Q: Why is there such a focus on surprise billing in the emergency room context? Are all physician groups impacted equally? | Physicians For Fair Coverage

A: The surprise insurance gap, which gives rise to surprise bills, can impact any physician in any practice. However, the problem tends to be more acute in the emergency room context because of prevailing federal rules and regulations. Specifically, hospital emergency departments operate under the Emergency Medical Treatment and Active Labor Act (EMTALA). The law requires hospitals to care for all patients in emergency care situations, regardless of his or her ability to pay. Insurance companies have the ability to decide which individuals to cover, as well as which physicians to bring into their network. As more insurance companies consolidate and narrow their network coverage of medical providers, they increase the likelihood patients may find themselves in out-of-network situations.

Compounding the problem, insurance company rules in the emergency department are so opaque even the savviest of patients have trouble navigating their rules. Many patients do the necessary research to ensure they have identified a hospital in their insurance network to go to in case of an emergency. But the insurance companies give patients no way to understand when doctors get forced out of the network. Imagine you go to an in-network hospital and find out the insurance company has forced your Emergency Department physician or anesthesiologist out of network? It’s not transparent and patients suffer. 

Further exacerbating the problem, insurers across the country have begun to institute policies that will limit coverage for emergency room services the insurer deems are unnecessary for members with individual plans (see Blue Cross in Georgia to Limit Emergency Room Coverage and In Indiana, Anthem Takes Harder Line on ER Visits). Such decisions will be made retroactively and will only exacerbate the problem with surprise bills if not discourage patients from seeking care altogether. 

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