Contact Your Senators and Representatives: Surprise Billing

Dear AAEM Members,

Now that the recent congressional recess is over, this is the perfect time to contact your senators and representatives about the "surprise bill" issue. As Congress works to protect patients from surprise out-of-network bills for emergency medical care, it can either preserve America's medical safety net in the process or destroy it. Which way this goes depends on how well Members of Congress understand the realities of emergency medicine, and that is up to us. AAEM's paper on this issue can be found here, and my most recent communication with my own senators and representative is below, as an example (please don't just copy it).

You may craft one single email and send it to both your senators and your representative via the AMA's Physicians Grassroots Network portal, here. Please take action. Our patients are depending on us.

Andy Walker, MD, FAAEM
Chair, AAEM Government and National Affairs Committee

Sample Letter

Like all emergency physicians, I have spent my entire career taking care of the poor and uninsured, along with a host of other patients considered undesirable by some other specialists and many hospital administrators: criminals, addicts, alcoholics, sex workers, illegal immigrants, etc. And like all emergency physicians, I am proud to help provide America's medical safety net, taking care of all who need my services regardless of the patient's insurance status or ability to pay for care. In fact, since 1986 our nation's emergency departments (EDs) and the emergency physicians who staff them have been required by federal law (EMTALA, the Emergency Medical Treatment and Active Labor Act) to do that. But while Congress gave us the responsibility to take care of everyone who comes through the doors of the ED - or is dropped unconscious at the curb outside - it never gave us the funding to do that job. To this day EMTALA remains a completely unfunded mandate. And yet the insurance industry - and some in Congress - have the gall to accuse us of greed, when it is the federal government that wants something for nothing.

Emergency physicians - and, I suspect, hospitals - would be quite happy to give up all balance billing of patients for emergency care, truly taking patients out of the middle of the conflict between providers and insurers. What we will not suffer in silence is Congress protecting the insurance industry, among the richest and most powerful corporations in the country, at our expense. Based on the compensation of their CEOs, they are doing just fine as it is, and need no more help from the federal government.

Since insurers know we are obligated by federal law to take care of their clients, our patients, they have little incentive as it is to negotiate in good faith and offer us fair contracts to get us in-network. The only leverage we have is the threat of staying out-of-network and billing the insurer (not the patient) at the higher "usual and customary" rate. If out-of-network charges to the insurer (again, not the patient) are capped at the 50th percentile of the insurer's local in-network rate - as the Alexander/Murray bill and some others would do - insurers will have no reason at all to want us in-network. What's more, they will have a powerful new incentive to drive down in-network rates, since that would automatically reduce what they have to pay for out-of-network care.

Neither EDs (hospitals) nor emergency physician groups can survive on what Medicare pays, much less Medicaid. We depend on the small minority of our patients with commercial insurance (usually 20-25%) to stay afloat. In other words, it is the cross-subsidy from privately insured patients that funds America's medical safety net and allows us to carry out our charity mission. The Alexander/Murray bill (S.1895), and the other bills capping out-of-network charges to insurers, would allow the insurance industry to stop subsidizing our charity mission and destroy the nation's medical safety net. Many emergency physician groups would go out of business and even more hospitals - especially rural and small community hospitals - would close. Unless, of course, the federal government started funding the EMTALA-mandated care that it hasn't funded for the last 33 years - and I think we all know how likely that is.

Furthermore, nearly all emergency physician groups want very much to be in-network. That not only attracts more privately insured patients, it gets us paid more quickly and reliably, with less hassle, lowering our overhead costs. It also reduces complaints from patients and hospital administrators, making our staffing contracts with hospitals more secure. We only stay out-of-network as a last resort, when insurers demand such severely discounted rates to be in-network that we couldn't survive. I know of only one instance when an emergency medicine group decided to stay out-of-network as a routine business practice and aggressively pursue patients for out-of-pocket costs - and that was one of the nation's biggest corporate staffing companies, owned by stockholders, not a physician-owned group. (The many evils of investor-owned medical practices is a topic for another letter.)

If it is to exist at all, America's medical safety net must be funded. Right now private insurers provide that funding. If Congress relieves them of that by capping out-of-network fees, Congress must then either replace the lost funding or watch the safety net disappear as hospitals close and emergency physician groups go out of business. Let's protect individual patients by eliminating all balance billing for emergency care, and the general public by capping out-of-network charges to insurers at no lower than the 80th percentile of the local "usual and customary" rate as determined by an independent database that isn't owned and controlled by the insurance industry, such as FAIR Health.

More Resources

AAEM Takes Firm Stance to Defend “Prudent Layperson” Definition of Medical Emergencies

AAEM Position Statement on Balance Billing and Out of Network Charges



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