ACEP sues federal government over coverage for 'out-of-network' patients

The American College of Emergency Physicians has filed a lawsuit in federal court against HHS, calling for transparency of data and fair insurance coverage for ED patients who are “out of network,” according to a statement released by the group.

The lawsuit, which accuses insurance companies of failing to provide fair coverage for emergency care, follows a new final rule issued by HHS allowing insurers to set their own rates for out-of-network patients. The rule further states that minimum standards of payment are not necessary in states that have banned balance billing. According to the ACEP, the rule allows insurance companies to “set whatever prices they want without regard to the consequences to patients, health care providers and our nation’s safety net of emergency care.”

“Patients can’t choose where and when they will need emergency care and should not be punished financially for having emergencies,” Jay Kaplan, MD, ACEP president, said in a press release. “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.”

The ACEP is asking the court to ultimately overturn the final rule, arguing that it violates the government’s rulemaking procedures and does not meet the standards mandated by the Affordable Care Act (ACA).

According to the ACEP, officials with HHS have acknowledged the ACA requires that a reasonable amount be paid based on an objective standard when patients receive emergency care from out-of-network health care providers. The lawsuit argues that the new final rule fails to hold insurance companies accountable that that requirement.

Kaplan added that ACEP officials had been working with CMS for 4 years on the out-of-network issue, and were “shocked” by the final rule.

“We are fighting for our patients to get the coverage they deserve and for the thousands of dedicated men and women who staff our nation’s emergency care safety net at all hours every day,” Kaplan said.