July 18, 2022

Emergency Physicians Strongly Oppose Insurer Efforts to Deny or Avoid Fair Reimbursement

Even during a global pandemic, insurance companies’ attempts to avoid reimbursement are persistent and expanding. The American College of Emergency Physicians (ACEP) applauds efforts to hold insurers accountable for these schemes and strongly supports laws and regulations meant to halt these patterns of bad behavior.

Insurers must not be permitted to skirt their legal obligation to provide fair reimbursement for emergency services.

The denial of valid claims, or attempts to “downcode” by lowering the level of service indicated on a claim, are insurer tactics directly in opposition to the Prudent Layperson Standard, a patient protection that is a bedrock principle of emergency medicine codified in state and federal law.

Despite unambiguous statutory language, insurers continue to ignore the requirements of the law and choose instead to trot out a well-worn playbook of maneuvers meant to pad their own coffers with little regard for emergency physicians or the well-being of their patients.

Many of these attempts have resulted in lawsuits and hefty fines. It is worrisome but not surprising that insurance companies seem undeterred.

Many emergency departments are already managing staffing constraints and resource challenges. It becomes incredibly difficult, especially in rural or underserved communities, for physicians to keep their practices fully operational without fair and timely reimbursement for services. 

Emergency physicians see firsthand that legislation that lacks a meaningful enforcement mechanism is only a stopgap solution.

ACEP will not hesitate to call out bad actors and is committed to continuing the work with Congress, regulators, and others to champion policies that require insurance companies to conduct their business in good faith and consistent with current law.

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