Uncertainty Over Health Plan Coverage Affects EDs
Patients are right to worry about out-of-pocket costs or whether their health plan will cover the visit. ED Management (EDM) spoke with Critical Care Medicine Associates President Rade Vukmir, MD, JD, FCCP, FACEP, FACHE, about what this means for EDs and about the current state of reimbursement for ED visits. (Editor’s Note: This transcript has been lightly edited for length and clarity.)
EDM: What are concerns with how health plans reimburse for ED visits? Are some insurers denying payment for these visits unfairly?
Vukmir: If you look at the federal governmental payors, they have a fairly explicit statement regarding an emergency. A lot of their language, through CMS, really has to do with life- and limb-threatening emergencies. Public information sites, such as HealthCare.gov, define an emergency medical condition as that which a reasonable person would seek immediate care to avoid harm.1
EMTALA uses language that is a lot broader. The EMTALA language has historically spoken about the obligation to care for any patient with serious impairment to bodily function or serious dysfunction of any bodily organ. Various federal government resources offer wide-ranging definitions of what constitutes an emergency condition that requires ED evaluation and care. There is often a little bit of a quandary for patients to understand what care resources to use for what conditions. But in terms of how health plans are reimbursing for ED visits, it has been relatively quiet now for years. With the Affordable Care Act, the “prudent layperson” standard was sort of codified. Previous to that, there was case law that described a prudent layperson standard. The other legal premise is the “reasonable person” scenario: What would a reasonable person think if someone came to an ED with abdominal pain and fever? Maybe it did not turn out to be appendicitis; in the ED, we don’t get the benefit of hindsight.
So what upset the apple cart? First, a couple of private insurers presented plans to not pay for visits where it turns out retrospectively not to be an emergency.2,3 (Editor’s Note: One of the insurers clarified there will be no imminent changes to its coverage criteria for emergency services.4)
From the ED perspective, we basically take care of everybody. I cannot remember a time where someone has said, “That isn’t an emergency, so you have to go somewhere else.” That just doesn’t happen in EDs. As we all recognize, during peak COVID-related emergency time periods, systematic triage, medical screening, and redirection may be necessary and appropriate. There is the perception that some populations tend to use the ED more frequently, including for primary care issues. They tend to be people who are more disadvantaged, with less access to primary care. But we are America’s safety net. We don’t ever suggest to the patient that somehow we wouldn’t care for them.
EDs provide a lot of care that is poorly reimbursed, with the gap between care expenditures and insurer prospective payment systems. Factoring in the programmed governmental payer rate and uninsured care component provided, these reimbursement rates are at a low point. COVID hit, and made everything exponentially worse in regards to resource availability, healthcare provider staffing, and nursing staffing.
At the end of the day, there are hospitals and provider groups that are struggling financially, often in rural or inner city areas. Due in part to issues with extraordinary resource needs, health plans are cutting reimbursement rates and attempting to deny payment for ED visits based on retrospective care outcome. Those are the people who need that care resource most.
EDM: How will the No Surprises Act will affect reimbursement for ED visits?
Vukmir: Until now, there was precarious balance of contractual patient network care obligations, balance billing prohibitions, and in/out of network payment mandates. The No Surprises Act provides statutory protection from large, unexpected bills, typically for out-of-network emergency care. Although well-intended, this then puts the burden of substantiating care with the providers to resolve with the insurers. The unintended consequence is that providers may not be adequately reimbursed to cover care costs. Instead of patients complaining to the hospital about the bill or to the insurer about the coverage, the burden is now shifted to the providers and insurers to resolve reimbursement discrepancies. Failure to amicably resolve [the problem] forces affected parties — providers, facilities, and insurers — to enter a dispute resolution and arbitration process.
[Emergency department billing practices] were largely settled. Now, it’s disrupted again. Patients and providers don’t know what to do. Ultimately, it has complicated things. To add this burden at this point in time, when the systems are COVID-stressed to their breaking point, it’s just not proper.
The act sounds good on paper. But is the law or its consequences funded? This is where EMTALA got into trouble. EMTALA literally changed everything in emergency medicine, and it was an unfunded mandate. We are likely at the same point again. If as a society we say, “We will use the ED to take care of everybody,” then you need to provide funding for that. If we say, “We only have the ED for emergencies,” that’s an approach as well. But we have to have care resources for the patients somewhere else. In the ED, we are still taking care of patients the way we have always done for anyone who comes in the door, whether it’s a simple complaint or a complicated complaint. We show up every day and work as hard as we can. But it’s gotten harder. The waits are now extraordinary. The systems are breaking.
EDM: What if patients are concerned about the cost of the visit? How should providers respond?
Vukmir: EDs try to be good stewards of the resources, to do things smarter, better, and more financially sound, for everybody. If the patient says, “I don’t know if this is covered,” we tell them, “Your health is the important thing now.” But, importantly, we don’t minimize the patient’s concerns about cost, because there are real financial repercussions.
As always, we first provide definitive screening, treatment, and stabilization. We then try to use registration, financial [assistance], or case management resources to try to assist. They may visit with the patient to help them navigate the insurance part and give guidance ... to help you navigate a complicated insurance process.
We also might have discussions about whether to do a test. A patient might actually request a different treatment pathway, or want to avoid the admission if possible. We will choose the safest course. But there is sometimes an alternative treatment plan, if that’s what the patient prefers. I usually ask the patient what they would like to do. What is your opinion about this testing strategy? Were you planning on going home?
Patients do bear some responsibility to know about their insurance — coverage, network status, and potential payment responsibilities. But if we can assist them somehow in navigating the system, whether through financial navigators, case management, or registration, and help the patient during a time of stress, we are happy to do so. This team approach is all part of the care process.
REFERENCES
- HealthCare.gov. Emergency medical condition.
- Chou SC, Gondi S, Baker O, et al. Analysis of a commercial insurance policy to deny coverage for emergency department visits with nonemergent diagnoses. JAMA Netw Open 2018;1:e183731.
- Abelson R. Outcry forces UnitedHealthcare to delay plan to deny coverage for some ER visits. The New York Times. June 10, 2021.
- American Hospital Association Special Bulletin. UnitedHealthcare clarifies no immediate changes to coverage criteria for emergency-level care. Dec. 31, 2021.
Patients are right to worry about out-of-pocket costs or whether their health plan will cover the visit. An expert explains more about what this means for EDs and about the current state of reimbursement for ED visits.
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