Washington, D.C. – The American College of Emergency Physicians (ACEP), the American Society of Anesthesiologists (ASA) and Physicians for Fair Coverage (PFC) today commend the American Medical Association’s (AMA) House of Delegates for approving Resolution #115 to end surprise insurance gaps by addressing out-of-network surprise billing in a way that holds patients financially harmless and uses a non-profit, conflict-free database to benchmark out-of-network payments.
The House of Delegates resolution also directs AMA to develop model state legislation addressing the coverage of and payment for unanticipated out-of-network care.
“Health insurance companies have a long history of denying care for emergency patients. They are misleading them by selling so-called ‘affordable’ health policies that cover very little, then blaming medical providers for the charges, said Rebecca Parker, M.D., FACEP, president of the American College of Emergency Physicians (ACEP). “Emergency physicians have proposed solutions such as a recently passed law in Connecticut which requires the use of an independent and transparent charge-based database for unexpected care. We are urging policymakers at the state level to implement these type of solutions, which will take patients out of the middle.”
The underlying cause of surprise medical bills is that insurance companies are creating extremely narrow physician networks – especially in emergency care. Insurers are using the Emergency Medical Treatment and Labor Act (EMTALA), which was originally established to ensure that patients are not turned away at the emergency department, to force physicians to accept take-it-or-leave-it reimbursement deals that can put them out of business or leave them practicing out-of-network. Unfortunately, these surprise insurance gaps leave patients and their physicians to deal with this issue while insurers wriggle out of coverage they should be providing and reap record profits year after year.
ACEP, ASA, PFC and other specialty organizations have led the fight in state legislatures to end surprise billing and close insurance gaps by advocating for legislation that takes patients out of the middle of billing disputes and uses a database of charges run by a non-profit national, independent, nonprofit organization dedicated to bringing transparency to health care costs and health insurance information.
“My family fell victim to this problem too,” said ASA President Jeffrey S. Plagenhoef, M.D. “I can share that while balance bills are the symptoms of the issue, the cause is gaps in insurance coverage. Maintaining accessible networks with adequate numbers of physicians and all services, as well as a mechanism for fair out-of-network payment are the keys to solving this problem, I’m thrilled the House of Medicine sees it that way too.”
“The entire House of Medicine is now united in how to end the surprise insurance gap and protect the patients for whom our physicians provide care,” said Michele Kimball, president and CEO of Physicians for Fair Coverage. “We’ve put forth solutions in state legislatures that bans surprise billing and hold insurance companies accountable in a way that also protects patients’ access to emergency services. This resolution means that every physician organization is proactively addressing this issue in a way that puts patients first. PFC is immensely grateful to ACEP and ASA for their leadership in bringing this before the AMA and working to secure its passage.”
The AMA House of Delegates Resolution is as follows:
1. Patients must not be financially penalized for receiving unanticipated care from an out-of-network provider.
2. Insurers must meet appropriate network adequacy standards that include adequate patient access to care, including access to hospital-based physician specialties. State regulators should enforce such standards through active regulation of health insurance company plans.
3. Insurers must be transparent and proactive in informing enrollees about all deductibles, copayments and other out-of-pocket costs that enrollees may incur.
4. Prior to scheduled procedures, insurers must provide enrollees with reasonable and timely access to in-network physicians.
5. Patients who are seeking emergency care should be protected under the "prudent layperson" legal standard as established in state and federal law, without regard to prior authorization or retrospective denial for services after emergency care is rendered.
6. Out-of-network payments must not be based on a contrived percentage of the Medicare rate or rates determined by the insurance company.
7. A minimum coverage standard for unanticipated out-of-network services should be identified. The minimum coverage standard should pay out-of-network providers at the usual and customary out-of-network charges for services, with the definition of usual and customary being based upon a percentile of all out-of-network charges for the particular health care service performed by a provider in the same or similar specialty and provided in the same geographical area as reported by a benchmarking database. Such a benchmarking database must be independently recognized and verifiable, completely transparent, independent of the control of either payers or providers and maintained by a non-profit organization. The non-profit organization shall not be affiliated with an insurer, a municipal cooperative health benefit plan or health management organization.
8. Mediation should be permitted in those instances where the physician's unique background or skills (i.e. the Gould Criteria) are not accounted for within a minimum coverage standard. (New HOD Policy); and be it further RESOLVED, that our AMA develop model state legislation addressing the coverage of and payment for unanticipated out-of-network care.
AMERICAN COLLEGE OF EMERGENCY PHYSICIANS
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.
THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 52,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring that physician anesthesiologists evaluate and supervise the medical care of patients before, during, and after surgery to provide the highest quality and safest care that every patient deserves.
For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/WhenSecondsCount.
PHYSICIANS FOR FAIR COVERAGE
Physicians for Fair Coverage (PFC) is a growing multi-specialty alliance of physician groups advocating to improve patient protections and End The Surprise Insurance Gap, while promoting transparency and increasing access to care. We are currently comprised of tens of thousands of emergency physicians, anesthesiologists, and radiologists nationwide who annually serve tens of millions of patients.