Hospitals are required to evaluate and provide emergency services to individuals who seek attention for emergency conditions. Most states, and now the federal government, have enacted laws that require insurance companies and other private sources of health coverage to reimburse hospitals for these services. Both state and federal laws prevent payers from denying coverage for emergency services due to medical necessity or failure to obtain authorization. However, payers persist in denying reimbursement—often based on commercial contractual language that is vague and not controlling when contrary to law.
TGF identifies applicable laws, interprets commercial contractual language, and requires payers to cover emergency medical services, thus preventing providers from losing money on care they are required to provide, while enforcing rights specifically granted to patients by state and federal governments.
- Hospitals are required to provide emergency services to individuals who arrive at their emergency departments
- Because emergency services are expensive, payers look for ways to deny payment
- TGF forces payers to comply with applicable laws and works on behalf of hospitals to prevent lost revenue in this area