Looking In from the Outside

Looking In from the Outside


POSTED IN: Fall 2016,

Daniel Theodoro, MD, MSCI

I’m documenting my experiences from external voyeur to committee member at the local ACEP level and today was my first in person conference call. Remember your first day as an intern in a new hospital with new practice standards and documentation systems? Well that’s a little bit of how it felt! Okay, maybe that’s a bit over exaggerated.

I’m older now and I’ve participated as a board member in large organizations. I know you start off as a committee member then, if you just show up and participate, you can move to board member—the proverbial “seat at the table” often sought by emergency physicians on hospital and healthcare issues. I couldn’t go in person to Jefferson City so I had to settle for the conference call.

What struck me about the call was the breadth of subjects that MOCEP covers! There were a lot of operational issues: finances, budgeting for residents and medical students to encourage their participation (a lot of time was spent on this so, residents and medical students, look out for great opportunities!) and committee reports. There’s a lot of time spent on legislative matters as bills, proposed by people with good intentions, wind their way through the halls of state legislature with feedback from constituents such as MOCEP. Sometimes it’s positive feedback but many times it’s not! In this context MOCEP serves as our local state advocate.

Local advocates frequently influence bills that touch upon daily emergency physician practice. A national issue playing out on the state level is “balanced billing” legislation. Insurers negotiate with “networks” of providers and accrue savings by obtaining discounted charges in exchange for referring patients for services. Balanced billing occurs when patients visit providers (physicians, nurse practitioners, etc.) who are not in their insurers networks—the so called “out of network provider.” Out of the network providers have no payment agreements, and may not accept the insurers terms and directly bill the patient for the “balance.” The balance on the “surprise bill” (another term referring to this practice) may be, well…surprisingly large. A 2011 New York Department of Financial services study found the average out-of-network emergency bill was $7,006 although a survey that same year found that only 8% of privately insured individuals used out-of-network care. Insurer networks are narrowing though so the practice may become more widespread.

EMTALA regulations make the environment even more hostile. Since emergency physicians are bound to care (or stabilize—is there ever a difference?) for emergency department patients by law, some insurers respond by negotiating paltry in-network fees. Not only do these insurers receive discounts for in-network emergency services, they pass the costs of out of network emergency care straight to the patient. While some states allow physicians to appeal payments for the balance to an independent arbiter, insurers know that such procedures cost time and money—barriers that dissuade physicians from chasing down payments.

To make matters more confusing is that in emergencies our unconscious patients don’t awaken to tell the medic what ambulance network they belong to and to please divert to a participating hospital. If that’s not confusing enough some hospitals are “in-network” but the doctors working at those hospitals are “out-of-network!” For example the emergency physician has negotiated charges but the radiologist interpreting the studies the emergency physician has ordered is out-of-network. This results in a patchwork of bills heaped on to charges the patient is already responsible for.

Several states outlaw balance billing to protect consumers. In others there is a ceiling to what can be charged frequently determined by a proportion of “usual and customary” charges for “in-network” services. However, the usual and customary charges are frequently in dispute between insurers and providers. In the state of New York, the local ACEP chapter (NYACEP) worked a bill through their legislature that finally offered some clarity. This bill defined usual and customary cost as the 80th percentile of charges for health services performed by a provider in the same specialty and geographic area. It also exempted bills for emergency services that are under $600 from the requirement to accept an insurer’s fee. Provisions in the law allow that amount to increase and if providers wish to further dispute with insurers there’s an independent body that will mediate the process. The impact of the bill on patients, physicians, and insurers remains to be seen. In the future, watch for similar bills to pass through Missouri. For now emergency physicians should remain content that MOCEP will have a “seat at the table” for these negotiations.

Up next: MOCEP Reception at National ACEP on October 17th, next issue to focus on MACRA, MIPS and CHIP!