WASHINGTON, Nov. 16, 2016 /PRNewswire-USNewswire/ -- Many patients don't realize how little coverage they have until they need medical care and then are shocked at how little their insurance pays, according to the American College of Emergency Physicians (ACEP), taking issue with a paper published today in the New England Journal of Medicine.
The study uses claims data from a large insurance company, which are not identified and not available for examination, showing the lack of transparency by the health insurance industry.
"The data do not make sense, and in some cases, border on preposterous," said Dr. Rebecca Parker, president of ACEP. "For example, the article refers to a $19,000 charge, which is likely a facility charge or some other specialist charge. It also mentions an 'average' physician charge of 798 percent of Medicare rates, which is absurd, in part because physician charges are consistently the smallest part of emergency care bills. The study does not discuss that insurance companies are misleading patients by selling so-called "affordable" policies that cover very little until large deductibles are met — then blaming physicians for charges."
Dr. Parker said ACEP has reviewed large numbers of insurance company "Explanation of Benefits" data for meetings with the federal government and found that insurance companies have significantly reduced payments for emergency care. She also said a report from Florida found the average emergency physician bill to be $679. In addition, it found that balance billing results when insurers refuse to contract for adequate payment for emergency physician providers, which occurred for only about 12 percent of insured Floridians.
"Most emergency physicians prefer to be 'in-network,' as long as insurance companies pay fairly," said Dr. Parker. "ACEP is calling on the insurance industry to be transparent and to use an independent database, such as Fair Health [FairHealth.org], to calculate payments. State and federal policymakers need to ensure that health insurance plans provide fair payment for emergency services and provide adequate rosters of physicians."
The Fair Health claims database was developed after United Healthcare was successfully sued by the State of New York for fraudulently calculating and significantly underpaying doctors for out-of-network medical services, using the Ingenix database.
"The formula that Ingenix used forced patients to overpay up to 30 percent for out-of-network doctors," said Dr. Parker. "The insurance company paid the largest settlement to the state of New York and the American Medical Association. Part of that settlement created the Fair Health database, which is an independent, unbiased source of health care cost information."
Dr. Parker said she was surprised this study was accepted by the journal, given the lack of transparency in insurance company data. "Insurance company data are often found to be inaccurate, including charges that are mis-classified, when held up to close scrutiny," said Dr. Parker.
Dr. Tim Seay, chairman of the Board of the Emergency Department Practice Management Association, one of the largest professional physician trade associations, said "Emergency medicine is the safety net for health care in the United States. The New England Journal opinion piece is not only based on a data set that is severely skewed by one high bill, it ignores the fact that emergency physicians provide care without regard to the ability to pay. The problem is inadequate insurance coverage and high deductibles."
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.