Advanced practice providers can help us improve flow; they are a great friendly face to take care of that laceration or ankle sprain or more of the straightforward work-up. Advanced practice providers are definitely my colleagues, working shoulder to shoulder with me even with complex patients, but they expand my ability to touch more patients than I would be able to just working by myself. Advanced practice providers and career supporters like scribes not only make your shifts more enjoyable, but they make you feel like you’re practicing to the top of your license. I think that’s something that we all should strive to do, including advanced practice providers.

KK: Out-of-network payments have been a big issue with health care reform. Could you summarize the issue?

MG: A good element of the Affordable Care Act (ACA) is adoption of the prudent layperson definition of an emergency. In other words, people should have emergency care provided in their health plans. However, part of the payment structure in America is that a group or an emergency physician has a choice to participate with a particular plan and insurance company or not participate. If you don’t participate, you’re out of network. The hospital may be in network, but the emergency physician is out of network. If they are out of network, the physician has the right to provide a bill that’s not covered by the insurance company’s usual rate. Insurance may only pay 60 percent, so a physician will send a bill for the balance—that’s called balance billing. Out-of-network bans say the doctors in emergency departments can’t send that balance bill for out-of-network care.

With the ACA, banning balance billing is not allowed. For billing fee disputes, the ACA created a rule called “the greatest of three” to help determine a fair reimbursement schedule. A reasonable usual and customary rate is: [1) the average amount negotiated with in-network providers for the emergency service furnished; 2) the amount for the emergency service calculated using the same method the plan generally uses to determine payments for out-of-network services (such as the usual, customary, and reasonable charges); or 3) the amount that would be paid under Medicare for the emergency service]. The lack of this type of methodology created the Ingenix crisis in New York state, when Attorney General Cuomo sued Ingenix because they were taking away some of the higher reimbursements in their nontransparent database, causing a downward spiral in the usual and customary rates in their database and saying that was the usual and customary rate. We have to revise the out-of-network rules and the CMS final rule on this regulation such that there is transparency—like in the FAIR Health data repository—and not a black box so that we can have a fair discussion about what is the usual and customary rate for out-of-network care.