Large insurance companies have been raking in profits while denying or reducing payments to emergency physicians, including many practices struggling to keep their doors open.
- The stress of the last several years has pushed health care workers to the brink while resource constraints and staffing challenges threaten the viability of many medical practices.
- As of July 22, 2022 hospitals in nearly 40 states reported critical staffing shortages, while hospitals in all 50 states said they expected to experience a shortage within a week.
- Insurer efforts to avoid fair or timely reimbursement can prevent physicians from making critical investments in new equipment, staffing, and other improvements necessary to meet the medical needs of the community.
- Still, emergency physicians have committed to treating anyone, anytime—even while exhausted, understaffed, and managing continued, persistent shortages of critical medications.
- That’s a stark contrast to significant profits recently reported by many of the largest insurance companies.
- In the second quarter of this year, UnitedHealth Group reported $5 billion in profit and both Anthem and Cigna each reported more than $1 billion in profit.
Emergency departments rely on fair reimbursement from insurers to keep the doors open 24/7.
However, insurers continue to embrace tactics that threaten emergency physicians’ livelihood and put access to lifesaving care at risk.
“Downcoding” is when an insurer decides that the level of care billed does not match the level of service provided, so the physicians’ reimbursement decreases, often without sufficient justification.
There are also troubling instances of insurers denying physician claims outright.
- As a recent example, ACEP and its California chapter have alerted California members of Congress about rampant misbehavior from Anthem Blue Cross California: the insurer is refusing to reimburse physicians for millions of dollars in care provided.
- Anthem appears to be targeting small physician practices that do not have the resources to fight back.
- It is common for health plans to review physician claims and determine whether they believe the claim should be adjusted. But it is unprecedented for a payer to stop payment to a physician group entirely because of a purported disagreement by the insurer over the code billed.
In some states, insurers use the No Surprises Act to game the system.
- In North Carolina, as soon as the Biden Administration announced its plans to implement the new surprise billing law, emergency physicians received a chilling letter from Blue Cross Blue Shield of North Carolina, threatening to end their agreement to be in-network unless the physicians accept a 20% cut in reimbursement for necessary medical care.
- Similarly, UnitedHealthcare attempted to bully physicians to accept a 40% cut or lose their contract.
- ACEP alerted legislatorsabout these strongarm tactics because insurance companies will continue unless they are stopped.
There are protections in state and federal law because insurers have a known history of this type of misbehavior.
- While physicians are required to provide care, insurance companies regularly violate the rules that require them to pay for it.
Without immediate action to strengthen the enforcement of existing laws meant to hold insurance companies accountable, we will see additional strain on emergency physicians that will hinder care delivery and could restrict patients’ options for care when they need it most.
[For California members:]
- Emergency physicians urge the California congressional delegation to request Anthem end its policy of rejecting Level 5 claims that have been correctly coded and billed by emergency physicians.
- Without immediate action, the continued non-payment of claims could result in emergency physician groups going out of business, destabilizing the health care safety net, and severely limiting access to the lifesaving emergency care that Californians need and deserve.
