ER Doctors Say that “Affordable” Premium Policies Mislead Patients

Ninety percent of emergency physicians say that health insurance companies mislead patients by offering affordable premiums for policies that actually cover very little, according to a survey by the American College of Emergency Physicians (ACEP). Ninety-six percent say that emergency patients don’t understand what their policies cover for emergency care. Eighty percent of ER doctors say they are seeing patients with health insurance who have missed or delayed medical care because of high insurance costs – a more than a 10% increase over six months ago.

Jay Kaplan, MD, FACEP, president of the American College of Emergency Physicians (ACEP) says, “Each day, emergency physicians are seeing patients who have significant co-pays for emergency care of up to $400 or more. It might as well be $4,000 for some people…Insurance companies must provide fair coverage…and be transparent about how they calculate payments. They need to pay reasonable charges, rather than setting arbitrary rates that don’t even cover the costs of care. Insurance companies are exploiting federal law to reduce coverage for emergency care knowing emergency departments have a federal mandate to care for all patients, regardless of their ability to pay. When plan reimbursements don’t cover the cost of providing services, physicians must choose between billing patients for the difference or going unpaid for their services. The vast majority of emergency physicians and their groups prefer to be in network.”

Dr. Kaplan says that health insurance companies are creating narrow networks of medical providers to increase profits, making it more likely for patients to go out-of-network. The survey of ER doctors also reveals the following:

  • 62% of ER doctors say that most health insurance companies provide inadequate coverage for emergency care visits.
    More than 80% of ER doctors who are aware of reimbursement issues agree that insurance companies have reduced emergency care reimbursements.
  • 60% of ER doctors say that, in the past year, they have had difficulty finding in-network specialists to care for patients with a quarter of them saying it happens daily.
  • 91% of ER doctors say that a new rule by the Centers for Medicare and Medicaid Services (CMS) would make it harder to find specialists and follow-up care for patients. The CMS rule exempts health insurance companies from meeting minimum standards to ensure adequate networks.
  • 79% of ER doctors who are familiar with the Fair Health database say it’s the best mechanism to ensure transparency and make sure that insurance companies don’t miscalculate payments.
  • 87% say that insurance companies should pay the in-network rate when an emergency patient does not have access to an in-network facility or physician.

Kaplan said, “Health insurance companies have a long history of not paying for emergency care and…discouraging their customers from seeking it. For example, United Healthcare was sued successfully by the State of New York for fraudulently calculating and significantly underpaying doctors for out-of-network medical services. They used the Ingenix database, which forced patients to overpay up to 30% for out-of-network doctors. The company, which, at the time, was led by the acting head of CMS, Andy Slavitt — paid the largest settlement to the state of New York and the American Medical Association. Part of that settlement created the Fair Health database.”

Emergency Visits Have Not Gone Down Since the ACA


Emergency visits are increasing despite the Affordable Care Act (ACA), according to a report by the Centers for Disease Control and Prevention. Jay Kaplan, MD, FACEP, president of the American College of Emergency Physicians (ACEP) said, “The reliance on emergency care remains stronger than ever. Just because you have health insurance does not mean you have access to timely medical care. Every shift, I treat patients who couldn’t access a primary care physician and had no choice but to come to the emergency department because their condition worsened dramatically. America has severe primary care physician shortages; many doctors will not accept Medicaid patients because Medicaid pays so inadequately.”

According to a 2015 ACEP poll, three-quarters of emergency doctors said that emergency visits had gone up since the implementation of the ACA. Most said that the availability of urgent care centers, retail clinics, and telephone triage lines have done little to reduce emergency visits.

There is strong evidence that Medicaid patients don’t have timely access to primary care and specialty care. The median wait time for Medicaid providers is two weeks, but over one-quarter have wait times of more than a month. More than half of providers listed by Medicaid managed care plans are not offering appointments to enrollees. This is despite an ACA provision that boosts pay to primary care doctors who treat Medicaid patients.


ER Visits Continue to Rise since Implementation of Affordable Care Act

Three-quarters of emergency physicians say that emergency visits are going up, according to a poll by the American College of Emergency Physicians (ACEP). This is a significant increase from just a year ago when less than half reported increases. Most report little or no reduction in emergency visits due to the availability of urgent care centers, retail clinics, and telephone triage lines. About 90% of more than 2,000 respondents have also seen an increase in the severity of illness or injury among emergency patients.

Michael Gerardi, MD, FAAP, FACEP, president of the ACEP said, “The reliance on emergency care remains stronger than ever. It’s the only place that’s open 24/7, and we never turn anyone away. Rather than trying to put a moat around us to keep people out, it’s time to recognize the incredible value of this model of medicine.”

Twenty-eight percent report significant increases in all emergency patients since the requirement to have health insurance took effect. In addition, 56% say the number of Medicaid patients is increasing.

A report by Health Policy Alternatives finds that policymakers and health insurance plans are failing in their efforts to drive Medicaid patients out of emergency departments and into primary care. More than half of providers listed by Medicaid managed care plans could not offer appointments to enrollees, despite a provision in the ACA boosting pay to primary care physicians who treat Medicaid patients. The median wait time was two weeks, but over one-quarter of providers had wait times of more than a month for an appointment.

“Medicaid access to primary and specialty care is not timely, leaving Medicaid patients with few options other than the emergency department. In addition, states with punitive policies toward Medicaid patients in the ER may be discouraging low-income patients with serious medical conditions from seeking necessary care, which is dangerous and wrong,” said Orlee Panitch, MD, FACEP, chair of EMAF and emergency physician for MEPHealth in Germantown, Maryland.

Gerardi said, “America has severe primary care physician shortages, and many physicians will not accept Medicaid patients because Medicaid pays so inadequately. Just because people have health insurance does not mean they have access to timely medical care.”

Dr. Gerardi raised concerns about the closure of hospitals and emergency departments in states that have not expanded Medicaid. “Hospitals received less Medicaid funding for charity care when the ACA took effect, because more people were supposed to have health insurance coverage. But hospitals are hurting in states that didn’t expand Medicaid. For example, the closure of a hospital in Baton Rouge resulted in a crisis for another hospital that inherited all the patients, many of whom are uninsured, and now this hospital may close as well. The average reimbursement for a Medicaid patient in the ER is about $43, but it’s much lower in many states,” he said.

Forty-two percent of emergency physicians would expect an increase in emergency visits if federal subsidies for health insurance coverage were to be eliminated in their states, which may happen if the Supreme Court decides in favor of the plaintiff in King v. Burwell

ER Visits Up Since Implementation of Affordable Care Act

Nearly half of emergency physicians responding to a poll are already seeing a rise in emergency visits since January 1 when expanded coverage under the Affordable Care Act (ACA) began to take effect. In an online poll conducted by the American College of Emergency Physicians (ACEP), 86% expect emergency visits to increase over the next three years. Seventy-seven percent say their ERs are not adequately prepared for significant increases.

Alex Rosenau, DO, FACEP, president of ACEP said, “Emergency visits will increase, in large part, because more people will have health insurance and therefore will be seeking medical care. But America has severe primary care physician shortages, and many physicians do not accept Medicaid patients because Medicaid pays so low. When people can’t get appointments with physicians, they will seek care in emergency departments. In addition, the population is aging, and older people are more likely to have chronic medical conditions that require emergency care.”

The data suggest that states that have expanded Medicaid are more likely to see increases in the volume of Medicaid emergency patients. He added, “Long-term solutions, such as increasing the supply of primary care physicians, will take years to develop and will not solve our immediate and short-term problems. Congress and President Obama must make it a national priority now to strengthen the emergency care system. ACEP is urging Congress to make a firm commitment to emergency patients by holding a hearing to examine whether additional strains are occurring in the emergency department safety net as a consequence of the Affordable Care Act.” An overwhelming 84% of emergency physicians report that psychiatric patients are being held in their emergency department, with 91% saying that this practice has led to violent behavior by distressed psychiatric patients, distracted staff, or bed shortages, all of which may harm patients.

“People having a mental health crisis seek care in emergency departments because other parts of the health care system have failed them. Because of the critical shortage of mental health resources, some of these vulnerable patients wait for days in emergency departments. It is simply inhumane,” said Dr. Rosenau. More than half of the physicians said that the time and effort their emergency department takes to transfer psychiatric patients who need admission has increased since January. For more information, visit

Are Patients with True Emergencies Being Discharged from the ER?

The American College of Emergency Physicians (ACEP) points to a growing practice of insurance carriers (including Medicaid) denying payment for so-called “non-emergency” visits to the ER. ACEP says that this practice is likely to discourage patients from seeking the appropriate care for true emergencies.

The small numbers of emergency patients who are discharged from the ER with “primary care treatable” diagnoses have the same symptoms as patients who have been determined to need immediate or emergency care, hospital admission, or surgery, according to a study to be published in the Journal of the American Medical Association (JAMA).

Lead study author Maria Raven, MD, MPH, FACEP said, “Two patients could come to the emergency department with the same symptoms; one could be diagnosed with a condition that is not that serious while another could be diagnosed with a life-threatening condition…There is no possible way to determine the outcome of the visit in advance, and our study has shown that it’s not good policy to do so after the fact. Insurance companies should not treat these two patients differently. Patients should never be burdened with the task of diagnosing themselves out of fear that their potential emergency isn’t covered by insurance.”


Although only 6.3% of emergency department visits were determined to have “primary care treatable” discharge diagnoses, the chief complaints for these visits were the same as those reported for 88.7% of all other emergency visits. A substantial portion of these visits required immediate emergency care or hospital admission. These findings suggest that these “primary care treatable” discharge diagnoses are unable to accurately identify non-emergency ER visits.

Dr. Raven said, “If a triage nurse were to redirect patients away from the ER based on non-emergency complaints, 93% of the redirected ER visits would not have had primary care-treatable diagnoses. The results call into question reimbursement policies that deny or limit payment based on discharge diagnosis. The majority of Medicaid patients, who stand to be disproportionately affected by such policies, visit the emergency department for urgent or more serious problems.” For more information, visit

Last Updated 07/21/2021

Arch Apple Financial Services | Individual & Family Health Plans, Affordable Care California, Group Medical Insurance, California Health Insurance Exchange Marketplace, Medicare Supplements, HMO & PPO Health Care Plans, Long Term Care & Disability Insurance, Life Insurance, Dental Insurance, Vision Insurance, Employee Benefits, Affordable Care Act Assistance, Health Benefits Exchange, Buy Health Insurance, Health Care Reform Plans, Insurance Agency, Westminster, Costa Mesa, Huntington Beach, Fountain Valley, Irvine, Santa Ana, Tustin, Aliso Viejo, Laguna Hills, Laguna Beach, Laguna Woods, Long Beach, Orange, Tustin Foothills, Seal Beach, Anaheim, Newport Beach, Yorba Linda, Placentia, Brea, La Habra, Orange County CA

12312 Pentagon Street - Garden Grove, CA 92841-3327 - Tel: 714.638.0853 - 800.731.2590
Copyright @ 2015 - Website Design and Search Engine Optimization by Blitz Mogul