The insurance coverage gap and how to address it: 3 takeaways

Many patients find themselves with unexpected medical expenses after health plans deny reimbursement for emergency department services, according to Ed Gaines, JD, chief compliance officer in the emergency medicine division at Zotec Partners.

Gaps in coverage can occur when a patient receives emergency care at an out-of-network hospital or from an out-of-network provider at an in-network facility.

Mr. Gaines discussed these "surprise coverage gaps" in detail and how to address them during Becker’s Hospital Review's 4th Annual Health IT + Revenue Cycle Conference.

Three takeaways:

1. Insurers used to deny coverage if the emergency patient's final diagnosis was deemed nonurgent, according to the American College of Emergency Physicians. But in the late 1990s, the Prudent Layperson Standard required Medicare and Medicaid managed care plans to provide emergency coverage based on a patient's symptoms, rather than a final diagnosis. In 2010, the ACA extended that law to individual- and small-group health plans and to self-funded employer plans.

2. Still, problems have persisted related to coverage gaps, said Mr. Gaines. For example, he cited Anthem's decision to implement a new emergency room policy in several states allowing the insurer to deny coverage of an ER visit that it deems nonurgent.

The policy, effective in Georgia, Kentucky, Ohio, Missouri, New Hampshire and Indiana, sparked pushback from emergency physicians and multiple lawsuits. A recent report from Sen. Claire McCaskill, D-Mo., found Anthem denied 12,200 claims from members in Missouri, Kentucky and Georgia during the second half of 2017 on the grounds the ER visits were "avoidable."

Anthem eventually increased the number of "always pay" exceptions under the policy.

Mr. Gaines said he believes other problems causing coverage gaps include insurers offering narrower plans and state insurance departments approving ACA plans with no in-network emergency physicians.

3. Some states have implemented their own laws to address the coverage gap. In New Jersey, lawmakers passed a bill that changes provider billing practices for "emergency or urgent" out-of-network care. The law sets limits on how much a provider may charge in excess of a deductible and the copayment or coinsurance amount the patient pays within their insurance network.

Mr. Gaines said databases that estimate what providers charge, as well as insurer reimbursement, would also help educate patients on their particular type of coverage and what it reimburses.

 

More articles on payers:
UnitedHealth warns hospitals it may drop Envision ER physicians from network
UnitedHealth, Texas medical group battle over claims processing technology
Humana's tax break for new digital health center delayed over labor dispute queries

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