Groups Work to Tackle Surprise Billing Qualms in The Emergency Department

Emergency physician groups outline solutions to improve the surprise billing law in a recently published letter.

The American College of Emergency Physicians (ACEP) and the Emergency Department Practice Management Association (EDPMA) recently outlined solutions to address the significant challenges facing emergency physicians who try to use the independent dispute resolution (IDR) process.

In the letter sent to the U.S. Departments of Health and Human Services, Labor, and Treasury, the groups outline the various ways these burdens related to the No Surprises Act can be alleviated moving forward.

For background, the administrative burden related to the No Surprises Act has been heavy for revenue cycle staff.

As outlined in the letter, with respect to scheduled healthcare, administrative staff not only verify first-level insurance information, but they also drill down to the patient’s individual health plan type before the patient enters the exam room or treatment space.

As the ACEP and EDPMA emphasize in the letter, emergency room visits are a whole other ball game.

In this setting, revenue cycle staff must wait until after the episode of care has occurred, and then wade through individual policy benefits, relying on costly and time-consuming administrative back and-forth that may even involve the patient for more clarification, the letter says.

These special circumstances have led to an immediate need for policy adjustment, the groups say.

The groups’ 17-page letter summarizes the major issues that these providers are experiencing and provides detail about the recommendations discussed during a January meeting including the Departments, emergency physicians, insurers, and others.  

Stakeholders at the meeting agreed that the statute’s lack of clarity on how to open negotiations before resorting to an independent arbiter impacts engagement in the process.

Also, the lack of information sharing from payers is delaying the IDR process before it even begins and “makes it difficult for providers and eventually for certified IDR entities to determine whether a claim is eligible for the federal IDR process,” the letter states.

During the meeting, concerns were also expressed that the qualified payment amount (QPA) methodology finalized by the departments is leading to artificially low QPAs that do not reflect market rates for services, the letter says. Further, payers are miscalculating the QPA, which drives payments down even lower.

“This combination of the QPA methodology and the miscalculations has led to QPAs that ‘don’t even pass the laugh test’—those that are so low that they are even significantly below Medicare and Medicaid payment rates,” the groups say.

The letter even outlines the experience of one physician group that said it has not received payments in more than 90% of the cases in which the IDR entity ruled in its favor.