Out-of-Network Payment in the Emergency Department and the End of the Payment Floor

POSTED IN: Advocacy, Featured Advocacy, Resources,

Emergency physicians had the rug pulled out from under them recently through federal regulations that all but removed the option of a payment floor for out-of-network services provided in the emergency department.

In a final rule issued jointly by the Centers for Medicare and Medicaid Services (CMS), the Department of Labor, and the Department of the Treasury to clarify the rules of Grandfathered Plans, Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, Dependent Coverage, Appeals, and Patient Protections Under the Affordable Care Act, no specific language was included to require a transparent minimum payment level for such services despite five years of negotiations between regulators and providers.

What was finalized is a guideline referred to as the “greatest of three,” which says out-of-network services provided in the emergency department should be reimbursed at the level of the greatest of the following: 1) the plan’s median in-network amount, 2) the amount the plan ordinarily pays for out-of-network services, and 3) the amount paid by Medicare. According to a recent Kaiser Health News article, physicians had wanted the payment standard for the first two “to be ‘usual and customary charges,’ adjusted for geographic variations, using a transparent, independent claims database such as that provided by the nonprofit group Fair Health.”


Read More