums for policies that actually cover very little. What they have called "surprise billing" should more accurately be called "surprise coverage."

As one health insurance company vice-president said on a panel at a recent America Medical Association conference, "the first and only thing which people look at is the affordability of the premium." Insurers are shifting costs onto patients through higher deductibles, co-pays and co-insurance, while increasing their profits. Many times what patients perceive as "surprise" bills are simply the high deductibles that come with low-priced premiums. The insurance companies are also are making it more likely that patients will find themselves in [an] out-of-network situation by creating narrow networks of medical providers. By reimbursing at ridiculously low rates, to the point of not covering costs, health insurance companies are driving doctors out-of-network.

Second, insurance companies are exploiting a federal law to reduce payments for emergency care. They know that hospital emergency departments have a federal mandate (Emergency Medical Treatment and Active Labor Act) to care for all patients, regardless of their ability to pay. While insurance companies may choose which patients they will cover, emergency physicians cannot.

Insurance companies have a history of data manipulation and not paying for emergency care. UnitedHealthcare for years fraudulently calculated and significantly underpaid doctors for out-of-network medical services (using Ingenix database). The company along with other insurers paid a $350 million settlement, of which $50 million was used to create the Fair Health database. The Fair Health database is the best mechanism available to ensure transparency and to make certain that insurance companies don’t miscalculate payments.

People can't choose where and when they will need emergency care and they should not be punished financially for having medical emergencies. According to a recent ACEP poll, seven in 10 emergency physicians saw patients with health insurance who had delayed medical care because of high out-of-pocket expenses, deductibles and co-insurance. This is unacceptable.

Finally, balance billing would not exist if insurance companies just paid what is known as "usual and customary" in the insurance industry and what's known as "fair" payment to everyone. These standards are incorporated into the Fair Health database.

It's important to remember — just because you have a health insurance card does not mean you have coverage for medical care. Read the details and know what your health plan covers.


Jay Kaplan, MD, FACEP

President, American College of Emergency Physicians


More articles on revenue cycle management issues: 

20 hospital, health systems seeking revenue cycle talent
20 things to know about balance billing
ECG Management Consultants establishes national bundled payments practice

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