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OP-ED: It’s Time to Come Together to Protect our Patients

Stethoscope

By Dr. Rebecca Parker

Emergency physicians are America’s first line of medical defense. We come to the aid of patients at their most critical times, often providing life-saving care. These dedicated physicians serve as the gateway to other areas of patient care, such as radiology, anesthesia, and other medical specialties.

As an emergency physician, I get concerned whenever patients delay their care because they fear unexpected bills. Nearly every shift, I see patients who were afraid to visit the emergency department because they worried about their financial risk and in the end put their lives at risk.

Why is this happening?

The insurance companies would have the public believe that healthcare providers are solely to blame for patients receiving unexpected bills for medical care. This couldn’t be further from the truth. This issue is not surprise billing by providers, it is surprise coverage by insurers.

The balance of power in our healthcare system currently rests with the insurance companies, who regularly deny coverage for diagnoses that they determine – after the fact – to be non-emergent emergency visits. These insurers refuse to use an independent and transparent system to determine reimbursement rates, raise deductibles to astronomical levels, offer a narrow availability of in-network emergency providers and unilaterally reduce negotiated payment rates to physicians. Because of inadequate insurance coverage, patients find themselves on the receiving end of surprise bills for medical care.

Rather than working together to fix this flawed system, insurance companies resort to fierce public attacks on physicians and hospitals. To complicate matters, the insurance industry has launched a smear campaign against healthcare providers and emergency physicians in particular. They are using flawed arguments and inaccurate research papers that are based on undisclosed data that have not been subject to the full peer review process. Unfortunately, it is just another tactic to divert attention from their own practices that ultimately harm patients. It is one reason why physician groups and hospitals are suing insurance companies.

It doesn’t have to be this way. Change is possible.

Doctors, insurers and policymakers have a responsibility to come together to be part of a solution that protects our patients from surprise coverage. This complex problem requires a multifaceted solution, and all members of the healthcare community, including insurance companies, must be equally committed to coming to a resolution. Healthcare providers are eager to cooperate with insurance companies and legislators in a productive and fair manner to ensure that patients are not saddled with unexpected bills.

First, insurance companies must immediately put a stop to the dangerous policy of denying coverage for emergency patients based on an arbitrary list of diagnoses. This practice has deathly serious health implications for patients, and often results in unexpected bills after-the-fact.

For more than 20 years, the “prudent layperson” standard has served as the basis for determining whether evaluation at an emergency department is justified. This proven health policy in emergency care should continue to be enforced. This standard, included in the Affordable Care Act and the vast majority of state laws, requires that insurance coverage be based on patients’ symptoms, not their final diagnosis. A patient who goes to the emergency department with chest pain thinking it may be a heart attack, but who is diagnosed with pleurisy, an inflammation of the lining of the lung, should be covered for their visit in its entirety. Unfortunately, certain insurance companies would deny payment, after the fact, making the patient financially responsible for the entire emergency visit. This practice, which creates an environment where patients dangerously self-diagnose, and are afraid to seek care, is wrong and should be stopped.

Second, insurance companies must come together with health care providers and insurance commissioners to prevent gaps in coverage due to out-of-network billing. Both the American Medical Association (AMA) and the National Association of Insurance Commissioners (NAIC) have proposed a solution. They put forth model legislation this year that addresses many of the issues surrounding surprise coverage. It establishes a minimum benefits standard that requires transparency, using an independent, nonprofit and verifiable charge database to determine reimbursement for all medical specialties. This gives patients peace of mind that when they need emergency care there won’t be a surprise bill while providing a fair and reliable baseline for physicians for the high quality of care they provide.

We are doing our part to ensure that our patients are protected. Emergency physicians are working together with the insurance companies in a good faith effort to move in-network whenever possible. In return, insurance companies must also fulfill their commitment to provide adequate physician networks for their patients.

Patients suffer when they receive unexpected bills due to a gap in coverage. Surprise coverage makes them afraid to seek care. Whatever the vehicle, it is incumbent upon the healthcare providers and the insurance companies to come together and work with legislators – on a bipartisan basis – at both the state and federal levels to develop solutions that work for everyone, most importantly the patient.

Dr. Rebecca Parker is a board certified, practicing emergency physician in the Chicago area and is the Senior Vice President for Advocacy and Leadership for Envision Physician Services. Rebecca Parker, MD, FACEP finished her term as President of the American College of Emergency Physicians (ACEP) in October 2017.

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