As Congress continues its efforts to advance legislation to protect patients from surprise medical bills, it is critical that important policy decisions are made based on accurate and reliable research. Unfortunately, media and some policymakers perpetuate flawed data and studies that drastically exaggerate the frequency and charges of balance billing by emergency physicians.
It may grab headlines, but ultimately hurts patients left to face the challenges of inadequate insurance coverage.
Media accounts of surprise medical bills often portray patients who received bills for thousands of dollars following emergency care. Yet what is often overlooked is that the emergency physician's charge comprises only a small portion of those costs.
Recent legislative proposals would only allow providers to access independent dispute resolution (IDR) when the median in-network amount for that service is over a certain dollar threshold ($750 in the latest HELP/Energy & Commerce proposal).
Such a high threshold would lock emergency physicians out from IDR over 99 percent of the time. Click here to see a zip code breakdown for each state of IDR-eligible emergency services.
While it's often cited that "1 in 3" or "1 in 4" emergency visits result in a surprise medical bill, the actual rate of care provided by emergency physicians who are out-of-network is estimated to range between 4 and 8 percent.
In other words, just 1 in 17 emergency visits could result in a surprise bill.
Many surprise bills result when patients discover the costly insurance premiums they paid each month gave little protection against the cost of care, due to high deductibles.
Deductibles have more than doubled in the last 10 years, and over 40 percent of those with insurance from their employer had deductibles over $2,000 in 2019.
At that amount, most will pay entirely out of their own pocket for a trip to the emergency department -- whether it was in- or out-of-network.
Yet 40 percent of Americans lack the savings to cover even a $400 emergency expense, according to the Federal Reserve Board. As a result, most emergency physician practices are at best only able to collect 40 cents on the dollar of patient cost-sharing owed by those with commercial insurance.
Yet even the commercially insured only make up 33 percent of emergency visits, nationally, leaving the remaining 67 percent without any coverage, or under-compensated by Medicaid or Medicare.
Medicaid patients make up the biggest portion of emergency patients: despite comprising just 4 percent of all US physicians, emergency physicians provide two-thirds of all acute care for the uninsured and half of it for Medicaid patients. Medicaid care is severely underfunded, with reimbursement rates often not even covering the overhead costs of providing care, much less the physician's time.
Medicare coverage also falls short -- adjusted for inflation in practice costs, physician reimbursement has actually declined 19 percent from 2001 to 2018.
Emergency physicians believe that all Americans deserve access to emergency care, regardless of their health care coverage status. Unlike most physicians, emergency physicians are prohibited by law from discussing with a patient any potential costs of care or insurance details until they are screened and stabilized. This is an important patient protection enacted under the Emergency Medical Treatment and Labor Act (EMTALA) that ensures care is focused on immediate medical needs. However, it also means that patients often do not fully understand the potential costs that could be involved in their care or the limitations of their insurance coverage until they get the bill.
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American College of Emergency Physicians