Contact Your Senators and Representatives: Surprise Billing

CALAAEM News Service at
Mon Sep 16 16:31:50 PDT 2019


Sept. 16, 2019


Contact Your Senators and Representatives: Surprise Billing


VO_uYr8Vkw> AAEM

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
of-network-charges> , 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


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
-definition-of-medical-emergencies> "Prudent Layperson" Definition of
Medical Emergencies

AAEM Position Statement on Balance Billing and Out of Network Charges





Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service


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