The Newnan Times-Herald


End the surprise insurance gap

  • By The Newnan Times-Herald
  • |
  • Feb. 03, 2017 - 7:52 AM

As someone who has practiced emergency medicine in metro Atlanta for almost 20 years, I am proud of the role my fellow physicians and I play in saving lives.

That’s why it’s so galling to see insurance companies taking advantage of a federal law that guarantees patients receive emergency care regardless of their ability to pay.

Insurance plans are creating extremely narrow physician networks – especially in emergency care – and hiding behind the Emergency Medical Treatment and Labor Act (EMTALA), which was established in 1986 to ensure patients are not turned away at the emergency department. Insurers are using EMTALA to force physicians to accept a take-it-or-leave-it reimbursement deal that can put them out of business or leave them practicing out of network. Unfortunately, the end result is a major cost shift from insurers to patients and physicians.

In some cases, patients – most of whom are simply unaware of the gaps in their insurance coverage – are surprised to learn that much of their emergency care is not covered by their health insurance plan. This may be because the physicians treating them were dropped from their network or were never actually in-network. Do you know that even if you go to the emergency room at an in-network hospital, the physician treating you may be out-of-network? Insurance plans have created a surprise insurance gap, leaving patients and their physicians to deal with the surprise bill while insurance companies wriggle out of coverage they should be providing, and yet reaping record profits year after year.  

Recognizing that this surprise insurance coverage gap is creating financial hardships for them and eroding the patient-physician relationship, physicians across Georgia have recently come together to do something about it.

Last week, the Georgia College of Emergency Medicine and the Medical Association of Georgia together with the Epilepsy Foundation of Georgia – patients and physicians – rallied in the Capitol rotunda to urge state lawmakers to end surprise billing.

Our mission is straightforward: to take the patient out of the middle.

Specifically, we’re urging the General Assembly to adopt the following guidelines in any legislation that bans surprise billing for emergency department services:

  • First, patients should be held financially harmless for unexpected out-of-network care.

  • Second, any patient deductibles and cost sharing for unexpected out-of-network care should be applied to in-network rates.

  • Third, an appropriate and fair payment standard should be created for unexpected out-of-network services that establishes a charge-based reimbursement schedule (meaning the 80th percentile) connected to an independently recognized and verified database.

  • Insursers should make network provider directories easily accessible for both patients and physicians, updated immediately and completely accurate.

  • Patients should have access to information on the average charge, reimbursement rate, and expected out-of-pocket costs for any care or procedure;

  • And lastly, insurance carriers should be prevented from providing false, misleading and/or confusing information on coverage.

Patients deserve insurance coverage that doesn’t abandon them in an emergency, and physicians should be fairly compensated for the medical care they provide in good faith. It’s important our legislature end the surprise insurance coverage gap and stop health insurance companies from playing games with patient coverage.

(Dr. Matthew Keadey, an emergency physician, is the the president-elect for the Georgia College of Emergency Physicians and a member of the Medical Association of Georgia.)