Texas’ Freestanding Emergency Centers Provide Critical Access to Care
A recent Houston Chronicle story highlighted consumer confusion about freestanding emergency centers (FECs) and questioned whether a patient’s ER care at an FEC would be covered by their insurance.
There is no doubt that confusion exists in the marketplace. However, the source of the confusion is grossly misattributed. It is not a coincidence that health insurance company profits are soaring to all-time highs while patients and providers pay an increasingly steep price.
Freestanding ERs provide real, life-saving emergency care. In numerous parts of the state, like Rockport—ground zero for Hurricane Harvey’s destruction—they may be the only access point to emergency care for many miles around.
However, with increasing regularity, some insurance carriers are not abiding by the rules that are meant to protect patients. They are purposely creating doubt in the minds of consumers about whether their emergency care will be covered at certain ER facilities, in order to increase their profits. This practice endangers lives. Through marketing ploys and profit-motivated legislative agendas, insurance carriers are steering patients to higher cost centers where they can reliably make more money on every patient visit.
Patients have been steered away from life-saving care by insurance carriers. It is a dangerous and growing problem. We want only what’s best for patients and their health and wellbeing. Texas families are counting on their elected officials to make the right decision when it comes to protecting their care. We will do all we can to push for these vital patient protections.
Here is the truth about FECs, emergency care in general, and patients’ insurance plans:
- In-network versus out-of-network is a red herring when it comes to ER care. According to the law, in a medical emergency, all patients with insurance should have their ER care covered because insurance carriers must apply benefits in an emergency using “in-network” cost sharing provisions.
- When consumers enroll in an insurance program, they receive a plan benefit document and a summary benefit document. If their health plan is compliant with the law, that document—which is essentially a contract between the consumer and the carrier—will state in some form that they are covered in an emergency no matter where they seek care under federal and state protections provided by the Prudent Layperson Standard.
- In most cases, consumers are able to “assign” their benefits, which FECs are able to accept.
- Freestanding Emergency Centers licensed by the State of Texas cannot turn patients away in an emergency. We are required to accept all patients regardless of insurance status or ability to pay, something we would gladly do even if it was not required.
- When consumers have an HMO plan or an EPO plan in Texas, their insurance carrier is required to hold them harmless for a “balance bill” in an emergency. With an alarming uptick in frequency, insurance carriers are sticking patients across our state with more and more of the bill.
- Texas consumers with fully funded PPOs have plans that require their insurance carrier to cover them at the “usual and customary charge.” The general consensus among freestanding ER operators and emergency physician groups is that the 80th Percentile of the FairHealth charge database constitutes what is usual and customary.
- If insurance carriers are abiding by the law and the contracts they have with consumers, there is little to no reason why a patient would ever receive a balance bill for emergency care (though it’s worth noting that this doesn’t mean patients won’t have to pay a deductible, copay, or co-insurance).
- “In-network” does not necessarily mean less expensive than “out-of-network.” This is important for all patients to know.
Large, consolidated health systems are often in-network because of their market power and ability to negotiate. Smaller providers such as independent ERs can operate at a lower cost due to our having less overhead.
However, most carriers won’t negotiate a fair contract in-network with independent freestanding ERs even though it would mean better pricing for their members (i.e. you, the patient) because it does not serve to increase their profits.
No Texan should ever be discouraged from seeking emergency care at the nearest ER. The predatory practice of some insurers to steer patients away from what may be the nearest and best ER option endangers the physician-patient relationship, the independent practice of medicine, decreases competition, hurts small businesses and the communities they serve, and ultimately increases costs for consumers.
This anti-competitive behavior and corporatization of medicine that puts profits before patient care should deeply concern patients, employers, consumers, and legislators. Texans need to look past the smoke and mirrors charade of the well-funded insurance lobby, and demand that fair and lawful coverage be provided to Texas healthcare insurance policyholders.
Dr. Carrie de Moor is the CEO of Code 3 Emergency Partners based in Frisco, TX.