ACEP Sues Federal Government Over Health Insurer Billing Practices

In a bold, unprecedented move, ACEP has sued the federal government to contest a regulation that impedes emergency physicians from receiving usual and customary payment for out-of-network services.

At issue is a regulation from the Centers for Medicare & Medicaid Services (CMS) for out-of-network emergency physician payment, which outlines the “greatest of three” options.

As written, this rule opens the door for insurers to use black box methods to determine physician payment without providing any means to verify the data.

Since 2010, ACEP has had numerous meetings with federal officials, sent formal comments, and drafted guidance to voice the concerns of our 35,000 members that the “greatest of three” rule cannot be enforced and has the potential to be manipulated by insurers without a transparent database of usual and customary charges.

Receiving little to no concern for this issue from the CMS leadership, the ACEP Board of Directors decided at its April 2016 Board meeting to move forward with a lawsuit urging the courts to rescind this rule. The lawsuit was filed in federal court on May 12.

Health insurance companies need to be transparent about the data they are using to pay for services provided by out-of-network providers. They have a history of data manipulation and not paying for emergency care. They are shifting their responsibility to our patients, and that is just wrong.

The federal government has done an injustice to emergency patients and emergency physicians by giving carte blanche to insurance companies to pay whatever they want. Historically, we know that amounts to as little as possible.

Thank you,
Jay A. Kaplan, MD, FACEP
ACEP President

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ICEP - Illinois College of Emergency Physicians
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