New York, with the participation of its ACEP chapter, recently passed legislation that might be a model for other states. This law obligates the carriers to hold patients harmless for care provided by out-of-network providers, with no increased out-of-pocket cost. It prohibits balance billing for nonemergency services and creates a dispute resolution process to determine payment levels. However, for emergency care provided by out-of-network physicians, balance billing is permitted. More critically, New York Chapter ACEP was successful in exempting the common ED services from the unwieldy and expensive dispute resolution process.4 Rather, ED services less than $600 (after any applicable copayment or deductible) that do not exceed 120 percent of the usual and customary cost (UCR) are to be paid in full by the carrier. UCR is determined by using the 80th percentile of the FAIR Health database as a benchmark.
Explore This IssueACEP Now: Vol 34 – No 11 – November 2015
We need to be at the table, proactively, with policy solutions that protect patients while preserving our ability to receive fair payment for services already provided.
This more balanced (forgive the term) approach ensures reasonable payment to emergency physicians, encourages carriers to keep emergency physicians in network, protects patients, and removes any incentive for physicians to escalate their prices beyond what is reasonable by establishing a benchmark for UCR. Determining UCR, or some agreed upon standard for reasonable charges for services, is a critical component of any workable solution. The New York FAIR Health database is a nonprofit corporation and generally considered unbiased. ACEP’s Emergency Medicine Action Fund is working to create an economic registry that might also serve a similar function.
ACEP remains active in addressing this matter. A task force has been convened to find policy solutions and develop model legislation that individual state chapters can bring to their legislators when this issue inevitably arises in their jurisdiction. As a specialty, our challenge is to recognize the unfavorable political terrain, to concede that the practice of balance billing is untenable, and to unite around a policy solution that protects patients while also maintaining the integrity of the safety net of the emergency department.
Dr. Yore is an emergency physician at Providence Regional Medical Center in Everett, Washington.
- Rosenthal E. After surgery, surprise $117,000 medical bill from doctor he didn’t know. The New York Times Web site. Accessed Oct. 19, 2015.
- Pao B, Riner M, Chan TC. Impact of the balance billing ban on California emergency providers. West J Emerg Med. 2014;15(4):518-522.
- Report of the commissioner of insurance to the Colorado General Assembly on consumer protections against balance billing. State of Colorado Web site. Accessed Oct. 19, 2015.
- New York ACEP scores a major victory on out-of-network. New York Chaper ACEP Web site. Accessed Oct. 19, 2015.