State-Level Support (previous years)

• Significant involvement by ACEP’s immediate Past President Michael J. Gerardi, MD, FAAP, FACEP, and others in molding the language of the National Conference of Insurance Legislators (NCOIL) model bill on balance billing disclosure, specifically excluding emergency care from balance billing bans or disclosure requirements.
• Chapter balance billing battles are consistent agenda items on annual ACEP chapter leaders and lobbyists conference calls (2014-New York, 2013-Nevada, 2012-Louisiana, 2010-New Jersey and Maryland, 2009-California and Texas)
• Presented out-of-network (OON) payment of emergency care concerns to American Medical Association (AMA) staff, other national specialty society staff, and state medical society staff during a presentation at a national conference in 2009 and on AMA state legislative conference calls in 2012.
• Provided a 2007 public policy grant of $12,500 to the California chapter to support PR, legal, and other advocacy efforts to combat a balance billing ban. 2009 public policy grant to California to assist in collecting data to help identify the impact of the ban on balance billing
• 2010 public policy grant of $12,500 to the New Jersey chapter to support coalition activities designed to combat insurer efforts to enact legislation that restricts payment of out-of-network emergency providers.
• 2011 public policy grant of $12,500 to the Illinois chapter to support legal challenge for out-of-network physicians to accept amount offered or be forced to instigate arbitration proceedings.
• September 2012 Information paper created by the State Legislative/Regulatory Committee and distributed to chapters on lessons learned from California and Nevada chapters regarding legislative efforts related to balance billing.
• State laws, NCOIL model, and other resources provided in 2013 to Nevada chapter  facing a balance billing ban. Similar resources provided to Louisiana chapter in multiple years (five past chapter presidents testified in 2012).
• Signed on to comment letter to National Association of Insurance Commissioners (NAIC) as part of an AMA letter and a separate hospital-based physician caucus letter in November 2014 regarding model legislation on out-of-network payment.
• Provided 2013 assistance to the New York chapter, including language review, strategy discussions, and work with NY Med Society and AMA to encourage more inclusion and acceptance of NYACEP position
• Development, placement. and promotion of online chapter resources including model legislation such as:
  • The Texas right to balance bill for all charges under $1,000, at which point patients could require arbitration.
  • The California legislation passed by the legislature but vetoed by the governor allowing for an interim out of network payment level of 250 percent of Medicare rates with an independent dispute resolution process available to any party to adjust that interim rate.
  • The ACEP model legislation based on using a percentile of charges maintained in an independent claims database. (This model was created before the creation of FAIR Health and could now be replaced with a greatest of four–type model as is sought at the federal level. See below regarding a new toolkit being developed by the Reimbursement Committee.)
• Lessons learned from various chapters in their efforts to fight off balance billing bans.
• Talking points related to balance billing from national ACEP and chapters.
• Sample testimony on balance billing, including Dr. Gerardi’s testimony to the National Conference of Insurance Legislators.
• Numerous victories over the years at the state level in combating balance billing bans and/or passing more favorable legislation including in Washington, Nevada, Louisiana, Florida, New Jersey, Virginia, Maryland, Texas, and North Carolina.

State-Level Support (Current Fiscal Year)

• Balance billing and related reimbursement issues continue to be included in the legislative tracking service that we provide for the 38 state chapters that request such information.
• The State Legislative/Regulatory Committee has the following objective on which it is working this year: Work with chapters to identify and report on the general impact on emergency medicine reimbursement from significant private payer legislation enacted in recent years in various states (ie, California, Texas, Illinois, and New York).
• Participation is ongoing in NAIC conference calls dedicated to the adoption of an updated network adequacy model law. Balance billing language is being debated as a part of that model. In conjunction with those calls, we have communicated and coordinated efforts with a group of hospital-based specialty organizations gathered informally by the AMA, with Barry Ziman of the College of American Pathologists, and with Lee Spangler of the Texas Medical Association. Future NAIC discussions to include a member of the ACEP Reimbursement Committee.
• At the request of a Board member, ACEP provided information regarding states with existing balance billing prohibitions. We provided information regarding a federal court case that ruled against a plaintiff seeking to invalidate state balance billing prohibitions on the basis of federal constitutional due process grounds. The Board member had expressed interest in such an approach.
• Based on intelligence received from Lee Spangler at the AMA’s November 2014 meeting in Dallas, ACEP emailed the Texas Chapter office informing them that balance billing legislation similar to the New York legislation would be considered in 2015, as well as an information request from Texas Medical Association regarding allegations offered by the health plans that a large number of emergency practice groups terminated contracts when the current law took effect.
• Out-of-network payment/balance billing was included on the agenda of the  Chapter Executives and Lobbyists call in December 2014. The discussion of the issue was led by Louise Prince, MD, FACEP, president of New York ACEP, who discussed that chapter’s experience in negotiating balance billing legislation in that state. This resulted in several states contacting the New York Chapter for more information.
• Karen Massey, MHA, FACMPE, CPMSM, on behalf of the Nevada Chapter, reached out to national ACEP regarding whether Texas mediation law would be an appropriate approach for them to take with regard to the perennial balance billing concerns being raised in the legislature there. She was advised that, to our understanding, both the Texas Chapter and the Texas Medical Association liked the current Texas statute, and was provided contact information for the Texas chapter.
• Worked with AMA on opportunity for Dr. Gerardi to speak as part of a pre-conference panel at the AMA’s State Legislative Advocacy Conference in January. In addition to Dr. Gerardi, the panel included the president of the New York State Medical Society and a physician member of the Texas General Assembly. Dr. Gerardi presented his take on balance billing and out of network payment issues, with a focus on the impact on emergency medicine.
• Provided numerous documents to the Florida Chapter regarding balance billing legislation, including information about the New York background and outcome and existing law in Colorado.
• Provided New Jersey Chapter lobbyist with talking points and background materials for use in balance billing legislative battle upcoming there.
• Preliminary objectives for 2015–2016 State Legislative/Regulatory Committee include the following:
  • Research and report on legislation addressing restrictions on balance billing, as well as legislation that sets forth a methodology for determining reimbursement from insurers for out of network services when balance billing is restricted or prohibited.
  • Work with the Reimbursement Committee on developing resources that would help chapters advocate for appropriate legislative solutions.
• Working on updating previous balance billing/out-of-network payment ACEP model to reflect recent developments.

Reimbursement Department Activities Related to Balance Billing and Fair Payment

• The Reimbursement Committee has an objective to work with the State Legislative Committee to develop an updated toolkit for chapters to use in dealing with state reimbursement issues.
• In 2009, developed ACEP policy statements on fair payment and balance billing
• Obtained a legal opinion on primacy of ACA versus state law.
• Working with outside counsel on a potential legal action against Data iSight for repricing out-of-network claims.

Other Reimbursement Department Activity Related to Reimbursement Support for Chapters

• Track payer activity by state and currently creating a spreadsheet for members to track activity by payer, by state.
• Speak at state reimbursement and coding conferences, and David McKenzie has spoken for chapters in Arizona, Georgia, Idaho, Massachusetts, Michigan, Pennsylvania, and Virginia.
• Work at RUC and CPT, which impacts all members. We obtained the highest percentage increase in Medicare payments of all specialties in 2015, and maintaining the geographic practice cost index work floor at 1.0 saves rural areas from steep cuts.
• Track Medicare frequency distributions at the state level and post those on the website.
• Track Medicaid payments by state and make those available to interested parties.
• Created new educational material on ICD-10 implementation and preparing for and surviving payer audits.
• Provided 37 sets of reimbursement and coding FAQs updated for 2015 at the ACEP website.
• Posted newly revised paper, “What Every Graduating Resident Needs to Know About Reimbursement”, on the ACEP website and made it available to residency programs.
• The Reimbursement office receives about 200 emails a day from members all over the country on reimbursement issues.

National ACEP Funding for Other State Reimbursement Issues

• 2008 public policy grant of $12,500 challenging Anthem payment for EMTALA services.
• 2010 grant of $3,600 to help Massachusetts chapter challenge Blue Cross Blue Shield credentialing policies for the payment of emergency ultrasound and $12,500 grant to help Michigan chapter challenge Blue Cross Blue Shield for refusal to pay emergency physicians for plain film interpretation.
• 2011 grant of $50,000 with Emergency Medicine Action Fund (EMAF) funding to help the Washington Chapter to avoid cuts to Medicaid visits and reimbursement (additional $50,000 was committed but unneeded by Washington Chapter).
• 2011 funded an Emergency Medicine Foundation/EMAF research project related to Medicaid reimbursement.
• 2012 public policy grant for $12,500 to assist the Washington chapter in combating state policy to limit the number of reimbursable nonemergency Medicaid visits to the ED.
• 2013 public policy grant of $12,500 to help New Jersey advocate for increased Medicaid rates for emergency physicians.
• 2015 grant to the Connecticut chapter with EMAF funding for plan to change state’s position on Medicaid reimbursement of emergency physicians.