In 2024, emergency physicians are grappling with growing challenges as major health insurance companies, specifically UnitedHealthcare, Blue Cross and Blue Shield, Aetna, and Cigna, continue to use unfair tactics to reduce payments to physicians. These practices are not just hurting physicians; they are also putting patient care at risk by making it harder for people to access the emergency medical care they need. Despite laws intended to protect patients, like the Prudent Lay Person (PLP) standard, insurance companies are finding ways to deny coverage and delay payments, forcing physicians to fight back through litigation and pleas to regulators.  

One particularly frustrating tactic is the prepayment review (PPR), where insurance companies put claims on hold and demand that additional documentation be provided before deciding whether to pay. Cigna, for example, uses software that automatically denies claims if the procedure and diagnosis codes do not perfectly match – without even a human review prior to the denial being issued. This approach alone has led to thousands of denied claims, leaving emergency departments struggling financially and adding to physician burnout rates. On top of that, payors have been found to frequently down code claims, which means they lower the payment by reclassifying the diagnosis, further hurting emergency physicians.  

These poor tactics result in more than just financial strain, they are a threat to the healthcare safety net. Emergency physicians are being pushed to their limits, and patient care is hanging in the balance. To combat these challenges, emergency groups must continue advocating for fair reimbursement and treatment and consider all their options, from mediation to litigation, to hold the insurance companies accountable. The stakes are high, and the healthcare system needs to protect the critical services that emergency physicians provide daily to all individuals seeking care.  

To learn more about how bad payor policies and tactics are impacting emergency physicians, tune in to our most recent episode of Zotec Answers.