PACEP NEWS SUMMER 2018
Executive Privilege “The Insurers are coming; the Insurers are coming!” What are they coming for? They are coming to pay you less, in order to maximize their bottom line. I know that this is not really news to us. It’s nothing new to have to fight for fair reimbursement for the federally-mandated EMTALA services we provide. However, insurance companies are feeling their bottom lines being pinched; and they are trying harder to avoid paying emergency providers. This is happening both locally and nationally. In states such as Georgia, Missouri, Ohio, Indiana, New Hampshire, and Kentucky, Anthem Blue Cross has implemented a well-publicized (and criticized) ED policy to deny payment for ED visits that could “safely [be] treated in less acute facilities”. This policy forces patients to triage their own medical complaints to avoid getting bills from the ED if, in Ankur A. Doshi, retrospect, their insurance company feels that an ED visit was not warranted. Our colleagues in these MD, FACEP states have begun receiving multiple denials of ED claims. This is despite nationally published data PACEP President that shows that only 3.3% of ED visits are avoidable. ACEP and state chapters in those states have been on the front line fighting for fair payment for our time and resources. Closer to home, PA Medicaid payors, such as Gateway Health Plan in Western PA, have attempted to limit patients’ use of the ED by paying providers only a ‘screening fee’ totaling $25 for visits they feel are non-emergent. PACEP was successful in having Gateway rescind this policy in 2016 when we provided data to the state Department of Insurance showing the inappropriate application of this policy. However, now, the state legislature is looking at legislation to restrict Medicaid beneficiaries from using their benefits for ‘non-emergent’ care, thereby raising the cost of care to some of our most vulnerable patients, contrary to the prudent layperson standard. PACEP has been engaged on this issue both politically and in the media. How can you help? On the Eastern side of the Commonwealth, Independence Blue Cross, and their NJ 1. Contact your legislators counterpart AmeriHealth, have implemented a policy to reduce payment by 50% to and ask them to back a fair providers who use modifier 25 in their claims. Modifier 25 is used in addition to an E&M payment standard for out-ofcode when a separate procedure is documented during the same encounter (suture network services in the ED. repair, incision and drainage, central access, etc). Although we have not heard of specific The fairest standard comes downcodes in PA so far, PACEP, along with PAMED and a coalition of PA and NJ providers, from an independent database have been engaged with the insurance companies to ask for an explanation and rescinding of charges (there is one!). of this policy. Insurers should pay us based on There’s more…As part of the pending PA House legislation on Balance Billing (see PACEP reasonable charges (75-80%) of NEWS July 2017 and October 2017), IBC has publicly proposed mandating all providers at the charges in a given region. an in-network facility to be in-network with the insurance plans. This, like the insurance 2. Host a legislator in your ED so companies’ other strategies, aims to limit providers’ ability to negotiate for a fair payment that person can see the work rate. Once ED physicians must be in-network with payors, those companies can limit their we do, and understand why fair payments as much as they want, without repercussion. In the same vein, the insurance payment is necessary companies would like to set a non-market-based standard for payment of out-of-network 3. Join our PACEP 911 Network care – presently 150% of Medicare. If an insurance company can set a maximum out-of(find it at: www.pacep.net) network rate of 150% of Medicare, they have little reason to negotiate for a more fair in4. Donate to PEP-PAC at www. network rate of payment. Our Chapter has been represented every hearing and stakeholder pacep.net so we can support meeting and our leadership is actively working to tell legislators that this is not good policy. those legislators who ‘get’ I don’t want to be a ‘Chicken Little’, sounding alarms unnecessarily, however now is the time Emergency Medicine and are to rally as a specialty to push back against “Insurers Behaving Badly”. willing to fight the insurance companies with us.