payment for emergency services). The third-party payor recognizes the patient’s assignment of benefits to the physician Prior to the delivery of an elective service, the physician needs to ensure that the patient has provided informed consent and signed an agreement to pay for the service. the physician who accepts assignment of benefits on behalf of the patient should confirm with the payor prior to the delivery of care that the payor will indeed honor the patient’s assignment of benefits to the physician. the physician also needs to determine what benefit, if any, is allowable under the patient’s health plan. in this instance, the payor responsibility would be deducted from the physician’s charge applied to each service performed, and the physician practice would collect the remaining patient responsibility from the patient at the time of service. The third-party payor pays the physician by mistake, when it intends to pay the patient sometimes a third-party payor may make an error and pay the physician directly when the health insurer typically does not accept assignment. in this instance, the health insurer may retrospectively attempt to recoup from the physician and in turn pay the patient directly for the services the physician provided. the physician is then in the untenable situation of having to find the patient and collect the appropriate payment from the patient several months after the delivery of care. Physicians are encouraged to collect directly from the patient when the physician is considered out of the patient’s health insurer’s physician network. The third-party payor adheres to Federal or state law (e.g., EMTALA requires payment on emergency services) the emergency medical treatment and labor act (emtala) (42 u.s.c. § 1395dd, et seq.) requires hospitals to provide certain types of emergency care to patients who come to emergency departments without regard for payment of such care (i.e., through health insurance coverage). many states have enacted laws that require health insurers to cover and, in some cases, actually reimburse emtala-mandated services. however, many health insurers interpret these state laws in a way that allows them to pay for emtala-mandated services at rates that health insurers themselves unilaterally determine, often below the reasonable value of the services provided. the ama supports the enforcement of existing laws and regulations that require health insurers to adequately compensate non-contracted physicians for emergency services provided to their enrollees. this issue of adequate reimbursement was reviewed under bell v. blue cross of california, 2005 cal. app. leXis 1119 (cal. app. 2d dist. july 21, 2005), and the court ruled that adequate reimbursement must be made at “a reasonable and customary amount for the services rendered.” the ama defines Usual, Customary, and Reasonable (UCR) as follows. • “usual”: the fee an individual physician usually charges his or her private patient for a given service (i.e., his or her own usual fee) • “customary”: a fee that is within the range of usual fees physicians of similar training and experience currently charge for the same service within the same specific and limited geographical area • “reasonable”: a fee that meets the above two criteria and is justifiable, considering the special circumstances of the particular case in question without regard to payments that governmental or private plans have discounted health insurers normally measure ucr values by using a percentile ranking of billed charges that other physicians within a given geographic region have submitted for each reported procedure. unfortunately, a universally accepted definition of a percentile does not exist. because definitions of a percentile differ, health insurers often have dramatically different ucr values, especially if the health insurer bases the calculation on relatively little data. AMA Practice Management Center Resource Tip + for more information regarding contacting health insurers about out-of-network payments, visit www.amaassn. org/go/out-of-network to access the “out of network toolkit,” which includes sample template letters (for ama members) to obtain additional information from a health insurer and other resources. the journal of the healthcare billing and management association 29
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