Health insurance companies must stop denying and delaying appropriate payment for emergency room services that are mandated by federal law. Such tactics pose serious financial burdens on hospitals and threaten patients' access to emergency care.
Letter to Health Insurers
'Stop Denials, Delays in Paying for Emergency Care'
By Leslie Champlin
10/20/2005
With that message, AAFP and 63 other national and state medical organizations signed onto a Sept. 29 letter (PDF file: 4 pages / 27 KB. More about PDFs.) calling on America's health insurers to comply with both the letter and the spirit of the Emergency Medical Treatment and Labor Act. Congress passed the law as part of the Consolidated Omnibus Budget Reconciliation Act of 1986 to ensure that patients had access to emergency services, regardless of their ability to pay for those services.
EMTALA requires that hospital emergency departments and the physicians who staff them provide certain types of emergency care, including screening and stabilization, to all patients. Since the act's implementation, however, health insurance companies and health maintenance organizations have retroactively denied payment for services the companies deemed nonemergent.
Noting hospitals and physicians are diligent in meeting the law's requirements, the letter says health plans and other third-party payers "misinterpret" terms in state laws that require payment for EMTALA-mandated services. For example, insurers define terms such as emergency medical condition, screening and stabilization "in ways that allow health plans to unilaterally decide which services will get paid." As a result, some health plans may pay physicians for mandated screenings but not for more costly stabilization treatments.
Moreover, many health plans initially deny payment for appropriately coded and billed emergency services until the physician or patient appeals.
"The added expense of appealing inappropriate denials of claims for emergency services further reduces the already often inadequate payment for EMTALA-mandated services," the letter says.
Equally disruptive is the practice among health plans of denying payment for services that a "prudent layperson" would consider an emergency.
The letter urges health insurers to "refrain from this practice and any other actions that add undue burden to the physician and patient in securing payment for care appropriately provided, accurately coded and correctly submitted on appropriate claim forms."
Such actions by health plans contribute to the demise of emergency rooms throughout the nation, according to the letter, which cited annual surveys reported by the California Medical Association.
"In a little more than a decade, more than 65 emergency rooms have closed," says the CMA report, A System in Continued Crisis (PDF file: 21 pages / 1.3 MB. More about PDFs.). According to the report, "Many HMOs reduce reimbursement, delegate the responsibility for payment to medical groups or refuse reimbursement completely because auditors have decided -- after the fact -- that the service provided was not an actual emergency."
The result is that recent data show hospital emergency rooms in California lost more than $460 million in fiscal year 2001-2002. Moreover, physicians' financial losses in those emergency departments reached more than $175 million.
Ending the denial and delay of claims would halt the financial insecurity of the nation's emergency room system, according to the letter from health care organizations.
"We must act now … if we are to reverse the significant problems reverberating throughout our health care system due to lack of adequate payments from private health insurers for EMTALA-mandated services."
The letter was sent to CIGNA Corp., Aetna Inc., America's Health Insurance Plans, BlueCross BlueShield Association, Health Care Service Corp., Health Net Inc., Humana Inc., UnitedHealth Group Inc. and WellPoint Inc.
EMTALA requires that hospital emergency departments and the physicians who staff them provide certain types of emergency care, including screening and stabilization, to all patients. Since the act's implementation, however, health insurance companies and health maintenance organizations have retroactively denied payment for services the companies deemed nonemergent.
Noting hospitals and physicians are diligent in meeting the law's requirements, the letter says health plans and other third-party payers "misinterpret" terms in state laws that require payment for EMTALA-mandated services. For example, insurers define terms such as emergency medical condition, screening and stabilization "in ways that allow health plans to unilaterally decide which services will get paid." As a result, some health plans may pay physicians for mandated screenings but not for more costly stabilization treatments.
Moreover, many health plans initially deny payment for appropriately coded and billed emergency services until the physician or patient appeals.
"The added expense of appealing inappropriate denials of claims for emergency services further reduces the already often inadequate payment for EMTALA-mandated services," the letter says.
Equally disruptive is the practice among health plans of denying payment for services that a "prudent layperson" would consider an emergency.
The letter urges health insurers to "refrain from this practice and any other actions that add undue burden to the physician and patient in securing payment for care appropriately provided, accurately coded and correctly submitted on appropriate claim forms."
Such actions by health plans contribute to the demise of emergency rooms throughout the nation, according to the letter, which cited annual surveys reported by the California Medical Association.
"In a little more than a decade, more than 65 emergency rooms have closed," says the CMA report, A System in Continued Crisis (PDF file: 21 pages / 1.3 MB. More about PDFs.). According to the report, "Many HMOs reduce reimbursement, delegate the responsibility for payment to medical groups or refuse reimbursement completely because auditors have decided -- after the fact -- that the service provided was not an actual emergency."
The result is that recent data show hospital emergency rooms in California lost more than $460 million in fiscal year 2001-2002. Moreover, physicians' financial losses in those emergency departments reached more than $175 million.
Ending the denial and delay of claims would halt the financial insecurity of the nation's emergency room system, according to the letter from health care organizations.
"We must act now … if we are to reverse the significant problems reverberating throughout our health care system due to lack of adequate payments from private health insurers for EMTALA-mandated services."
The letter was sent to CIGNA Corp., Aetna Inc., America's Health Insurance Plans, BlueCross BlueShield Association, Health Care Service Corp., Health Net Inc., Humana Inc., UnitedHealth Group Inc. and WellPoint Inc.
