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TrumpetDoc

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What a crock! I am at a loss right now. I hope ACEP plans on further action beyond a letter!
Guess it may pay to know if you live in a state that has banned balanced billing.


http://newsroom.acep.org/2015-1...

Health Plans Not Required To Pay Fairly for Emergency Care, Under New Regulation
Dec 1, 2015

WASHINGTON, Dec. 1, 2015 /PRNewswire-USNewswire/ -- The federal government last week issued a new regulation that allows health insurance companies to pay doctors in emergency departments essentially whatever they like, opening the door to the possibility of reimbursements that do not even cover the costs of care. The American College of Emergency Physicians (ACEP) expressed astonishment at the ruling, given the feedback emergency physicians have given to CMS over several years, as well as the timing. Dr. Jay Kaplan, president of ACEP, said that the organization was considering legal action.

"This new ruling will significantly benefit health insurance companies at the expense of physicians, because they know hospital emergency departments have a federal mandate to care for everyone, regardless of ability to pay," said Dr. Jay Kaplan. "They will continue to shift costs onto patients and medical providers, as well as shrink the number of doctors available in plans. Instead of requiring health plans to pay fairly, this ruling guarantees that insurance companies can pay whatever they want for emergency care. If history tells us anything it's that insurance companies prefer to pay as close to nothing as possible, while building their war chest for profits and litigation."

According to the ruling, even the minimum standards of payment are "not necessary" in states that have banned balance billing. Balance billing occurs when health plans pay unreasonably low reimbursements, and physicians are forced to bill patients for the unpaid "balances" (similar to how a dentist bills). Health insurance companies have taken gross advantage of patients and emergency medical providers since the ACA, arbitrarily slashing payments to physicians by as much as 70 percent.

"This is a scary environment for patients," said Dr. Kaplan. "Insurance companies are alleging that doctors are charging too much, rather than admitting they are paying too little. This ruling by CMS unfortunately suggests that the federal government is on the side of Big Insurance rather than patients and their physicians."

In a recent poll, seven in 10 emergency physicians responding to a poll reported seeing patients with health insurance who delayed medical care because of high out-of-pocket expenses, high deductibles or high co-insurance.

The new regulation was issued by the Department of the Treasury, the Department of Labor and the Department of Health and Human Services.

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I can't get that link to work, but I wonder if this is a consequence of actively encouraging people to use ERs for everything and then the hospitals and doctors taking advance of higher ER billing fees.

Free standing ERs are a perfect example of this. For many things they are no different than urgent cares, yet the charged fees are different. I'm not excusing the insurance companies because I think they are a large part of our current health care problem, but the hospitals and doctors have been taking advantage of this loophole for personal profit.

If people were paying directly for care, costs across the board would fall very quickly. Hospitals and ER groups are exploiting the system and because people aren't directly responsible for the costs, the insurance company is eating the higher cost. This is the same thing (although much less markup) as that ceo at Turing pharmaceuticals buying Daraprim and then raising the cost 5000%.

Hopefully this will mitigate the billboards with "ER wait time X minutes" and allowing people to make an appointment to the ER. If you want to advertise the ER like a glorified clinic, don't be surprised when insurance starts paying you like one.
 
I can't get that link to work, but I wonder if this is a consequence of actively encouraging people to use ERs for everything and then the hospitals and doctors taking advance of higher ER billing fees.

Free standing ERs are a perfect example of this. For many things they are no different than urgent cares, yet the charged fees are different. I'm not excusing the insurance companies because I think they are a large part of our current health care problem, but the hospitals and doctors have been taking advantage of this loophole for personal profit.

If people were paying directly for care, costs across the board would fall very quickly. Hospitals and ER groups are exploiting the system and because people aren't directly responsible for the costs, the insurance company is eating the higher cost. This is the same thing (although much less markup) as that ceo at Turing pharmaceuticals buying Daraprim and then raising the cost 5000%.

Hopefully this will mitigate the billboards with "ER wait time X minutes" and allowing people to make an appointment to the ER. If you want to advertise the ER like a glorified clinic, don't be surprised when insurance starts paying you like one.

I'm just going to have to completely disagree with you on this. The physicians are not taking advantage of the situation at all. We are the willing victim of an unfunded mandate. I am legally obligated to take care of every patient who walks through the door despite the fact that in many locations 1 out of 3 of them have no intention of paying. That number goes up when you include Medicaid which basically pays nothing in many states as well. The really fun kicker is that despite my charitable act of caring for them regardless of ability to pay, I can be sued by those same nonpaying patients. Picture this situation in any other situation and it's ludicrous. Umm, yes sir, I would like to walk into your restaurant and order your most expensive meal but I have no intention of paying for it. By the way, after stealing your food and services I may decide to bring a meritless lawsuit against you based on how I perceive the quality of said stolen goods to be.

I love my job and love EM but to say we as physicians in the ED are financially taking advantage of the situation is somewhere between incredibly ignorant and insane.
 
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If you don't have a contract with the insurance company, they were required to pay a reasonable rate. Now they're not. They could offer you $5- take it or leave it, and you have no recourse. It's only an issue because of EMTALA.
 
If you don't have a contract with the insurance company, they were required to pay a reasonable rate. Now they're not. They could offer you $5- take it or leave it, and you have no recourse. It's only an issue because of EMTALA.
Ah, so its an out of network issue. Does sound like a raw deal.
 
What does this mean for EM in regards to reimbursement? How can EDs be expected to function? How does something like this even pass?
 
What does this mean for EM in regards to reimbursement? How can EDs be expected to function? How does something like this even pass?

That's what I wonder. I will have to read the actual piece from CMS as I didn't catch that it was only for out of network pts.

I imagine that with this will come revisiting of all the contracts by the ins co and that is what I fear.
 
Well, your first option is to balance bill the patient. But that is already outlawed in some states and may become so in other states.

Yea...this just seems too much out of left field. Talked with our billing co and this was not on his radar. I imaging a lot of delayed AR, and likely a crap ton of appeals/no pays:/
 
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The devil in the details--
https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-29294.pdf2

Part I sounds OK for us, then you get to Part II...

Part I
"b. Out-of-network cost-sharing requirements 75 Cost-sharing requirements expressed as a copayment amount or coinsurance rate imposed for out-of-network emergency services cannot exceed the cost-sharing requirements that would be imposed if the services were provided in-network. The preamble to the interim final regulations explained that out-of-network providers may bill patients for the difference between the providers’ billed charges and the amount collected from the plan or issuer and the amount collected from the patient in the form of a copayment or coinsurance amount (referred to as balance billing84). Section 1302(c)(3)(B) of the Affordable Care Act excludes such balance billing amounts from the definition of cost sharing, and the requirement in section 2719A(b)(1)(C)(ii)(II) that cost sharing for out-of-network services be limited to that imposed in network only applies to cost sharing expressed as a copayment amount or coinsurance rate. Because the statute neither requires plans or issuers to cover balance billing amounts, nor prohibits balance billing, even where the protections in the statute apply, patients may still be subject to balance billing. In the preamble to the interim final regulations under PHS Act section 2719A, the Departments explained that it would defeat the purpose of the protections in the statute if a plan or issuer paid an unreasonably low amount to a provider, even while limiting the coinsurance or copayment associated with that amount to in-network amounts.85 To avoid the circumvention of the protections of PHS Act section 2719A, the Departments determined it necessary that a reasonable amount be paid before a patient becomes responsible for a balance billing amount. Therefore, as provided in the interim final regulations and these final regulations, a plan or issuer must pay a reasonable amount for emergency services by some objective standard. Specifically, a plan or issuer satisfies the copayment or coinsurance 84 See Uniform Glossary of Health Coverage and Medical Terms at http://www.dol.gov/ebsa/pdf/sbcuniformglossaryproposed.pdf and https://www.cms.gov/apps/glossary. 85 75 FR 37188, 37194 (June 28, 2010). 76 limitations in the statute if it provides benefits for out-of-network emergency services (prior to imposing in-network cost sharing) in an amount at least equal the greatest of: (1) the median amount negotiated with in-network providers for the emergency service; (2) the amount for the emergency service calculated using the same method the plan generally uses to determine payments for out-of-network services (such as the usual, customary, and reasonable amount); or (3) the amount that would be paid under Medicare for the emergency service (minimum payment standards). The interim final regulations under PHS Act section 2719 clarified that the costsharing requirements create a minimum payment requirement. The cost-sharing requirements do not prohibit a group health plan or health insurance from providing benefits with respect to an emergency service that are greater than the amounts specified in the regulations. Some commenters expressed concern about the level of payment for out-of-network emergency services and urged the Departments to require plans and issuers to use a transparent database to determine out-of-network amounts. The Departments believe that this concern is addressed by our requirement that the amount be the greatest of the three amounts specified in paragraphs (b)(3)(i)(A), (b)(3)(i)(B), and (b)(3)(i)(C) of this section (which are adjusted for innetwork cost-sharing requirements)"

Part II
"The minimum payment standards are designed to reduce potential amounts of balance billing to patients. Stakeholders commented that in circumstances where patients will not be balance billed (because balance billing is prohibited or because the issuer, rather than the patient, is required to cover the balance bill), the minimum payment standards are not necessary. In response to these comments, the Departments issued an FAQ86 stating that the minimum payment standards set forth in the interim final regulations were developed to protect patients from being financially penalized for obtaining emergency services on an out-of-network basis. If State law prohibits balance billing, plans and issuers are not required to satisfy the payment minimum set forth in the regulations. Similarly, if a plan or issuer is contractually responsible for any amounts balanced billed by an out-of-network emergency services provider, the plan or issuer is not required to satisfy the payment minimum. In both situations, however, a plan or issuer may not impose any copayment or coinsurance requirement for out-of-network emergency services that is higher than the copayment or coinsurance requirement that would apply if the 86 See Affordable Care Act Implementation FAQ Part I Q15 at http://www.dol.gov/ebsa/faqs/faq-aca.html and.https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs.html. 78 services were provided in-network. In addition, a plan or issuer must provide an enrollee or beneficiary adequate and prominent notice of their lack of financial responsibility with respect to amounts balance billed in order to prevent inadvertent payment by an enrollee or beneficiary. These final regulations incorporate this clarification. The regulations do not preempt existing State consumer protection laws and do not prohibit States from enacting new laws with respect to balance billing that would provide consumer protections at least as strong as the Federal statute."

OR alternatively you can read the FAQ they cite--
"
Out-Of-Network Emergency Services
Q15: Public Health Service Act (PHS Act) section 2719A generally provides, among other things, that if a group health plan or health insurance coverage provides any benefits for emergency services in an emergency department of a hospital, the plan or issuer must cover emergency services without regard to whether a particular health care provider is an in-network provider with respect to the services, and generally cannot impose any copayment or coinsurance that is greater than what would be imposed if services were provided in network. At the same time, the statute does not require plans or issuers to cover amounts that out-of-network providers may "balance bill". Accordingly, the interim final regulations under section 2719A set forth minimum payment standards in paragraph (b)(3) to ensure that a plan or issuer does not pay an unreasonably low amount to an out-of-network emergency service provider who, in turn, could simply balance bill the patient.
Are the minimum payment standards in paragraph (b)(3) of the regulations intended to apply in circumstances where State law prohibits balance billing? (Similarly, what if a plan or issuer is contractually obligated to bear the cost of any amounts balance billed, so that the patient is held harmless from those costs?)

No. As stated in the preamble to the interim final regulations under section 2719A, the minimum payment standards set forth in paragraph (b)(3) of the regulations were developed to protect patients from being financially penalized for obtaining emergency services on an out-of-network basis. If a State law prohibits balance billing, plans and issuers are not required to satisfy the payment minimums set forth in the regulations. Similarly, if a plan or issuer is contractually responsible for any amounts balance billed by an out-of-network emergency services provider, the plan or issuer is not required to satisfy the payment minimums. In both situations, however, patients must be provided with adequate and prominent notice of their lack of financial responsibility with respect to such amounts, to prevent inadvertent payment by the patient. Nonetheless, even if State law prohibits balance billing, or if the plan or issuer is contractually responsible for amounts balance billed, the plan or issuer may not impose any copayment or coinsurance requirement that is higher than the copayment or coinsurance requirement that would apply if the services were provided in network."
 
Politicians + Imbalanced Budget = .....

Ooh ooh! Let me try.

Politicians + Imbalanced Budget = Well-considered decisions made with the long-term consequences in mind?
 
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Am I misreading it, or is this basically a mandate to make all ED services absolutely free for everyone?

Ie, used to be EMTALA forced you to see patients regardless of their ability to pay, but you at least could bill them and the ones who had insurance or something to lose would end up paying in the end.

Now, a patient can come in "with insurance" that reimburses the ED with a tootsie roll and a 15% off coupon to Great Clips, as is their prerogative under this new legislation. But since the patient fulfilled his end of the bargain by "having insurance," the ED cannot send him a bill, either! In fact, the party that's on the hook for the cost of the ED services rendered is the ED itself.

Is this basically the situation? And if so, what does this mean? EMTALA was a load of BS to begin with, but you could at least charge for your services. Now that the very act of charging for services has been outlawed, what happens? Providing a service with high overhead for which you are not allowed to charge under penalty of law does not seem like a sustainable business model.
 
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At least most states in the 5th column are a "No". Physicians in all of the "Yes" states would pack up and move if they were smart. Only be leaving those states and causing a shortage of providers will things change. Alas, most docs won't do this.....yet.
 
I imagine that rather than change this...most, if not all, states will ban balanced billing and give us the finger.
 
I imagine that rather than change this...most, if not all, states will ban balanced billing and give us the finger.

True. But this bill along with balance billing bans could effectively make emergency medicine and specialist coverage financially unsupportable. One of two things will happen:

1. Hospitals give heavy subsidies to the CMGs to keep emergency coverage

2. The system collapses.

I suspect number one will be most likely. Smart states like Texas would be wise to not enact balance billing laws, hence keeping their doctors and attracting more.
 
Eh...I could only hope. Often I feel this system needs a wake up call.
But instead, hospitals/CMGs will mandate more MLP hours less physician hours and more pts/hr...
I see the powers than be (and this includes CMGs since they have such a huge market share) just bending over and accepting this.
 
Eh...I could only hope. Often I feel this system needs a wake up call.
But instead, hospitals/CMGs will mandate more MLP hours less physician hours and more pts/hr...
I see the powers than be (and this includes CMGs since they have such a huge market share) just bending over and accepting this.

Isn't it fantastic when government gets involved in healthcare?
 
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Isn't it fantastic when government gets involved in healthcare?

I will argue that the good bit about the ACA and government involvement is that they've held the insurance companies' "feet to the fire" and have mandated that they (the insurers) cannot deny anyone for pre-existing conditions. Otherwise, I would not see the sense in toiling away (including exposure to liability) for a system that will not insure me... such that I can get back out there and work for it.

It was late in my intern year when all of a sudden, autoimmunity hit me. Boom. No warning. I went from a good 160 lb (and "fighting shape") fella to a withering, weak 130 in a month. My residency program (and in particular, my PD) pulled every string to help me out. But when it came down to buying my own insurance with my hard earned money... Denied.

Before anyone argues that the insurance companies are simply looking out for themselves and excluding "uninsurables", let me say this; my wife was declared "uninsurable" back in 2012. Reason being; she once upon a time, smoked (tobacco-free for five years at age 28) - and was seen once formally for depression/anxiety.

Boom. "High-risk", "Uninsurable", came the letters. This is a girl who is a brilliant bench scientist, who helped to bring us things like "Gardasil" and "Rotateq". She paid her tax dollars to the system to help those who have never worked, and have no inclination to work, and saved her money to go purchase insurance when she left her last job.

Denied. By most of the big insurers.

In my book, corporate greed is one of the most poisonous things on the planet. That includes the CMGs, the insurance companies, and (gasp) the federal government as well; it just so happened that (I think) that Capitol Hill got this one small detail correct. We work for the system. The system needs to work for us.
 
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Btw, if balance billing from crappy insurance is now illegal, can docs/hospitals simply decline known crappy insurance and bill the patients direct? Have them fight the insurance for reimbursement? I assume EMTALA forces you to treat patients regardless of their ability to pay or the type of insurance they have, but it does not force you to accept any given insurance once treatment has been rendered, right?
 
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Btw, if balance billing from crappy insurance is now illegal, can docs/hospitals simply decline known crappy insurance and bill the patients direct? Have them fight the insurance for reimbursement? I assume EMTALA forces you to treat patients regardless of their ability to pay or the type of insurance they have, but it does not force you to accept any given insurance once treatment has been rendered, right?


It would seem like a logical next step, but it would backfire. However, the hospital may want to take insurance A because it pays reasonably well for in hospital visits, even though it pays poorly for emergency visits. The hospital would then need to accept Insurance A or lose out on that market share.

I think the most logical step is to somehow split all ED's into an urgent care and an emergency room. Patient's can decide which door they enter. UC gets you in and out, but is not subject to EMTALA, and is billed as an office visit 99204. ED is subject to EMTALA and is billed as a such, a 99284.

This would cute down on a lot of the uncompensated care ED's provide, while not costing the hospital a major revenue stream, which is admissions that almost exclusively come from the ED these days.
 
It would seem like a logical next step, but it would backfire. However, the hospital may want to take insurance A because it pays reasonably well for in hospital visits, even though it pays poorly for emergency visits. The hospital would then need to accept Insurance A or lose out on that market share.

I think the most logical step is to somehow split all ED's into an urgent care and an emergency room. Patient's can decide which door they enter. UC gets you in and out, but is not subject to EMTALA, and is billed as an office visit 99204. ED is subject to EMTALA and is billed as a such, a 99284.

This would cute down on a lot of the uncompensated care ED's provide, while not costing the hospital a major revenue stream, which is admissions that almost exclusively come from the ED these days.

I don't think patients are capable of making that decision. Almost every complaint is an "emergency" to that person. If they feel they are going to get a bigger workup, be seen faster, or by a "doctor" then they are always going to choose door #2. Patients always opt for more care, not less even if they don't need it.
 
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I will argue that the good bit about the ACA and government involvement is that they've held the insurance companies' "feet to the fire" and have mandated that they (the insurers) cannot deny anyone for pre-existing conditions. Otherwise, I would not see the sense in toiling away (including exposure to liability) for a system that will not insure me... such that I can get back out there and work for it.

It was late in my intern year when all of a sudden, autoimmunity hit me. Boom. No warning. I went from a good 160 lb (and "fighting shape") fella to a withering, weak 130 in a month. My residency program (and in particular, my PD) pulled every string to help me out. But when it came down to buying my own insurance with my hard earned money... Denied.

Before anyone argues that the insurance companies are simply looking out for themselves and excluding "uninsurables", let me say this; my wife was declared "uninsurable" back in 2012. Reason being; she once upon a time, smoked (tobacco-free for five years at age 28) - and was seen once formally for depression/anxiety.

Boom. "High-risk", "Uninsurable", came the letters. This is a girl who is a brilliant bench scientist, who helped to bring us things like "Gardasil" and "Rotateq". She paid her tax dollars to the system to help those who have never worked, and have no inclination to work, and saved her money to go purchase insurance when she left her last job.

Denied. By most of the big insurers.

In my book, corporate greed is one of the most poisonous things on the planet. That includes the CMGs, the insurance companies, and (gasp) the federal government as well; it just so happened that (I think) that Capitol Hill got this one small detail correct. We work for the system. The system needs to work for us.

Not to get into an ACA debate with you, however once you start having guaranteed issue and subsidized rates it's no longer really insurance. Insurance is based on actuarial tables and costs. Insurance companies will charge you a cost based on your risk. What you describe is not insurance since you are not being charged based on your known risk. Like it or not it's essentially welfare at the point where you are paying less than the cost of your care at the expense of someone else.
 
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Not to get into an ACA debate with you, however once you start having guaranteed issue and subsidized rates it's no longer really insurance. Insurance is based on actuarial tables and costs. Insurance companies will charge you a cost based on your risk. What you describe is not insurance since you are not being charged based on your known risk. Like it or not it's essentially welfare at the point where you are paying less than the cost of your care at the expense of someone else.
Well it still kinda is, just with fewer variables - age and tobacco.
 
Well it still kinda is, just with fewer variables - age and tobacco.

No, insurance is designed to pay for something that "might" happen. At the point you are covering pre-existing conditions you are essentially subsidizing care for an event that has already happened. There are only four options for the insurer at that point:

1. Charge the patient more than the projected cost of treatment for the pre-existing condition
2. Get a subsidy from the government
3. Charge other people more to pay the cost of the pre-existing condition
4. Lose money

The ACA basically allows insurers to do #2 and #3. What we are finding out with United healthcare and the Co-Ops is that #4 is starting to happen too.
 
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Not to get into an ACA debate with you, however once you start having guaranteed issue and subsidized rates it's no longer really insurance. Insurance is based on actuarial tables and costs. Insurance companies will charge you a cost based on your risk. What you describe is not insurance since you are not being charged based on your known risk. Like it or not it's essentially welfare at the point where you are paying less than the cost of your care at the expense of someone else.

I get your point, man - and I love crossing swords with you - but here's the rub:

1.) The criteria for exclusion based on "high-risk!/uninsurable!" assessments is unreal. My wife, a perfectly healthy female in her late 20s was labeled as such for a subjective smoking history (social smoking during college) and "depression/anxiety". By that criteria; we are hereby all uninsurable Philistines and are to be "cast out". If you say "No, I'm not." - I challenge you to look long into your personal history and answer honestly whether you have never smoked **anything!** in your life, and if you have never felt anxious or depressed. I argue that the nature of our work, is rather depressing and anxiety-inducing. - And for the number of "craft-brew" threads that get bumped around here, I'm not going to buy that we're all "risk-free" individuals. Who, then - is "insurable" ?!


2.) We have a system in place (call it insurance, call it welfare, call it whatever you want... because by your definition, most insurance is welfare when you include the idea of chronic disease and its complications) that bends over backwards to provide every necessity (and even luxury!) to those who have never worked, and have no inclination to work. - yet, that same system turns its back on those who fund it thru the fruits of their labor, and even work FOR it to increase their profits!... something is very wrong with that, man. When Joe Welfare who has cigarettes and Mountain Dew for breakfast shows off his CABG scar to me at work and brags about how he survived that ordeal needs to be a "satisfied customer", yet my wife and I are excluded from coverage... you get the idea.
 
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No, insurance is designed to pay for something that "might" happen. At the point you are covering pre-existing conditions you are essentially subsidizing care for an event that has already happened. There are only four options for the insurer at that point:

1. Charge the patient more than the projected cost of treatment for the pre-existing condition
2. Get a subsidy from the government
3. Charge other people more to pay the cost of the pre-existing condition
4. Lose money

The ACA basically allows insurers to do #2 and #3. What we are finding out with United healthcare and the Co-Ops is that #4 is starting to happen too.
Well by that definition we haven't had true health insurance in America in a very long time. More like pre-paid health plans with some redistribution.

Personally, I think the high deductible plans (with or without exclusions) are the closest we are going to get to insurance. Most diabetics/hypertensives/autoimmune patients are still going to have trouble spending enough to hit those marks in a given year... unless their doctors use all brand name drugs.
 
I can't get that link to work, but I wonder if this is a consequence of actively encouraging people to use ERs for everything and then the hospitals and doctors taking advance of higher ER billing fees.

Free standing ERs are a perfect example of this. For many things they are no different than urgent cares, yet the charged fees are different. I'm not excusing the insurance companies because I think they are a large part of our current health care problem, but the hospitals and doctors have been taking advantage of this loophole for personal profit.

If people were paying directly for care, costs across the board would fall very quickly. Hospitals and ER groups are exploiting the system and because people aren't directly responsible for the costs, the insurance company is eating the higher cost. This is the same thing (although much less markup) as that ceo at Turing pharmaceuticals buying Daraprim and then raising the cost 5000%.

Hopefully this will mitigate the billboards with "ER wait time X minutes" and allowing people to make an appointment to the ER. If you want to advertise the ER like a glorified clinic, don't be surprised when insurance starts paying you like one.

Are you an Emergency Physician? Have you worked in a freestanding ER before?

An FEC is far different than an Urgent Care, they are more similar, and often times, more advanced than a hospital based ER.

So you say ER's are a bad idea and instead they should have scheduled visits or just go to an Urgent Care? What presentations in particular should? Patients less than 30 with chest pain maybe (we all can tell you about that STEMI that was 24 years old)? Simple cough (that ended up being hypoxic or had the saddle PE)? Maybe just the simple twisted ankle (that actually was a significant fracture and ended up in the OR)?

Free standing ERs are the future of Emergency Medicine. They are often cheaper than a hospital, MUCH more efficient, offer similar or better care, and do it all in a matter of minutes without a wait.
 
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Are you an Emergency Physician? Have you worked in a freestanding ER before?

An FEC is far different than an Urgent Care, they are more similar, and often times, more advanced than a hospital based ER.

So you say ER's are a bad idea and instead they should have scheduled visits or just go to an Urgent Care? What presentations in particular should? Patients less than 30 with chest pain maybe (we all can tell you about that STEMI that was 24 years old)? Simple cough (that ended up being hypoxic or had the saddle PE)? Maybe just the simple twisted ankle (that actually was a significant fracture and ended up in the OR)?

Free standing ERs are the future of Emergency Medicine. They are often cheaper than a hospital, MUCH more efficient, offer similar or better care, and do it all in a matter of minutes without a wait.
 
So, does balance billing even work? Do patients actually pay the bills the doctor charges them? Are ED doctors even making money in states that have balance billing? How is that 5th column, where we're allowed to balance bill patients, mean that we will not be affected by the legislation immediately?
 
So, does balance billing even work? Do patients actually pay the bills the doctor charges them? Are ED doctors even making money in states that have balance billing? How is that 5th column, where we're allowed to balance bill patients, mean that we will not be affected by the legislation immediately?

I do not know for certain but I fear significantly delayed ARs, lots of appeals of the charges, asking for payment installments, potential legal battles, prob more audits of charts since pts footing the bill...
 
Are you an Emergency Physician? Have you worked in a freestanding ER before?

An FEC is far different than an Urgent Care, they are more similar, and often times, more advanced than a hospital based ER.

So you say ER's are a bad idea and instead they should have scheduled visits or just go to an Urgent Care? What presentations in particular should? Patients less than 30 with chest pain maybe (we all can tell you about that STEMI that was 24 years old)? Simple cough (that ended up being hypoxic or had the saddle PE)? Maybe just the simple twisted ankle (that actually was a significant fracture and ended up in the OR)?

Free standing ERs are the future of Emergency Medicine. They are often cheaper than a hospital, MUCH more efficient, offer similar or better care, and do it all in a matter of minutes without a wait.

We are all familiar the zebras. The problem is that emergency rooms are increasingly being used for non-emergencies and are even being advertised to the public to encourage them to come for anything they want. Compare this to places like the UK where they run campaigns essentially telling people to see their gp and not waste ER resources for minor things.

If doctors and hospitals want to be able to charge more for ER visits, then stop promoting the ER as being no different than a primary care office or urgent care. The billboards with wait times, the 15 min door to doc times, allowing people to book appointments to the ER... these all have to stop. The whole purpose of an ER is to triage and treat based on priority of medical emergency. By treating everything as an emergency, nothing is.

The health care industry (doctors included) only has itself to blame. The greed has caused a system that is a failure. People can't get in to see providers and people can't afford care. People are being left untreated or bankrupt. But rather than do things like encourage mid level primary care, the physicians fight tooth and nail to protect their own interests under the guise of "patient safety" when the reality is that much routine primary care doesn't require a physician level of a care; not to mention the fact that most medical students don't even want to do primary care.

Same goes for the ER. I didn't train to be a resuscitation and trauma specialist so that I can spend my day treating things that should be seen at a walkin clinic. And before everyone says "well zebras exist!"... yes I am aware of this and part of the responsibility of the doctor is to be extremely thorough in regards to differential diagnosis. But when we act like everything must be seen right away and when we encourage people to use the ER for non-emergencies, we are making the ERS unsafe and unable to function in the capacity they were intended. The treatment of actual emergencies suffers as a result of all this.

But please let me hear more about docs routinely seeing 3pph as if there's any chance those are all actual medical emergencies and that there's even a chance the doctor is using their brain with every case to take a thorough history, perform a complete exam, consider an exhaustive differential, and perform the appropriate workup and treatment.

The fact that er docs routinely even see 3 pph is the greatest argument in favor of not paying a premium for emergency care.
 
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We are all familiar the zebras. The problem is that emergency rooms are increasingly being used for non-emergencies and are even being advertised to the public to encourage them to come for anything they want. Compare this to places like the UK where they run campaigns essentially telling people to see their gp and not waste ER resources for minor things.

If doctors and hospitals want to be able to charge more for ER visits, then stop promoting the ER as being no different than a primary care office or urgent care. The billboards with wait times, the 15 min door to doc times, allowing people to book appointments to the ER... these all have to stop. The whole purpose of an ER is to triage and treat based on priority of medical emergency. By treating everything as an emergency, nothing is.

The health care industry (doctors included) only has itself to blame. The greed has caused a system that is a failure. People can't get in to see providers and people can't afford care. People are being left untreated or bankrupt. But rather than do things like encourage mid level primary care, the physicians fight tooth and nail to protect their own interests under the guise of "patient safety" when the reality is that much routine primary care doesn't require a physician level of a care; not to mention the fact that most medical students don't even want to do primary care.

Same goes for the ER. I didn't train to be a resuscitation and trauma specialist so that I can spend my day treating things that should be seen at a walkin clinic. And before everyone says "well zebras exist!"... yes I am aware of this and part of the responsibility of the doctor is to be extremely thorough in regards to differential diagnosis. But when we act like everything must be seen right away and when we encourage people to use the ER for non-emergencies, we are making the ERS unsafe and unable to function in the capacity they were intended. The treatment of actual emergencies suffers as a result of all this.

But please let me hear more about docs routinely seeing 3pph as if there's any chance those are all actual medical emergencies and that there's even a chance the doctor is using their brain with every case to take a thorough history, perform a complete exam, consider an exhaustive differential, and perform the appropriate workup and treatment.

The fact that er docs routinely even see 3 pph is the greatest argument in favor of not paying a premium for emergency care.


I agree with the above. Patients get downright angry when I explain to them that my specialty is dealing with "Emergencies" and that their chronic problem of many years is best handled by a PCP. I'd love to devote my time to taking care of the sicker patients rather than dealing with minor nonsense and the walking well.

The flip side is that treating and billing for all this low acuity BS is what keeps our salaries high, and our specialty in demand. Would I treat the BS nonsense if I can make $100K more per year? Yes, and I do.
 
I agree with the above. Patients get downright angry when I explain to them that my specialty is dealing with "Emergencies" and that their chronic problem of many years is best handled by a PCP. I'd love to devote my time to taking care of the sicker patients rather than dealing with minor nonsense and the walking well.

The flip side is that treating and billing for all this low acuity BS is what keeps our salaries high, and our specialty in demand. Would I treat the BS nonsense if I can make $100K more per year? Yes, and I do.
Yeah, my patients come back from EDs furious as well. I generally try to explain exactly what you do - luckily, they take it pretty well from me.
 
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Yeah, my patients come back from EDs furious as well. I generally try to explain exactly what you do - luckily, they take it pretty well from me.

Can I hire you to follow me around on shift and explain stuff like this to patients? That might be a novel concept. Kinda like a scribe, but instead of doing my charting you do my empathy instead.
 
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I think the most logical step is to somehow split all ED's into an urgent care and an emergency room. Patient's can decide which door they enter. UC gets you in and out, but is not subject to EMTALA, and is billed as an office visit 99204. ED is subject to EMTALA and is billed as a such, a 99284.
The hospital where I work (not in the ED) is in the middle of a remodel of their ED that will have a UC built in. As I understand the plan (from a friend of mind who is an ED doc there), the doc/mid-levels assigned to UC for the day will be doing an MSE on all non-critical (no...I don't know how they're going to define that, but I assume peri-oral cheetosis BIBA will count as non-critical) patients walking in the door and shunt them to one side or the other as felt appropriate.

I'm curious to see how this will work. It's a new model in this state, but not a new model overall. This hospital system runs a wide range of EDs (Level 1 Trauma down to tiny community place with a crash cart that would embarrass the average IM resident) as well as a bunch of UCs so they clearly have the expertise to do everything along the spectrum.
 
We are all familiar the zebras. The problem is that emergency rooms are increasingly being used for non-emergencies and are even being advertised to the public to encourage them to come for anything they want. Compare this to places like the UK where they run campaigns essentially telling people to see their gp and not waste ER resources for minor things.

If doctors and hospitals want to be able to charge more for ER visits, then stop promoting the ER as being no different than a primary care office or urgent care. The billboards with wait times, the 15 min door to doc times, allowing people to book appointments to the ER... these all have to stop. The whole purpose of an ER is to triage and treat based on priority of medical emergency. By treating everything as an emergency, nothing is...

The problem with the idea behind your whole post is that everyone wants the ERs available for their use 24/7. Patients, private medical doctors, hospitals, etc. They want board certified physicians able to take care of their (anything), possibly emergent or can't-fit-it-in-my-clinic, 24/7/365 including holidays. The entire medical system relies on emergency departments to do all of this work like a fish relies on water. You can't just take it away and you can't just say you're not going to pay for it. Well, I suppose you could try, but nobody, and I mean nobody, is going to like the result.

And there is no good way at the door to say, emergencies only - everything else out. This puts excess liability on the provider, on the hospital, the patient's PCP (if they have one), don't want that, and most importantly, patients do not want that.

I don't like treating the probably non emergent but one-in-500-ectopic pelvic pain at 3 AM on Christmas. But guess what - nobody else wants to do my job. And because that patient wants me to do it, the patient's OBGYN wants me to do it (they don't want to do it themselves, understandably), the hospital wants me to do it (front door of the hospital for more than half of the admissions), I do it. If there is another avenue out there capable of handling the absolutely astronomical volume of work that we do (and we are overwhelmed as it is)... go for it.
 
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The problem with the idea behind your whole post is that everyone wants the ERs available for their use 24/7. Patients, private medical doctors, hospitals, etc. They want board certified physicians able to take care of their (anything), possibly emergent or can't-fit-it-in-my-clinic, 24/7/365 including holidays. The entire medical system relies on emergency departments to do all of this work like a fish relies on water. You can't just take it away and you can't just say you're not going to pay for it. Well, I suppose you could try, but nobody, and I mean nobody, is going to like the result.

And there is no good way at the door to say, emergencies only - everything else out. This puts excess liability on the provider, on the hospital, the patient's PCP (if they have one), don't want that, and most importantly, patients do not want that.

I don't like treating the probably non emergent but one-in-500-ectopic pelvic pain at 3 AM on Christmas. But guess what - nobody else wants to do my job. And because that patient wants me to do it, the patient's OBGYN wants me to do it (they don't want to do it themselves, understandably), the hospital wants me to do it (front door of the hospital for more than half of the admissions), I do it. If there is another avenue out there capable of handling the absolutely astronomical volume of work that we do (and we are overwhelmed as it is)... go for it.

Very true...but CMS just said it doesn't give a $$(@& about us or what we do or what value we think we provide.
 
Can I hire you to follow me around on shift and explain stuff like this to patients? That might be a novel concept. Kinda like a scribe, but instead of doing my charting you do my empathy instead.
Sadly, it only works if they are my clinic patient to begin with.

That said, my patients all have my cell phone number so feel free to call me at discharge - though since they have that, they rarely darken the ED doors unless I really think they need to be there.
 
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Very true...but CMS just said it doesn't give a $$(@& about us or what we do or what value we think we provide.

Right but what CMS says is irrelevent from the business aspect of things. EDs have already been closing over the last 10 years in places like Los Angeles. If doctors, hospitals, and hospital systems start losing big money on them, which is the logical outcome of this law, then even more will close causing a public health crisis. I hope this does indeed happen, to prove our value to society and to give a black eye to all of the big government meddlers who think they know best.
 
Right but what CMS says is irrelevent from the business aspect of things. EDs have already been closing over the last 10 years in places like Los Angeles. If doctors, hospitals, and hospital systems start losing big money on them, which is the logical outcome of this law, then even more will close causing a public health crisis. I hope this does indeed happen, to prove our value to society and to give a black eye to all of the big government meddlers who think they know best.

It looks like the law will only impact the professional fee and not the hospital's. Mom sure the hospitals/their lobby has known about this for a while. They may just expect us to take it and be "old caring doctors" like we have always been as a profession.

And what else scares me is that as soon as groups start to complain or fight this (ask for stipends) there will be some CMG who will ride in and offer to take it as a "loss". This "loss" will only be to the docs and MLPs (most will be new grads) as the suits just expand their market share and wealth!
 
It looks like the law will only impact the professional fee and not the hospital's. Mom sure the hospitals/their lobby has known about this for a while. They may just expect us to take it and be "old caring doctors" like we have always been as a profession.

And what else scares me is that as soon as groups start to complain or fight this (ask for stipends) there will be some CMG who will ride in and offer to take it as a "loss". This "loss" will only be to the docs and MLPs (most will be new grads) as the suits just expand their market share and wealth!

Fortunately free market economics will still apply. Places which ban balance billing will see huge drops in physician salaries, assuming that insurers take full advantage of the laws. That will result in shortages of physicians in those states. Hopefully that shortage will serve to drive up salaries in compensation. The hospitals and/or CMGs would have no choice but to eat the added costs in that circumstance.
 
That's assuming it will drive out docs.
I sure as heck hope it would!
As a collective group docs would have to stand their ground against working for crap as well.
 
At what point would doctors leave? If you had a 50K pay cut would you leave your job? How about 100K?

The problem with us in general is that we don't stick up for ourselves. I'm guilty of it too, working at a job for 5 years that paid less and less each year. Now that my eyes are open, I realize that our mobility is key for us. Any place that cuts my pay now, I'm going to leave and go elsewhere. I wish every physician would do the same and then we'd have more control.
 
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