BASTROP, Texas (Nexstar) — Texas is home to more than 200 independent, freestanding emergency centers. They aren’t affiliated with a hospital and aren’t recognized by the Centers for Medicare and Medicaid Services, so people with that insurance may have to pay full price if they go there.
Sen. Bill Cassidy, M.D., R-LA, has introduced a bill titled the “Emergency Care Improvement Act,” which would provide Medicare and Medicaid recognition of freestanding emergency centers and provide a certain level of reimbursement for these facilities.
• Freestanding emergency centers in urban and suburban areas would be reimbursed at 75 percent of Medicare’s hospital rate, but lower-acuity patients typically seen by urgent care would not get facility payments
• Facilities located in rural areas would be reimbursed at 95 percent of Medicare’s hospital rate
Facilities would also need to follow emergency care regulations, such as the Emergency Medical Treatment and Labor Act. It’s a federal law that ensures patient access to emergency services, regardless of ability to pay.
“We see this as the statutes at the federal and state level just need to be caught up to the current healthcare landscape in the state of Texas,” said Brad Shields, executive director of the Texas Association of Freestanding Emergency Centers and its national affiliation. “It really is just a leveling of the playing field.”
How patients are affected
At Physicians Premier in Bastrop, there is signage on the front door that states how the facility does not participate in Medicare and Medicaid programs and, as a result, services provided at the location cannot be billed to Medicare or Medicaid.
“That’s painful for us to have people bypass us, go further, suffer more or potentially die,” said Dr. Christion Rice, an emergency physician at Physicians Premier. “That’s not something we like to see in medicine.
Rice explained how Physicians Premier recently ended up helping a Medicaid patient who needed immediate care with her pregnancy.
“She required lots of medication, lots of equipment and tools, lots of time from our staff,” Rice said. “This facility cannot bill her insurance, so facilities like ours are left with either leaving that bill for the patient or not getting any compensation,” he continued. “Every facility is a little different. What this bill would do is it would allow facilities like ours to be guaranteed recognition and hopefully some form of compensation for care like that.”
According to the Texas Association of Freestanding Emergency Centers’ analysis in 2016, the independent freestanding emergency department community in the state provided about $40 million of uncompensated care.
Rice also says this bill would allow patients to feel comfortable accessing freestanding emergency centers and would impact rural healthcare access in Texas.
“I think that this bill will allow freestanding emergency centers to become an alternative to hospitals that are going under, so that way patients in those areas still have access to lifesaving care when they need it and immediate access,” he said.
Physicians Premier has only been in Bastrop for a few months, but its team says the facility has received positive patient feedback.
“Just having an extra provider available around has made it amazing for patients to be seen faster, get out and get back to their lives quicker,” said DeAnna Gillespie, a nurse at the facility.
Gillespie said the Medicaid patient she and her co-workers helped reached out after receiving treatment.
“She contacted me a few weeks later, right before Thanksgiving, and told us that we at Physicians Premier gave her and her baby an opportunity to see another day,” she said.
Confusion in Texas
Private freestanding emergency centers in Texas have faced criticism for their practices. There has been confusion over freestanding emergency departments and urgent care facilities. In 2017, lawmakers passed legislation that requires freestanding emergency centers to be more transparent about their costs and network status. Legislators also expanded a patient’s right to challenge a surprise medical bill and leave the dispute to the insurance company and provider.
H.B. 3276 requires freestanding emergency centers to post notice about how a facility charges rates comparable to a hospital emergency room and may charge a facility fee and could be out of network. Facilities are also required to post information online listing the health benefit plans in which they are a participating provider in the health benefit plan’s provider network and provide patients written confirmation whether it is in-network under their health coverage.
S.B. 507 expands the mediation system under the Texas Department of Insurance to include all types of out-of-network providers treating patients at in-network hospitals and other facilities, such as freestanding emergency departments. It allows for mediation for emergent care balance bills over $500 at any healthcare facility, whether in-network or out-of-network.
Most recently, Texas Association of Health Plans CEO Jamie Dudensing also testified before the Senate Business and Commerce Committee about issues affecting the state’s health insurance marketplace. Dudensing cited problems with freestanding emergency centers, such as surprise billing and treatment of non-emergent diagnoses such as a cough.
In August, Blue Cross Blue Shield of Texas, the state’s largest healthcare provider, also adjusted some of its policies regarding emergency room benefits. The website states for patients under a Health Maintenance Organization (HMO), the company is taking extra steps to make sure they’re billed correctly, checking that services they received were for covered emergency care and medically necessary and reminding them that there is no benefit for out-of-network emergency room use for issues that aren’t serious or life-threatening, such as a sports physical.
In response to medical overbilling, the Texas Association of Freestanding Emergency Centers posted an outline on its website, recommending patients contact the facility they received treatment at or their insurance providers before making any payments if they believe they’ve been overcharged for services.
Additional efforts to protect patients from surprise medical bills
Sen. Cassidy has also joined other lawmakers in a bipartisan effort in Congress to fight surprise medical bills. They released draft legislation in September.
The Protecting Patients from Surprise Medical Bills Act would:
• Ensure that a patient is only required to pay the cost-sharing amount required by their health plan and a provider can’t bill the patient for an additional payment
• Require a patient to sign a written acknowledgement of a notification about a higher cost-sharing if they received a non-emergency service from an out-of-network healthcare provider or facility
• Ensure that a health plan or out-of-network provider can’t bill a patient beyond their in-network cost-sharing in a situation where a patient receives a non-emergency service from an out-of-network provider in a facility that is in-network