The American College of Emergency Physicians is suing HHS, claiming a provision of the Affordable Care Act allows insurers to underpay for out-of-network emergency medical services.
The federal lawsuit asks that insurers be transparent on the data they're using to pay for services rendered by an out-of-network hospital.
The ACA established that in these cases, insurers must pay the greatest of three costs: the insurers' in-network amount, the Medicare amount or the usual, customary and reasonable amount. The UCR, the amount physicians charge for care, is often the greatest of the three.
Insurers previously have been accused of manipulating UCR figures to lower their obligation, leaving patients with a greater amount to pay out of pocket. Some states require the ER physician to accept the insurers' payment, even if it is far below the doctor's set fee.
The ACEP is asking the federal government to overturn and amend the provision.
The government has not yet responded to the lawsuit, according to Dr. Jay Kaplan, president of the American College of Emergency Physicians, which represents 34,000 physicians.
Requests for comment from the government were not immediately successful Tuesday afternoon.
Kaplan said insurers should be required to be transparent with their data.
"We should be able to say: How did you calculate this? And show us the data,” said Kaplan, who has been an emergency medicine physician for 37 years.
Kaplan said emergency room physicians are more likely to treat out-of-network patients because the Emergency Medical Treatment and Labor Act requires them to care for anyone who walks into an emergency room regardless of their ability to pay.
Kaplan said his colleagues are worried they won't have any protections in states that prevent unexpected out-of-network bills, such as New York, which requires insurers and providers that disagree on out-of-network payment to go through an independent dispute-resolution process.
