Report: Federal Rule Could Trigger Higher Bills for Emergency Care

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The new rule has been issued just as states are cracking down on the practice of balance billing patients who take steps to use in-network hospitals, only to be balanced billed anyway if they are seen by a provider not on their health plan.

Groups representing emergency department physicians say a federal rule could force patients to pay more if they need unexpected out-of-network care. But, according to a report from Kaiser Health News, some consumer experts think the doctors’ cure is worse than the disease.

The warning comes as scores of states are weighing plans that would curtail or eliminate “surprise” medical bills, which are arriving with greater frequency as patients seek emergency care in the era of narrow networks.

The Affordable Care Act doesn’t allow health plans to charge consumers more than they would pay under their own plan for care if they have to visit an emergency department that’s not in their network. But that doesn’t stop individual doctors and hospitals from balance billing for these emergencies if the insurers won’t pay the full amount.

What’s worse, some consumers who take steps to use an in-network for an emergency still get caught in the balancing billing game, if their case involves a specialist or anesthesiologist who is not on their health plan. Depending on their condition, patients may have no idea an out-of-network provider got involved until the bill shows up in their mailbox.


Consumers are often in a bind—even if the charges seem unjust, failure to pay puts them at risk of having the unpaid amount reported to credit bureaus, if they live in a state that has not banned this practice.

“Our main interest is getting consumers out of the middle,” said Chuck Bell of the Consumers Union, an advocacy group that has worked on efforts at the state level, told KHN.

Since the ACA passed in 2010, relationships between hospitals and health plans that are not contracted with each other have operated under an interim rule that has slowly caused health plans to cut back on what they pay for emergency care to out-of-network facilities. This has only escalated the need for a resolution, as the horror stories among consumers spread.

But the American College of Emergency Physicians and Emergency Department Practice Management Association say the final rule recently published in the Federal Register does little to offer assurances that emergency departments will be fairly compensated by health plans. These groups point out that emergency departments must treat everyone who walks through the door.

The rule states that insurers must pay a “reasonable” amount before they can bill patients for the balance, which is defined as the greatest of 3 options:

· The median amount negotiated with in-network providers for emergency care.

· An amount similarly calculated, using methods that would pay for out-of-network services.

· The amount paid by Medicare.

Emergency department (ED) professionals say the first 2 standards are meaningless, because they reference proprietary information off-limits to out-of-network providers. Medicare pays rates below commercial coverage. ED groups instead want to use the “usual and customary” standard, but the group America’s Health Insurance Plans (AHIP) says these rates may be inflated and unfair.

Bell wants the federal government to eliminate the practice of balance billing for emergency care altogether, which has happened in about a dozen states. An AHIP spokeswoman said the group doesn’t necessarily advocate using Medicare as a benchmark for out-of-network rates, but it does encourage the government to question some charges.

“It comes down to the prices emergency doctors are charging, which are often far higher than what Medicare pays,” Clare Krusing, an AHIP spokeswoman, told KHN. “So the question really is, ‘Are these fair prices in the first place?’”