ACEP argued that a better approach would be for state regulators, legislators, insurers, and emergency medicine providers to develop fair payment methodologies and rates, while including assurances for all parties that there are reasonable ways to obtain a balanced review of disputed claims. In addition to being involved in FAIR Health, established in 2009 with the mission to help ensure fairness and transparency in out-of-network reimbursement, ACEP presented to NCOIL model legislation that outlines key elements that should be included in a fair payment system for emergency care.

Dr. R. Myles Riner, consultant to MedAmerica, helped author ACEP’s fair payment model legislation, which prohibits balance billing but contains critical safeguards to ensure that emergency care services are fairly reimbursed based on usual and customary charges for each geographic region.

Emergency physicians in California provide an average of $150,000 annually in charity care – 4 to 10 times as much as any other physician specialty, according to Dr. Riner.

“EMTALA demands free care for anyone who needs it and can’t pay, so it’s a particular burden for emergency physicians because 100% of our practice is EMTALA obligated,” Dr. Riner said. “We’re required to see every patient, and to meet that mission we need to be adequately paid when we treat insured patients in order to make up for underpayments by Medicaid, Medicare, and the uninsured. Once you’ve lost the right to balance bill, things become very difficult, and if you don’t have a fair payment standard, then you’re really behind the eight ball.”

With a reasonable fair payment standard in place, emergency physicians wouldn’t need to balance bill patients. “We don’t like balance billing – it’s not our objective,” Dr. Riner said. “It’s just what we’ve been forced to do in order to continue treating all our patients.”

“Adequate reimbursement is the lifeblood of our survival,” said Dr. Gerardi. “When we put on our white coats, my colleagues and I don’t worry for 1 second about CMS, health plans, or fair reimbursement. Why is it then that insurance companies can retrospectively and capriciously undervalue my emergency team’s role in the health care system by disallowing or underpaying our claims? When we’re done treating the patient, we still have to meet our mortgage. We’ve devoted our lives to this and we’ve got to be treated fairly.”

What You Can Do to Help

Despite ACEP’s efforts, insurers continue pushing for legislation to ban balance billing without requiring that insurers pay fairly for out-of-network emergency care. The 2011 state legislative sessions have brought forward bills to ban balance billing in Washington and Nevada, and more states will likely follow. “Emergency physicians across the country should keep a close eye on their state legislatures to protect their right to fair payment,” Dr. Gerardi said.