Willing Healthcare Providers Seek Fair In-Network Contracts

One of the most critical issues impacting the healthcare of North Texans is timely access to it. In fact, the American College of Emergency Physicians gave Texas an “F” in access to emergency care in their 2014 Report Card. Unethical business practices and actions taken by health insurance companies are keeping Texans from being able to choose expeditious and cost-effective emergency services.

Independent freestanding ERs offer a high quality, fast, and cost-effective alternative for acute, unscheduled care. Yet, there is a coordinated effort by health insurers to keep these facilities out of their contracted health networks. As an owner of both freestanding ERs and urgent care facilities in the Dallas-Fort Worth area, I am familiar with in-network negotiations and have successfully secured multiple in-network contracts for my urgent care centers. However in my opinion, when it comes to freestanding ERs, insurance companies have not acted in good faith.

Being an in-network provider helps consumers anticipate expected medical bills, and have confidence in the options available to them in the event of an emergency. Even though independent freestanding ERs are a growing healthcare delivery model in Texas, insurance companies have shown resistance to working with them.

North Texas is home to 40 independent freestanding ERs that provide a less expensive alternative to more than 100 hospital-owned and operated ERs in the area. My experience attempting to become an in-network provider for my freestanding ERs was time consuming—lasting two years—and, ultimately, fruitless. Currently, none of my freestanding ERs are in-network, although by law, we must see and treat all patients with an emergency. As a physician and ethical business woman, it was a frustrating experience to negotiate a reasonable payment rate on behalf of our patients.

For the few companies willing to communicate with me beyond an initial email, they refused in-person meetings and full disclosure of methodologies, and attempted to lock me in at a low rate that would be unsustainable for any viable medical practice. To me, their final goal was to set a low payment rate, and then drive up deductibles and patient responsibility–essentially turning my facilities into a credit card system for the insurance companies.

Unfortunately, most freestanding ER operators have had a similar experience. A recent poll of freestanding ERs in Texas found that 64 percent had not been contacted by a health plan to contract, despite the operators’ repeated attempts to do so. Forty-five percent said their inability to obtain in-network status was due to unreasonably low offers for contract rates, which were too low to allow them to stay in business. In these instances, the only reasonable option for healthcare providers is to opt out. If we choose to accept the ridiculously low payment rates, we won’t be able to sustain our business. Either way, Texans lose.

As an individual insurance policyholder, I experience the same frustration when I question my medical bills. Insurance companies are attempting to obscure methods for determining usual and customary rates of coverage for patients. In Texas, narrow networks are not due to an insufficient number of healthcare providers. Many providers are lined up waiting for a reasonable offer from health insurance companies. If insurers want enrollees to have timely access to care, they would allow freestanding ERs to join their networks and offer reasonable payment. We stand by ready and willing to do the job.

Dr. Carrie de Moor is president and CEO of Frisco-based Code 3 Emergency Physicians and chairman of the American College of Emergency Physicians’ Freestanding Emergency Centers Section.

Posted in Expert Opinions.
  • Muffi Bootwala

    Totally agree with everything shared in this article.
    i own a home health agency and have the same problem. Large insurers have closed their network stating there are enough providers in the area…while on the other hand we have to turn down referrals on a weekly basis because we are unable to accept the insurance (being out of network).
    In my experience with talking to other agency owners who are in network, they don’t want to accept those patients because of the ridiculously low bill rates and end up turning down the referrals anyways.
    In this whole provider-insurance-hospital battle; the only one that loses is THE PATIENT!!

  • blueapple78

    I too agree 100%. The republicans are making me nuts with disjointed they are with healthcare reform. Even if you keep the 10 EHBs (though I believe it should be a larger basket) and allow primary care and DPC to receive a fee for care, i.e., the tax credit, then we would save money. You half the average they are spending with insurers.
    What’s left is ER and hospitalization. I would do the same thing. ERs could have agreements with the primary care and also receive a subsidy for the same patients whether you see them or not. This would guarantee competition with the insurers. And like primary care, ERs would have an incentive to keep patients out of the hospital through expanded care if they had beds of their own.

  • Lori Debetaz

    There is nothing cost-effective about freestanding emergency rooms. They are largely unnecessary and increase healthcare costs for everyone. They are primarily set up in affluent areas where the majority of people have private employer-based insurance and hence, the high prices these ERs charge are still likely to be paid by a combination of the insurance company and the sticker-shocked patients. People need night-time and weekend access to health care that primary care practices generally don’t provide. But overpriced freestanding ERs are not the solution.

    • Jarred

      Increasing access to PCP is a good solution, but it doesn’t diminish the need for increased emergency care. Medical experts, MedPAC, and others recommend freestanding ERs as the best solution to solve access to care issues across the country. As traditional hospitals struggle financially and community hospitals close, smaller and more efficient freestanding ERs are the best fit to maintain emergency care in these areas (pending federal reimbursement for Medicaid/Medicare patients). The hub and spoke model is the future of emergency care, and it does reduce costs.

      • Lori Debetaz

        To the contrary, MedPAC has concerns about the proliferation of freestanding ERs. (http://medpac.gov/docs/default-source/meeting-materials/standaloneeds_nov16_for_laptop.pdf?sfvrsn=0) Such ERs may be a possible solution for lack of access in isolated rural areas but the vast majority of these ERs are in urban and suburban areas in higher income areas and within 10 miles of hospitals. Freestanding ERs do not provide all of the services of hospital-based EDs such as trauma care or operating rooms. The only individuals and organizations highly recommending these over-priced unnecessary facilities are those who are benefiting financially from them.

        • Jarred

          FYI – FECs do not receive reimbursement for treating CMS patients currently, which is why I mentioned “pending federal reimbursement for Medicaid/Medicare patients”, which would allow FECs to serve these areas with higher concentrations of CMS patients. Currently, FECs treat these patients for free. If FECs are able to receive payment for treating these patients, we will see a shift into new, rural markets where access to care is restricted. I would be happy to send you the report from MedPAC saying FECs are a top solution, and recommending that FECs receive payments for treating these patients.

          • Lori Debetaz

            As an account manager for Influence Opinions, the marketing and communications agency employed by the Texas Association of Freestanding Emergency Centers (TAFEC), you are paid to promote these facilities. As I mentioned in my earlier comment, MedPAC has commented that FECs might be helpful in isolated rural areas. But these facilities in urban and suburban high income areas are unnecessary and contribute to high healthcare costs for all of us. If FECs in Texas had to meet determination-of-need regulations, we wouldn’t have seen such a ridiculous proliferation of these facilities.

          • Jarred

            And I am happy to support these innovative facilities, which will most certainly improve the delivery of emergency care. I would respectfully disagree that all urban and suburban facilities are unnecessary, given long hospital wait times and the growing number of emergency visits. But I, and even FEC operators, will agree with you that the proliferation and site selection in certain areas was highly concentrated, offering too much access to care – which is why we have seen some FECs closing or merging, because ultimately the market will determine what businesses will succeed and what will not.

          • blueapple78

            I agree with Jarred. The idea that freestanding facilities are unnecessary is wrong. What we have is an oversupply of hospital beds and overutilization of ERs. The fact of the matter is that if we’re going to bring down the costs of healthcare we should be open to all new models.
            I believe that freestanding ERs opened in urban areas, especially low income areas would relieve the burden on both public hospitals and the charity care costs that impact both nonprofit and for profit. Diversion and long wait times are a problem for all ERs.