Insurance Companies Mislead Patients By Selling "Affordable" Policies That Cover Very Little - May 9, 2016

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Insurance Companies Mislead Patients By Selling "Affordable" Policies That Cover Very Little
8 In 10 ER Docs Say Patients Sacrifice Care Because of Out-Of-Pocket Costs, Poll Finds
May 9, 2016

WASHINGTON, May 9, 2016 /PRNewswire-USNewswire/ -- Nine in 10 emergency physicians responding to a new poll say that health insurance companies are misleading patients by offering "affordable" premiums for policies that actually cover very little. Nearly all (96 percent) said that emergency patients do not understand what their policies cover for emergency care. The poll has responses from 1,924 emergency physicians in all 50 states, the District of Columbia and Puerto Rico.

"Each day, emergency physicians are seeing patients who have significant co-pays, up to $400 or more, for emergency care," said Jay Kaplan, MD, FACEP, president of the American College of Emergency Physicians (ACEP). "It might as well be $4,000 for some people. Patients should not be punished financially for having emergencies or discouraged from seeking medical attention when they are sick or injured. No plan is affordable if it abandons you when you need it most."

According to the poll, 8 in 10 emergency physicians are seeing patients with health insurance who have sacrificed or delayed medical care because of high out-of-pocket costs, co-insurance or high deductibles. This is more than a 10-percent increase over 6 months ago when emergency physicians were asked the same question. 

In addition, Dr. Kaplan said that health insurance companies are creating narrow networks of medical providers to increase profits, making it more likely that patients will be out of network.  They have created a situation whereby patients are receiving additional bills from medical providers.

"Insurance companies must provide fair coverage for their beneficiaries and be transparent about how they calculate payments," said Dr. Kaplan. "They need to pay reasonable charges, rather than setting arbitrary rates that don't even cover the costs of care. Insurance companies are exploiting federal law [EMTALA] to reduce coverage for emergency care knowing emergency departments have a federal mandate to care for all patients, regardless of their ability to pay."

When plan reimbursements do not cover the cost of providing services, physicians must choose between billing patients for the difference or going unpaid for their services. The vast majority of emergency physicians and their groups prefer to be "in network."

According to the poll of 1,924 emergency physicians, conducted by ACEP in April 2016:

  • Nearly two-thirds (62 percent) say most health insurance companies provide less than adequate coverage for emergency care visits to their beneficiaries.
  • More than 60 percent of emergency physicians have had difficulty in the past year finding in-network specialists to care for patients with a quarter of them saying it happens daily.
  • 91 percent of emergency physicians say a new rule by the Centers for Medicare and Medicaid Services (CMS) exempting health insurance companies from meeting minimum standards — to ensure adequate networks —would make finding specialists and follow-up care for patients more difficult.
  • Of the 934 emergency physicians who were knowledgeable about reimbursement issues, more than 80 percent said that insurance companies have reduced the amount they reimburse for emergency care.
  • 79 percent of the emergency physicians who were familiar with the Fair Health database said it is the best mechanism available to ensure transparency and to make sure insurance companies don't miscalculate payments.

Health insurance companies have a long history of not paying for emergency care and of actively discouraging their customers from seeking it. For example, United Healthcare was sued successfully by the State of New York for fraudulently calculating and significantly underpaying doctors for out-of-network medical services. They used the Ingenix database which forced patients to overpay up to 30 percent for out-of-network doctors. The company — which at the time was led by the current acting head of CMS, Andy Slavitt — paid the largest settlement to the state of New York and the American Medical Association.  Part of that settlement created the Fair Health database.

"Just because you have health insurance doesn't mean you have coverage," said Dr. Kaplan. "State and federal policymakers need to ensure that health insurance plans provide adequate rosters of physicians and fair payment for emergency services. We encourage all patients to investigate what their health insurance policy covers and demand fair and reasonable coverage for emergency care."

This survey was conducted online in the United States by Marketing General Incorporated on behalf of the American College of Emergency Physicians between April 4-11, 2016, among 1,924 emergency physicians, providing a response rate of 7 percent and a margin of error of 2.2 percent.

ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. 

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Mike Baldyga

9 in 10 Emergency Physicians Say Health Insurance Companies Are Misleading Patients


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SOURCE American College of Emergency Physicians (ACEP)