The Critical Role of Physician Advocacy in Combating Insurer Abuses and Protecting Emergency Care

By Jamie Shoemaker, MD, FACEP

Emergency medicine is a cornerstone of the healthcare system, serving as the safety net for patients in their most vulnerable moments. Yet, this vital specialty faces significant challenges—chief among them, the increasing pressure from healthcare insurers and the declining reimbursement rates that threaten the sustainability of emergency medical services. In recent years, insurer bad behaviors, such as downcoding, misinterpretation of key federal statutes, and the erosion of the physician fee schedule, have created a dangerous environment for emergency physicians and the patients they serve.

Physician advocacy at the local, state, and national levels is crucial to combat these harmful practices and to ensure that emergency medicine remains viable. Our collective voice is powerful; it is essential that we use it to protect the emergency medicine safety net, safeguard fair reimbursement, and ultimately defend our patients’ right to accessible and high-quality care.

Insurer Bad Behaviors: Downcoding and the Erosion of Statutory Protections

One of the most egregious issues facing emergency physicians today is the practice of downcoding by insurers. Downcoding occurs when insurers evaluate a claim and deliberately assign a lower level of care than what was provided to the patient, resulting in reduced or no payments to physicians. This practice undermines the integrity of emergency care and devalues the life-saving work done in emergency departments (EDs) every day. It also places an unnecessary financial burden on physicians, who are already working under significant pressures.

Moreover, insurers have increasingly misinterpreted or ignored key federal statutes designed to protect patients. For example, the Prudent Layperson Standard—enshrined in both federal law and many state laws—requires that insurance coverage be based on the patient’s symptoms rather than the final diagnosis. This is a critical protection, as it ensures that patients are not penalized for seeking emergency care when they reasonably believe they are experiencing a medical emergency. However, insurers have begun to challenge this standard, leading to coverage denials for emergency services that are, by law, required to be covered.

Similarly, insurers have sought to sidestep or weaponize the Emergency Medical Treatment and Labor Act (EMTALA), which mandates that anyone arriving at an emergency department must be stabilized and treated, regardless of their insurance status or ability to pay. Insurers know that Emergency physicians are obligated to see all-comers to the ED 24/7/365 and we do so happily. However, when we assess, evaluate, and treat patients and who are ultimately not deemed to be sick enough by the insurer to necessitate Emergency care, they refuse to pay the level code appropriate for the services and professional care provided. This would be like hiring an electrician or plumber to come to our homes and refusing to pay for the services provided because the issue was not as complex or complicated as the homeowner anticipated. It is nonsensical. By narrowing the interpretation of these protections, insurers are eroding the very foundation of emergency care, leaving both physicians and patients vulnerable.

Additionally, the No Surprises Act, designed to protect patients from surprise medical bills, has been misapplied by some insurers to further diminish reimbursement for out-of-network care. While this act was intended to shield patients from unexpected costs, it has been exploited by insurers to artificially lower payments to emergency physicians, undermining the financial viability of EDs.

The Impact of Declining Medicare Reimbursement and the Physician Fee Schedule

Beyond insurer malfeasance, emergency physicians are also grappling with the long-term effects of inadequate Medicare reimbursement. Over the past two decades, a lack of inflationary adjustments has led to a staggering 29% reduction in physician reimbursement when adjusted for inflation. This decline has made it increasingly difficult for emergency departments to operate sustainably, especially in underserved and rural areas where Medicare represents a significant portion of revenue.

The depressed physician fee schedule, which has not kept pace with the rising costs of providing care, compounds these challenges. As inflation continues to drive up the cost of running emergency departments—from staff salaries to medical supplies—physicians are receiving less and less for the services they provide. This financial squeeze threatens the stability of emergency departments across the country, putting patient care at risk.

The Emergency Medicine Safety Net is at Risk

Emergency medicine serves as the healthcare system’s safety net, ensuring that all patients, regardless of their ability to pay or the complexity of their conditions, can access life-saving care when they need it most. However, the combination of declining reimbursement, insurer abuses, and the stagnant physician fee schedule is fraying this safety net. Physicians are being asked to do more with less, and many EDs are facing financial uncertainty, which is leading to staffing shortages, reduced access to care, and even ED closures.

The Power of Physician Advocacy: Our Voice Matters

In this environment, physician advocacy has never been more important. Emergency physicians must actively engage at the local, state, and national levels to fight back against insurer abuses, protect statutory safeguards like the Prudent Layperson Standard, and advocate for fair and sustainable reimbursement.

Forming a relationship with your local, state, and national legislators is essential to have a proverbial seat at the table and not be on the menu.

1. At the local level, physicians can work directly with hospital leadership and local policymakers to highlight the impact of insurer practices on patient care and hospital operations. Grassroots advocacy is essential for drawing attention to the real-world consequences of downcoding, coverage denials, and declining Medicare payments.
   
   
2. At the state level, physicians must engage with state legislatures to reinforce the importance of the Prudent Layperson Standard and EMTALA, pushing for stronger enforcement and penalties for non-compliant insurers. Many of the protections emergency physicians rely on are codified in state law, making state-level advocacy a critical battleground.
   
   
3. At the national level, emergency physicians must work with professional organizations, such as the American College of Emergency Physicians (ACEP) and the Emergency Department Practice Management Association (EDPMA), to lobby Congress for Medicare payment reform, inflationary adjustments to the physician fee schedule, and stronger oversight of insurer behaviors. National advocacy efforts are critical for ensuring that federal statutes are not diluted by insurer interpretations and that physician reimbursement is fair and reflective of the services provided.

Advocacy Protects Patients and the Future of Emergency Medicine

At its core, advocacy is about protecting patients. When insurers are allowed to manipulate coding practices, ignore statutory protections, and reduce physician reimbursement, patients suffer. They face reduced access to emergency care, longer wait times, and the potential loss of their local EDs altogether. By advocating for fair reimbursement, stronger enforcement of federal laws, and protection from insurer abuses, physicians are safeguarding not only their profession but also the patients who depend on them in their most critical moments.

Our voice matters. Advocacy is the key to ensuring that emergency medicine continues to fulfill its mission as the healthcare system’s safety net. Ventra Health recognizes the vital importance of advocacy at every level, ensuring our clients—and ultimately their patients—are represented and supported in achieving the best possible care and outcomes. We must fight to protect the financial stability of emergency departments, ensure that patients receive the care they need without fear of coverage denials, and hold insurers accountable for their actions. By doing so, we can secure a future where emergency medicine remains strong, resilient, and focused on delivering life-saving care to all who need it.