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Fair Coverage Fact Sheet

www.FairCoverage.org

Many people don’t realize how little insurance coverage they have until they need emergency care — and then they are shocked at how little their insurance companies pay. Health insurance companies are misleading patients by selling so-called “affordable” policies that cover very little (until large deductibles are met) — then blaming medical providers for charges. 

Patients are experiencing consequences because they are delaying emergency care. 

  • Nearly one in four Americans (registered voters) reported their medical conditions got worse — because they didn’t go to the emergency department out of fear their health insurance companies wouldn’t cover the costs (Morning Consult 2016).[i] 
  • One in four (24 percent) Americans said they’ve lost access to doctors in the past year because the doctors were no longer in their insurance companies’ networks (Morning Consult 2016).

Patients can’t choose where and when they will need emergency care and should not be punished financially for having emergencies.

  • More than half (55 percent) reported paying more for insurance coverage; 20 percent say they are paying “much more” (Morning Consult 2016).
  • Twice as many Americans said their health insurance coverage has gotten worse (30 percent) in the past year, compared with those who said it has gotten better (15 percent) (Morning Consult 2016).

This is a scary environment for patients. No insurance policy is affordable if it abandons you in an emergency.

  • Emergency care is part of the essential benefits package in the Affordable Care Act, but high-deductible plans are leaving patients with too little insurance.
  • The number of people enrolled in low-premium, high-deductible health plans has increased by 40 percent in the last six years, according to the CDC.

Patients should not be forced to diagnose themselves. It’s dangerous.

  • Most patients lack the training to determine, for example, the difference between abdominal pain that is life-threatening and abdominal pain that isn’t.
  • Nearly one in five Americans (19 percent) said they contacted or went to urgent care centers or doctors’ offices but were sent directly to an emergency department because they needed higher levels of care than those facilities could provide (Morning Consult 2016).
  • Emergency physicians are calling for transparency by insurance companies and use of independent databases, such as Fair Health (www.fairhealth.org).
  • Payments for emergency visits must be based on a reasonable portion of charges (usual and customary), rather than arbitrary rates that don’t even cover the costs of care.

State and federal policymakers need to ensure that health insurance plans provide adequate rosters of physicians and fair payment for emergency services.

  • The Fair Health claims database (www.fairhealth.org) was developed after United Healthcare was successfully sued by the State of New York for fraudulently calculating and significantly underpaying doctors for out-of-network medical services (using Ingenix database).  The formula they used forced patients to overpay up to 30 percent for out-of-network doctors.  The company paid the largest settlement to the state of New York and the American Medical Association.  Part of the settlement created the Fair Health database, which is an independent, unbiased source of health care cost information.

Health insurance companies have a long history of devaluing and discrediting emergency patients.

  • Health insurance companies for years denied claims based on final diagnoses instead of symptoms. In other words, if chest pain brought you to the emergency department, but turned out to be indigestion, the insurance company wouldn’t pay. Emergency physicians successfully fought back against these policies.
  • Insurance companies now are exploiting a federal law [EMTALA] mandating that hospital emergency departments see all patients, regardless of their ability to pay.
  • Insurance companies are shifting costs onto patients and medical providers to enrich themselves.

Everyone needs to find out what their health insurance policy covers and demand fair and reasonable coverage for emergency care.

  • State and federal policymakers need to ensure that health plans provide fair payment for emergency services or emergency patients will suffer.  
  • States that seek to ban balance billing without ensuring fair coverage of emergency care will create huge benefits for health insurance companies while endangering patients and the medical safety net.
  • Patients and physicians must work together to combat these harmful practices by health insurance companies. (Contact your state legislators.)

[i] Morning Consult conducted a survey of 2,016 registered voters on September 8-10, 2016, on behalf of the American College of Emergency Physicians, using 2016 scientifically selected registered voters. There is a margin of error of ± 2 percent.


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