Since 1970, advocates for the Emergency Medicine specialty.
reimbursement
The topic of reimbursement is not, as some critics incorrectly claim, about increasing doctor salaries. It is about the payments insurance companies and the government (Medicare/Medicaid) are contractually obligated to pay emergency departments for the services provided. Emergency physicians want to ensure fair reimbursement, which is reinvested into emergency department equipment, staff, and training.
DOWNCODING
In 2020, Virginia’s budget began inappropriately and automatically cutting Medicaid reimbursements for emergency department visits that are on a list of 800 emergency conditions for Medicaid patients — many of them common and acute diagnoses. The policy was officially rescinded in June 2023 after significant advocacy from VACEP.
This list of diagnoses was intended to help managed-care organizations identify patients that are visiting the ED so frequently that they need additional assistance getting connected to other providers, like primary care and behavioral health. Instead, the list was used to penalize emergency departments while doing nothing to aid patients with high ED utilization. Read more about the Downcoding Provision.
Out-of-network billing
Virginia’s balance billing law (effective January 2021) protects patients from getting billed by an out-of-network health care provider for emergency services at a hospital. If a patient who has health insurance is treated by an out-of-network provider or facility for their healthcare needs, the provider or facility will submit the claim to the patient’s insurer.
But what happens with the provider or facility doesn’t have an agreement with the insurance company? The law requires insurers pay a “commercially reasonable amount” based on payments for the same or similar services in a similar geographic area. If the provider or facility and insurer do not agree to what is a commercially reasonable amount, then an arbitration process is available to resolve disputes.
VACEP is working with the state and insurers to improve the arbitration process and improve the shared database of commercially reasonable amounts for services.