ACEP sues HHS over out-of-network reimbursement

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The AmericanCollege of Emergency Physicians has filed a lawsuit against HHS, alleging an Affordable Care Act provision fails to ensure reasonable payment to physicians for out-of-network emergency services.

In its complaint filed May 12, the ACEP asks the federal government to invalidate and amend regulations that outline how insurance companies reimburse for out-of-network emergency services. In 2010, HHS, the Department of Labor and the Department of Treasury issued an interim final rule to implement an ACA provision, which established the "greatest of three methodology." Under the final rule, insurers pay the greatest of three possible costs for out-of-network emergency services — the insurer's in-network amount, the Medicare amount or the usual, customary and reasonable amount.

The UCR is typically the greatest of the three costs, however some stakeholders have argued insurers manipulate UCR amounts to reduce their own financial obligations.

One of the more notable instances of UCR fraud involved UnitedHealthcare in 2010, when the insurer paid $350 million to resolve allegations it manipulated claims data in its Ingenix database to systematically low-ball reimbursement rates for out-of-network medical services. 

In the lawsuit, ACEP has asked the federal government to address the need for insurers to be more transparent with the data they use to pay out-of-network emergency physicians.


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