WASHINGTON, D.C.—Nine in 10 emergency physicians responding to a new poll said that health insurance companies are misleading patients by offering “affordable” premiums for policies that actually cover very little. Nearly all (96 percent) said that emergency patients do not understand what their policies cover for emergency care.

“Each day, emergency physicians are seeing patients who have paid significant co-pays, up to $400 or more, for emergency care,” said Jay Kaplan, MD, FACEP, President of ACEP. “For many people, this is too much of a financial burden and will deter them from seeking emergency care. Patients should not be punished financially for having emergencies or discouraged from seeking medical attention when they are sick or injured. No plan is affordable if it abandons you when you need it most.”

According to the poll, which was conducted in the United States by Marketing General Incorporated on behalf of ACEP, eight in 10 emergency physicians are seeing patients with health insurance who have sacrificed or delayed medical care because of high out-of-pocket costs, co-insurance, or high deductibles. This is more than a 10 percent increase over six months ago when emergency physicians were asked the same question.

In addition, Dr. Kaplan said that health insurance companies are creating narrow networks of medical providers to save money, making it more likely that patients will be out of network. They have created a situation where patients are receiving additional bills from medical providers.

“Insurance companies must be transparent about how they calculate payments and provide fair coverage for their beneficiaries and pay reasonable charges rather than setting arbitrary rates that don’t even cover the costs of care. They are exploiting federal law [EMTALA] to reduce coverage for emergency care, knowing emergency departments have a federal mandate to care for all patients regardless of their ability to pay.” —Jay Kaplan, MD, FACEP

“Insurance companies must be transparent about how they calculate payments and provide fair coverage for their beneficiaries and pay reasonable charges rather than setting arbitrary rates that don’t even cover the costs of care,” said Dr. Kaplan. “They are exploiting federal law [EMTALA] to reduce coverage for emergency care, knowing emergency departments have a federal mandate to care for all patients regardless of their ability to pay. Because of this, when plan reimbursements do not cover the cost of providing services, physicians must choose between billing patients for the difference or going unpaid for their services. The vast majority of emergency physicians and their groups prefer to be ‘in network.’”

According to the poll of 1,924 emergency physicians conducted in April 2016:

• Nearly two-thirds (61 percent) said most health insurance companies provide less-than-adequate coverage for emergency care visits to their beneficiaries.
• More than 60 percent of emergency physicians have had difficulty in the past year finding in-network specialists to care for patients, with a quarter of them saying it happens daily.
• 91 percent of emergency physicians said a new rule by the Centers for Medicare & Medicaid Services (CMS) exempting health insurance companies from meeting minimum standards—to ensure adequate networks—would make finding specialists and follow-up care for patients more difficult.
• Of the 934 emergency physicians who were knowledgeable about reimbursement issues, more than 78 percent said that insurance companies have reduced the amount they reimburse for emergency care.
• 79 percent of the emergency physicians who were familiar with the FAIR Health database said it is the best mechanism available to ensure transparency and to make sure insurance companies don’t miscalculate payments.

Dr. Kaplan said health insurance companies have a long history of not paying for emergency care and of actively discouraging their customers from seeking it. For example, UnitedHealthcare was sued successfully by New York state for fraudulently calculating and significantly underpaying doctors for out-of-network medical services. They used the Ingenix database, which forced patients to overpay up to 30 percent for out-of-network physicians. The company—which at the time was led by the current acting head of CMS, Andy Slavitt—paid the largest settlement to New York state and the American Medical Association. Part of that settlement created the FAIR Health database.

“Just because you have health insurance doesn’t mean you have access to medical care,” said Dr. Kaplan. “State and federal policy makers need to ensure that health insurance plans provide adequate rosters of physicians and fair payment for emergency services. We encourage all patients to investigate what their health insurance policy covers and demand fair and reasonable coverage for emergency care.”