Florida Data Suggest Balance Billing is Rare in Emergency Medicine

PR Newswire

WASHINGTON, Dec. 16, 2016 /PRNewswire-USNewswire/ -- With the support of the American College of Emergency Physicians (ACEP), the Florida College of Emergency Physicians (FCEP) today urged state and national policymakers to investigate the reimbursement practices of insurance companies, especially when patients go out of network for emergency medical care.

"We are urging Senator Bill Nelson to investigate fully what is happening in his own state before calling for an inquiry into 'surprise bills' by emergency physicians," said Jay Falk, MD, FACEP, president of FCEP. "Our report shows that less than 4 percent of privately insured patients in Florida actually received balance bills. We are calling for an examination of what insurers are offering their patients under high-deductible plans. Many insurers pay a percentage of what they call 'usual and customary allowables' which is typically well below actual charges, or usual and customary charges listed by the Fair Health™, a national independent database of insurance claims. They must be held accountable under the newly passed legislation in Florida addressing 'surprise bills.' The fair payment provisions of the law must be enforced."

FCEP conducted an analysis of billing data provided by Martin Gottlieb & Associates, a medical billing company. Of all Floridians, about 26 percent had private insurance (the rest were either uninsured or had Medicare or Medicaid). Of privately insured emergency patients, 88 percent were treated by in-network emergency physicians. Among the 12 percent of patients who were treated by emergency physicians who were out of their insurer's network, the average emergency physician out-of-network charge was $679. The average insurer's payment was $307 and the average patient payment was just $49.

"More national data are needed, but it's reasonable to say the Florida data, which represent 10 percent of all Florida emergency department visits, could be extrapolated to other states as well as nationally," said ACEP's president Rebecca Parker, MD, FACEP. "Recent focus by the media on a select group of theoretical balance bills from emergency physicians severely distorts what is really happening and distracts policymakers from what is in the best interests of patients and the health care system. The few balance bills that exist in Florida result from unwillingness by insurers to contract for fair and reasonable payment to medical providers, such as emergency physicians."

The Fair Health claims database (www.fairhealth.org) was developed after United Healthcare was successfully sued by the State of New York for fraudulently calculating and significantly underpaying doctors for out-of-network medical services (using Ingenix database). The formula they used forced patients to overpay up to 30 percent for out-of-network doctors. Four out of five big insurers have been sued for illegally manipulating what is deemed "usual and customary" medical charges.

"The Florida Legislature agreed a "surprise bill" should not occur when care is provided in a scenario where a patient does not have a choice of providers, and clearly defined what should be paid for out-of-network care, both for HMO and PPO patients," said Dr. Falk. "With payment now stipulated at the provider's usual and customary charge, insurers will be paying their fair share and shifting costs less to patients. Prior to the law change, insurers were underpaying for care, which was unfair to both patients and physicians. Florida's new law, if enforced, will prevent this practice."

"ACEP is committed to getting patients out of the middle and proposing solutions to escalating health care costs," said Dr. Parker. "But bullying tactics by the insurance industry and their surrogates are creating a lot of confusion for our patients who want what emergency physicians are advocating for: fair coverage for emergency care."

ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.