Dive Brief:
- The American College of Emergency Physicians has filed suit against HHS over a provision in the Affordable Care Act health law they say lets insurers get away with underpayments for out-of-network emergency care, Modern Healthcare reported.
- ACEP's lawsuit argues insurers should be required to provide transparency on how they are calculating payments for out-of-network hospital care.
- The group is highly invested in the issue given emergency physicians regularly treat out-of-network patients due their obligations under the Emergency Medical Treatment and Labor Act that requires ERs to care for patients regardless of ability to pay.
Dive Insight:
ACEP has asked federal health law be changed from the current arrangement in which insurers must pay the highest of three possible costs--their own in-network amount, Medicare's amount or the "usual, customary and reasonable amount," (UCR) which often tends to be the highest.
Some stakeholders have argued insurers can easily manipulate UCR figures to reduce their own obligation and pass on a higher out-of-pocket price to the patient, Modern Healthcare reported, and some states leave no recourse, requiring ER phsyicians to take the payment even if it is significantly under the provider's regular fee.
To prevent that possibility, insurers should have to be transparent about their payments, ACEP argued.
"We should be able to say: How did you calculate this? And show us the data,” ACEP president Dr. Jay Kaplan told Modern Healthcare.