A long-fought battle over fair reimbursement rates for both in-network and out-of-network medical coverage has largely pitted payers against providers. When navigating a complicated and embittered topic, it is critical to shed light on the various agents involved in and affected by the fight for fair reimbursement.
In response to a recent article on balance billing, Jay Kaplan, MD, president of the American College of Emergency Physicians in Washington D.C., shared his expertise on balance billing with Becker's Hospital Review to address the challenges emergency physicians face when negotiating sustainable payment rates.
ACEP represents more than 35,000 practicing emergency physicians nationally.
1. Surprise billing, or surprise coverage? A recent study by Crowe Horwath shows consistent growth in the share of uncompensated care costs associated with insured patient populations. Similarly, a Kaiser Family Foundation and New York Times report found for Americans aged 65 or under who have insurance, 20 percent report problems paying medical bills in the past year due to out-of-network care or unexpected claims denials.
Americans who have chosen health plans based on affordable premiums have found themselves unable to afford relatively high deductibles. Many times what a patient perceives as a surprise medical bill is simply the high deductible associated with low-priced premium, Dr. Kaplan believes. "[Insurers] are misleading patients by offering 'affordable' premiums for policies that actually cover very little," says Dr. Kaplan. "What they have called 'surprise billing' should more accurately be called 'surprise coverage.'"
2. Insurers are driving providers out-of-network with low reimbursement rates. "By reimbursing at ridiculously low rates, to the point of not covering costs, health insurance companies are driving physicians out-of-network," says Dr. Kaplan. The news has been rife with payer-provider contract disputes over the past year, largely centered on unfair reimbursement rates that shift financial responsibility onto patients and physicians.
Late last year, Carondelet Health Network in Tucson, Ariz., accused Blue Cross Blue Shield of paying extremely low reimbursement rates, and threatened to leave the BCBS network unless rates changed. Community Health System in Munster, Ind., severed ties with Anthem BCBS earlier this year citing an inability to agree on fair and sustainable network costs.
3. Insurance companies may choose which patients to cover, whereas emergency physicians cannot. Hospital emergency departments operate under a federal mandate — Emergency Medical Treatment and Active Labor Act — that requires physicians to care for all patients, regardless of his or her ability to pay. Insurance companies have the ability to decide which individuals to cover, as well as which physicians to bring into their network. As more insurance companies consolidate and narrow their network coverage of medical providers, they increase the likelihood patients may find themselves in out-of-network situations, says Dr. Kaplan. In this way, some providers feel purposefully narrow emergency physician networks take advantage of a physician's mandate to provide care with the possibility of not getting paid.
4. Some payers have fraudulently calculated data to manipulate provider reimbursement rates. In 2010, UnitedHealthcare paid a $350 million settlement to resolve allegations the insurer used the Ingenix database to systematically low-ball reimbursement rates, thereby shortchanging physicians for out-of-network medical services. The settlement required UnitedHealthcare to scrap two major databases sold by wholly owned subsidiary Ingenix and used by most major insurers to determine usual, customary and reasonable reimbursement rates for out-of-network services. Former American Medical Association President Nancy Nielsen, MD, PhD, said the artificially low UCR figures given to patients meant patients would assume their physicians were overcharging them for services, creating a rift between patient and provider, reports American Medical News. As part of the settlement, UnitedHealthcare pledged $50 million to establish the independent Fair Health database.
5. Insured patients have increasingly delayed medical care due to high out-of-pocket expenses. According to a recent ACEP poll, 7 in 10 emergency physicians saw patients with health insurance who had delayed medical care because of high out-of-pocket expenses associated with high deductibles and co-insurance costs. According to a study from Kaiser Family Foundation and New York Times, 62 percent of insurance carriers facing financial difficulties with medical costs delayed dental care, 43 percent skipped physician-recommended tests or treatment, and 41 percent did not fill a prescription.
When patients delay timely medical intervention, they may increase their chance of eventually ending up in the emergency room for care, where they may not be in a state to choose in-network from out-of-network services. "This is unacceptable," says Dr. Kaplan.
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