Surprise-billing research doesn't account for regional market differences, ER physicians say

Amid a federal surprise-billing debate, the American College of Emergency Physicians is expressing concerns about research on the issue.

The national medical society said Aug. 28 that research on the subject is "fundamentally flawed" and doesn't account for regional differences in the healthcare market.   

"The authors overstate the number of out-of-network emergency visits and exaggerate the frequency of balance billing, which may grab headlines but ultimately does a disservice to the patients left to face the challenges of inadequate insurance coverage," the physicians group said.

The group referred to a study published Aug. 12 in JAMA Internal Medicine that showed out-of-network billing became increasingly prevalent between 2010 and 2016 for privately insured patients in emergency department and inpatient settings at in-network hospitals.

The study — led by researchers from Stanford (Calif.) University — found that 32.3 percent of privately insured patients faced out-of-network bills after ED visits at in-network hospitals in 2010. That's compared to 42.8 percent in 2016.

The findings were based on a March analysis of more than 5.4 million inpatient admissions and more than 13.5 million emergency department visits between 2010 and 2016 in Optum's Clinformatics Data Mart database.

But emergency physicians say that the researchers used an "oddly selective sample" of emergency visit claims and "conflate claims submitted to the insurer by the physician with bills sent to the patient."

Their concerns about the research come as federal lawmakers are considering various federal proposals to end surprise medical bills that occur after patients unintentionally receive out-of-network care in emergency situations or at in-network hospitals. One idea under consideration is a dispute resolution process, such as arbitration, for out-of-network payments between providers and insurance companies. A benchmarking approach for these out-of-network payments is also under consideration.

 The emergency physicians group supports independent dispute resolution.


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