Out of Network Emergency Care: Three Components of Asking For Higher Payment

Are insurers calculating your out-of-network emergency claim payments correctly?  How do you know?

Emergency care is one of the most protected areas of medical care. While scheduled procedures fall under a number of cost-containment features, emergency care is by definition not as easily managed by managed care. Further, there are a number of state and federal mandates which protect patients from unjust penalization from seeking emergency care from the most easily accessible emergency care provider.

If that provider is your organization, it pays to carefully assess insurance benefit calculations and determine if full benefits were released. Appeal Solutions has developed a Three Point Appeal approach for Out-of-Network Emergency Care Appeals which focuses on the following three issues:

(1) Clinical Information – Emergency care appeals should summarize the patient’s condition upon admit and detail the emergency care service provided including both critical care and post-stabilization care. Attaching medical records is not sufficient. Medical records contain important information but do not adequately address the treatment in the context of your internal quality care guidelines and pertinent industry standards of care. The internal criteria being used by the insurance carrier may not be as up-to-date or thorough as the clinical standards followed by your organization and your appeal is the opportunity to detail this information.

(2) Disclosure Request - Emergency care appeals should demand full disclosure of denial details. Denials can be vague. Even clearly stated denials such as "denied due to lack of medical necessity for emergency care" does not provide you with important information such as the clinical criteria used to assess treatment. Therefore, a Level I appeal should request the specific written limitation, exclusion or internal guideline which applies to the denial. Further, if the appeal is related to poor reimbursement, your letter should request disclosure of the methodology used to calculate the payment.

(3) Compliance Review - Each appeal should identify any potential compliance issue regarding the carrier's legal and/or contractual claim processing obligations. This requires being well educated on both state and federal claim processing requirements and potentially applicable utilization review standards. Some of the legal protections applicable to out-of-network care include federal and state disclosure laws related to benefit calculation disclosure, state emergency and trauma coverage laws and prudent layperson federal and state mandates.