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 Doctors Complain About New Balanced Billing Reg

The federal government 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, according to the American College of Emergency Physicians (ACEP). Dr. Jay Kaplan, president of ACEP said that the organization is considering legal action. 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 reimbursements, and physicians bill patients for the unpaid balances.

Kaplan said, “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%. 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. They will continue to shift costs onto patients and medical providers, and 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.” The new regulation was issued by the Department of the Treasury, the Department of Labor and the Department of Health and Human Services.

Sports Injuries Land Many Californians In the ER

Over 300,000 Californian athletes visit the ER annually, which is a rising financial risk for families as high deductible health insurance grows and health coverage shrinks, according to a Sun Life Financial report. More Californians participate in each of five sports – baseball, basketball, softball, soccer, and volleyball – than do residents in any other state. The report reveals the following sobering statistics:
• A household has a 50% chance of having an emergency room injury within five years when a family member participates in football, ice hockey, or soccer.
• Injuries from seven popular sports lead to average ER medical costs of $3,000 to $4,000.
• Football, which has the highest sports injury rate at 8.5%, leads to over 60,000 California ER visits this year, second only to basketball. Soccer is expected to generate over 40,000 California ER visits this year.
• Increasingly popular high deductible health insurance plans have average deductibles of $4,000 for a family deductible and $2,000 for an individual.
• Accident insurance can fill widening gaps in medical insurance coverage. Beginning in 2018, a 40% excise tax will be imposed on the value of health insurance benefits exceeding a certain threshold. The estimated thresholds are $10,200 for individual coverage and $27,500 for family coverage. Employers are starting to phase out medical coverage that would be subject to the tax.

One doctor, who was interviewed for the survey, reports a disturbing number of people who refuse essential emergency care because of medical costs. He says that agility training can prevent injury by increasing the ability to anticipate an accident. For more information, visit

Medicaid Patients Use, Not Abuse Emergency Rooms

Medicaid enrollees visit the emergency department appropriately like most patients, but have more complex health needs and less access to primary care, according to a report from the Medicaid and CHIP Payment and Access Commission (MACPAC).  Non-urgent visits accounted for just 10% of Medicaid visits to the ER, which is very close to that of the general population – about 8%. Most have serious and complex medical problems that can only be addressed in the emergency department. Given Medicaid’s historically low reimbursement rates, the shortage of primary care physicians accepting these patients isn’t surprising. The lack of access to primary care is even more acute for Medicaid patients with disabilities who are disproportionately represented on Medicaid rolls. Alex Rosenau, DO, FACEP, president of the American College of Emergency Physicians  said, “The lack of access to primary care certainly contributes to Medicaid patients’ use of the ER, but for Medicaid patients with serious mental illness, multiple illnesses and homelessness, even having a primary care physician is no bar against appropriate emergency department use. In general, the combination of poverty and illness present challenges with few genuinely simple solutions, despite misplaced beliefs that significant health care costs could be saved by keeping patients out of the ER. Efforts by various states to deny payment for Medicaid visits to emergency departments are dangerous and wrong.” 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

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