As the voice of Virginia’s emergency physicians, we take a stand on the issues that matter to not only our members, but by extension, the patients to whom we provide care every day. Here, learn more about the issues we are monitoring on a state, national, and global basis.

Balance billing

Balance billing

Balance billing occurs when a health insurance company does not fully reimburse for healthcare costs. This phenomenon might better be referred to as the surprise insurance gap.

How does this affect the patient?

Patients are led to believe that their health insurance company will cover the cost of all – or the majority of – medical expenses. This is not the case in modern America.

Insurance companies are charging higher premiums and providing less coverage than in the past, and patients are often stuck with higher out-of-pocket costs with higher deductibles and co-insurance.

To enroll more people, insurance companies offer plans with “affordable” premiums that often leave the patient with very little coverage for emergency medical costs. This shifts cost to the patient and medical providers, and enriches the insurance companies.

  • Fifty five percent of voters reported paying more for insurance coverage than they have in the past. (Morning Consult, 2016)
  • Twice as many Americans said that their insurance coverage has gotten worse (30 percent) in the past year, compared to those who said that it had gotten better (15 percent). (Morning Consult, 2016)

The Emergency Medicine Treatment and Labor Act (EMTALA) mandates that any patient who presents to an emergency department must be stabilized and treated regardless of insurance coverage or the ability to pay. Knowing this, insurance companies are refusing to negotiate fair payments for emergency care with hospitals and emergency physicians, making these services out of network (OON). After the fact, the insurance provider decides how much to pay the hospital or emergency provider, leaving the patient to cover the remainder of the cost. This results in a surprise bill to the patient for the uncovered emergency care.

Often times, insurance companies refuse to cover out of network (OON) medical care. In recent years, insurance companies have created smaller and smaller networks in order to save money. However, patients cannot choose when and where they will need emergency care, and should not be financially punished for this with a surprise bill. As a result, many people do not promptly seek emergency medical care, and often become more sick, out of fear that an emergency department visit will not be covered.

  • One in four (24 percent) Americans said that they have lost access to primary care and specialist doctors because of shrinking networks created by their insurance company. (Morning Consult, 2016)
  • In one poll, 80% of emergency physicians said that they treated patients who could not find a medical specialist to care for them because their health plan limited the number of medical providers available to them. (ACEP Poll, 2015)
  • Nearly one in four Americans said that their medical condition got worse because they did not seek immediate emergency medical care out of fear that their health insurance company would not cover the cost. (Morning Consult, 2016)

How does this affect patients and emergency medicine providers?

Emergency departments across the country are feeling the harmful effects of the balance billing practice. The financial costs to keep emergency departments open and fully staffed 24 /7/365 are astronomical. As insurance companies provide less and less coverage, patients are often times unable to pay their medical bills. When this occurs, the hospital or emergency department loses money, but is still responsible for covering the cost of running an expensive emergency department. For this reason, emergency departments around the country are shutting their doors and closing permanently, leaving patients without access to emergency medical care.

What are emergency physicians doing to combat this issue?

Emergency physicians in Virginia are partnering with Physicians for Fair Coverage (PFC), a national, nonprofit alliance of physicians and advocates for fair insurance coverage for patients. Together we are working towards a solution for the surprise insurance gap, otherwise known as balance billing.

Emergency physicians in Virginia  believe that patients should have access to emergency care wherever and whenever they need it. We are advocating for in increased transparency in medical billing practices, and we support FAIR Health and its mission. FAIR Health is a national, nonprofit organization that has created a database consisting of billions of insurance claims, with the purpose of providing patients with average costs for specific medical treatments. By utilizing the FAIR Health database to set fair payments for emergency care, emergency departments will be able to keep their doors open and provide their communities with timely emergency medical care. This will also end the surprise insurance gap, protecting patients from “balance bills” and ensure that insurance covers the medical care that patients need, when and where they need it.