When insured patients are treated in the hospital, they should be confident in the knowledge that their health
insurance will cover them. Unfortunately, a growing number of these patients are finding out too late that their
coverage is far less comprehensive than they thought. Increasingly, insurers are making unsuspecting patients
responsible for additional payments of covered services provided by hospital-based physicians who are not in their
insurer’s network. Insurers have been further worsening this problem by enticing consumers to enroll in plans
with ever-growing deductibles and ever-narrowing networks of providers. These are intentional business decisions
by the insurers that allow them to reduce costs by shifting significantly more of the cost-sharing burden onto
patients and by limiting the pool of physicians in their networks to those who agree to contract at greatly reduced
rates that may be well below market value. Since the insurance industry is intensifying its efforts to narrow
networks further and force more physicians out of network, we believe a fair and equitable solution to the out-of-network balance billing issue should be developed that protects unsuspecting patients from facing significant
financial hardships simply because the hospital services they needed at that moment were provided by an out of-network physician. The following shared principles of consensus are agreed to and will be supported by hospital-based physician specialties:
- Insurers must meet appropriate network adequacy standards that include adequate patient access to specialty
care, including access to hospital-based physician specialties. State regulators should uphold such standards in
approving health insurance company plans. - All persons and entities involved in providing and financing health care have an obligation of transparency to
patients and health care consumers. However, any discussion of transparency in the emergency setting must
recognize that federal requirements under EMTALA statutes provide that patients seeking emergency care
have unfettered access to a diagnostic evaluation and stabilizing treatment without regard to their ability to
pay, thus appropriately restricting any discussion of costs and insurance status until a patient is stabilized. - The vast majority of physicians want to participate in network with insurance companies, but can only do so
when insurers negotiate in good faith for fair reimbursement.
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