Emergency department (ED) medicine is facing significant challenges amidst the ongoing changes in the healthcare landscape. The effects of the COVID-19 pandemic, coupled with Medicare reimbursement cuts and evolving billing requirements, have created a complex and demanding environment for emergency providers. This article will explore the difficulties emergency departments are currently grappling with and shed light on the hurdles they must overcome to continue providing quality care to patients in need.

Impact of the Aftershock Post-Pandemic:

Emergency department providers are still reeling from the lingering effects of the COVID-19 pandemic. Despite some relief with the rollout of vaccines, healthcare systems continue to face staffing shortages and financial burdens. Hospitals and health systems entered 2023 with a 2 percent year-over-year increase in total expenses, and emergency department labor costs saw a staggering 50 percent increase from pre-pandemic levels.

  • A) Staffing Challenges: The pandemic has taken a toll on the healthcare workforce, leading to increased burnout and exhaustion among emergency department staff. The relentless demands during the peak of the pandemic have left many healthcare professionals feeling physically and emotionally drained. Staff shortages persist, as some have chosen to leave the healthcare industry altogether or seek fewer demanding roles. Finding qualified personnel to fill these gaps has become a formidable task, hampering emergency departments' ability to deliver timely and efficient care.

  • B) Financial Strains: Despite providing critical care during the pandemic, emergency departments and healthcare systems are facing lingering financial difficulties. The surge in COVID-19 cases resulted in increased expenditures for personal protective equipment (PPE), testing supplies, and additional healthcare equipment. Simultaneously, the suspension of elective procedures and a decrease in non-COVID-19 patient volumes during the height of the pandemic resulted in a significant revenue loss. These financial strains have persisted post-pandemic, impacting emergency department labor costs and overall expenses.

  • C) Changes in Patient Behavior: The pandemic has led to shifts in patient behavior, affecting emergency department utilization patterns. Fear of exposure to the virus and uncertainty about seeking healthcare have led some patients to delay or avoid seeking medical attention until their conditions worsen. This phenomenon has resulted in an increase in patients presenting with more severe illnesses, potentially leading to longer hospital stays and more complex cases for emergency providers.

Medicare Reimbursement Cuts:

Emergency physicians and healthcare organizations had braced themselves for significant Medicare reimbursement cuts in 2022. Initially, a total reduction of 9.75 percent was expected, including a 2 percent Medicare sequester, a 4 percent "Pay-Go" sequester, and a 3.75 percent reduction in the Medicare Conversion Factor. Fortunately, last-minute Congressional action resulted in a one-year Medicare fix, leading to a weighted average reduction of -2 percent for the year. While this provided temporary relief, there remains uncertainty about future reimbursement levels.

The Impact of the Federal No Surprises Act (NSA):

The federal No Surprises Act (NSA) went into effect on January 1, 2022, to protect patients from surprise medical bills. Specifically, it targeted surprise bills resulting from out-of-network (OON) emergency services, items, and services provided by OON providers at in-network facilities, and OON air ambulance services.

Under this law, OON providers cannot bill patients for an amount greater than the patient's in-network cost-sharing obligation. Instead, OON providers must negotiate with the patient's insurer to collect adequate payment for their services. While the law achieved its goal of protecting patients, it created challenges on the provider reimbursement side. The rules remained unclear or under construction for a significant part of the year, leading to an indirect impact on the entire reimbursement landscape.

Payer Behavior Changes Following the Passage of the NSA:

Provider groups initially believed that the NSA's impact on their practices would be limited, as the law focused narrowly on OON medical services. However, when the law went into effect, there was an abrupt change in payer behavior. Many payers lost interest in maintaining in-network status, leading some to walk away from active in-network negotiations or send letters of cancellation to their in-network providers. This shift resulted in pushing more providers into OON status, with payers significantly reducing payment rates for OON services, leading to an explosion of OON payment disputes being submitted for independent dispute resolution (IDR).

IDR Challenges and Lack of Information Sharing:

When the NSA was established, there was a general belief that the IDR process would have moderate or low usage. However, data shows that more than 90,000 disputes have already been submitted since the IDR portal launched in April, with more than half of those cases requiring IDR. This has led to a growing backlog of delayed cases, with less than 18,000 payment determinations made during the same period. Payers' reluctance to share information and apply specific codes at the time of payment has placed a burden on IDR entities, causing added administrative work and unnecessary expenses.


Emergency department medicine is facing an amalgamation of challenges arising from the ongoing pandemic, changes in Medicare reimbursement, and evolving billing requirements, as well as the implementation of the federal No Surprises Act. Staffing shortages, escalating labor costs, and financial pressures continue to strain healthcare systems. While the one-year Medicare fix provides temporary relief, the need for a lasting solution remains pressing. Emergency providers must navigate the intricacies of split/shared visits, critical care billing, and the complexities of the No Surprises Act, emphasizing accurate documentation and compliance to overcome these hurdles.

Despite these difficulties, emergency department teams persevere, providing critical care to patients when they need it most. Collaboration, adaptability, and advocacy will be crucial for sustaining quality emergency medicine and ensuring the best possible patient outcomes. As the healthcare landscape continues to evolve, it is essential for providers, payers, and regulators to work together in addressing the challenges and finding equitable solutions for the benefit of patients and emergency medicine as a whole.

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