The American College of Emergency Physicians has endorsed using the FAIR Health consumer database as a tool to help stabilize the medical billing reimbursement process, which has been in upheaval in recent years. The FAIR Health database, which became available in 2009, is a free website for consumers to use to research the approximate cost of out-of-network medical services in their geographic area.
Explore This IssueACEP News: Vol 31 – No 07 – July 2012
Because the database pulls information from millions of actual medical bills, ACEP’s stance is that insurance companies should also integrate it into the system by which reimbursement rates are set for medical claims.
“We understand that the patient shouldn’t be made to pay an unfair burden. Reluctantly, we understand that the insurance companies can’t just pay actual charges with no upper limit for these services,” said David McKenzie, ACEP Reimbursement
Director. “But there has to be some mechanism to determine fair payment. Because this tool is available, it makes sense to use it.”
Emergency physicians face some unique challenges amid the changing health care landscape. Unlike most specialties, emergency providers are obligated to treat patients, regardless of their ability to pay. But when it comes to getting reimbursed for those services, emergency physicians say insurers have been unwilling to offer in-network rates or take other steps to help doctors recover their costs.
“Insurance companies should negotiate with emergency providers for in-network rates,” said ACEP President Dr. David C. Seaberg. “But what is happening in the real world is that insurance companies are not negotiating with emergency physicians.”
Although emergency care accounts for only 2% of the U.S. health care dollar, emergency physicians say they’re caught between their obligation to treat patients and a reimbursement system that sometimes treats them as interlopers.
“There’s a perception that emergency medicine is expensive and there’s a lot of patients who are there who don’t need to be,” Dr. Seaberg said. “Honestly, that’s not true.”
Health insurance companies set reimbursement rates for out-of-network services using the greatest of several options: the amount negotiated by in-network providers; adjusted “usual, customary, and reasonable” (UCR) charges; or the amount Medicare would pay for the service. But emergency providers say the first two options are too easily manipulated by insurers.
And the Medicare reimbursement rates are artificially low. Consumers are experiencing similar frustration as insurers have increasingly tied reimbursement rates to Medicare.
“There are huge disparities between using the UCR charges and Medicare-based formulas,” said Robin Gelburd, FAIR Health’s President. “There’s a tidal wave of consumer complaints.”