American College of Emergency Physicians sues HHS for OON emergency payment rules — 5 key points

Written by Mary Rechtoris | May 25, 2016 | Print  |

The American College of Emergency Physicians filed a civil lawsuit in the U.S. District Count against the Department of Health and Human Services and other federal agencies for implementing payment rules that resulted in insufficient reimbursement for out-of-network emergency services, according to Healthcare Finance News.

Here are five key points:

1. In the suit, ACEP argues payers set lower reimbursement rates than what HHS considers a reasonable rate.

2. The group is imploring the court to overturn the federal regulating by setting a reasonable reimbursement rate for OON emergency services.

3. The government issued a final rule in 2010 on OON emergency services provisions, thereby creating the "greatest of three" methodology to set payments. Based on this methodology, the insurer, in theory, should pay the greatest amount of:
•    The in-network amount
•    The customary and reason amount, or
•    The Medicare amount

4. While the methodology aims to give the maximum payment for OON services, the suit claims "insurers have historically understated and prevented public verification of the oayment amounts." Thus, ACEP is asking officials to require payers to use payments that are transparent and publicly verifiable.

5. ACEP also claims the payments may force emergency medicine physicians out of practice if they don't receive fair rates.

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