Tuesday, November 25, 2014

Health Plans Must Provide a Robust Network of ER Doctors

By Diana Fite, MD, FACEP 
Houston emergency physician

I have seen several articles about patients getting large bills for out-of-network emergency physician services the patients received at a hospital in their insurance network. This is a huge issue for emergency medicine physicians as well. Why is your insurance company not paying or paying only a fraction of the costs of this highly trained and experienced emergency medicine physician who just saved your life?

Many insurance carriers offer a “take it or leave it” contract — with extremely low payment rates — to emergency physicians. Shouldn’t your insurance be required to pay the majority of cost for an emergency physician’s services? Wouldn’t you expect your insurance to cover the majority of the repair bill if your car was in an accident?

Emergency physicians work nights, weekends, and holidays to be ready to save your life, or your child’s life, at a moment’s notice. We are highly trained and qualified specialists who work in extremely stressful, sometimes dangerous situations.  When you get wheeled into the emergency room, we are focused on your condition, not your insurance, which is how it should be. Therefore, we provide a lot of charity care or unreimbursed care. The federal government has estimated that 55 percent of emergency physicians’ care is uncompensated.

Health plans know they can pay less by not including physicians in their networks so patients must go out of network, thus costing the patient more. According to a 2013 survey by Mercer of employer-sponsored health plans, many offer plans with limited networks of providers as a cost-saving method.

Whose costs? It is not the patient’s costs they are cutting.

As a patient, if you are given a choice of plans by your employer or through the Affordable Care Act marketplace, look at the networks. Often a lower insurance premium equals a narrower network, which translates into more out-of-pocket costs.

As a patient, you can complain to the Texas Department of Insurance as well as your insurance carrier about the carrier not having an adequate network of emergency physician specialists. Unfortunately, only you, the patient, can file a complaint. The physician or the physician’s billing company cannot file a complaint about not being included in the network.

As long as an insurance company can say it has an adequate network of physicians in any specialty, the physician has no negotiating power to ask to be treated fairly. This allows the insurance company to have narrower networks (i.e., fewer physicians) so they can pay less and leave you, the patient, to pay more. If you want qualified and experienced physicians to be ready to work on you in an emergency, tell your insurance company and the Texas Department of Insurance to make sure all health plans have a robust network of emergency physicians.

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