Doc-to-Doc Series: The Undermining of Emergency Medicine: Insurer Tactics, the Fragile Safety Net, and the Fight for Just Compensation 

By Jamie Shoemaker, MD, FACEP

Emergency physicians serve on the front lines of America’s healthcare safety net, providing essential, life-saving care to anyone at any time, regardless of their ability to pay. Yet this mission is increasingly imperiled by aggressive, opaque, and often egregious tactics employed by healthcare insurers to delay, reduce or outright deny payment for these services. Emergency departments (EDs), which already operate under financial strain, now face compounding threats due to healthcare insurer reimbursement practices that jeopardize both physician viability and patient access. 

Insurer Tactics That Devalue Emergency Care 

Healthcare insurers are deploying increasingly sophisticated and harmful strategies to reduce payments to emergency physicians: 

• Downcoding of Claims: Insurers routinely downcode submitted evaluation and management (E/M) levels, reclassifying a Level 4 or 5 visit to a lower-paying Level 3, despite documentation supporting higher acuity. This practice undermines the complexity of emergency care, disregards the real-time decisions made without benefit of hindsight, and flies in the face of Federal Prudent Layperson and Emergency Medical Treatment and Labor Act (EMTALA) mandates. 
• Prepayment Reviews and Delays: Some payers implement prepayment reviews under the guise of fraud prevention, delaying reimbursement for months or even years. This introduces cash flow uncertainty and administrative burden that many physician groups cannot sustain. 
• Automated Denials via AI: Insurers are increasingly using artificial intelligence algorithms to rapidly deny large batches of claims without human review. While pitched as “efficiency,” these tools often lack transparency, clinical nuance or due process, and are extremely difficult to appeal successfully. They are banking on physician groups to throw their hands in the air and accept lower reimbursement rather than appeal and fight for just compensation. 
• Discharge Diagnosis as a Payment Gatekeeper: Some payers deny claims based on the patient’s discharge diagnosis, rather than the presenting symptoms. This retroactive logic completely ignores EMTALA, which mandates treatment based on symptoms, not outcomes. It punishes physicians for performing their duty. There is no justification for this egregious practice. 
• Bundling and Misclassification of Services: Payers often bundle separately billable procedures, or misclassify services to a lesser reimbursement category, with little justification and few avenues for recourse. 

A Fragile and Failing Safety Net: Data from RAND 

The RAND Corporation’s 2024 study on the stability of emergency medicine paints a stark picture of a specialty under siege. The report reveals that over 50% of ED physician groups have experienced a significant decline in reimbursement in the past three years, with nearly 30% contemplating staffing cuts or service reductions. Perhaps most alarming, rural EDs and smaller groups are disproportionately affected, accelerating the closure of already vulnerable hospitals and reducing access to care in medically underserved areas. 

RAND underscores that emergency departments are increasingly being relied upon to fill care gaps—particularly for behavioral health and the uninsured—even as the reimbursement model becomes more volatile and less predictable. This dynamic is unsustainable. The ED safety net is fraying, and without meaningful reform, the public’s access to timely emergency care is at risk. 

The No Surprises Act: Good Intentions, Problematic Implementation 

The No Surprises Act (NSA) was intended to protect patients from surprise medical bills—a goal emergency physicians strongly support.  However, the Independent Dispute Resolution (IDR) process intended to ensure fair physician compensation has proven to be both burdensome and biased. Physicians are required to front arbitration fees, wait months for decisions, and navigate opaque processes that frequently default to insurer-calculated median in-network rates, which are often artificially suppressed. 

Even when physicians prevail in the IDR process, many struggle to collect the awarded amounts. Insurers delay payments, refuse to honor decisions or push claims into endless administrative loops. The imbalance of power is stark—and the NSA, in its current form, fails to provide emergency physicians the protection or reimbursement they are owed. 

Conclusion 

Emergency medicine is a public trust and a national necessity. Yet insurers continue to erode this foundation through strategic underpayment, administrative abuse and regulatory manipulation. The RAND study confirms what frontline clinicians have known for years: our safety net is under threat. Navigating the post-NSA world, defending claims, and ensuring just compensation requires more than resilience—it requires the right partner. In the face of this hostile landscape, physician groups need more than just a billing company—they need a true strategic partner. Ventra Health stands out as a positive disruptor, combining cutting-edge analytics, meticulous coding oversight and payer negotiation expertise to ensure emergency physicians are compensated fairly and promptly. 

Ventra leverages its best-in-class analytics platform, vSight^tm, to monitor underpayment trends, detect patterns in downcoding or denials and generate actionable intelligence that allows real-time revenue recovery. With a team of experienced coders and revenue cycle strategists, Ventra ensures clinical documentation is optimized, claims are submitted cleanly and appeals are pursued aggressively.