When The Emergency Room Is “In Network” But The ER Doc Isn’t

I’ve become intimately familiar with our medical system over the past three months. My mother has been hospitalized twice (One of them was necessary. One?…) My uncle had a serious heart attack. Jon remains in treatment for cancer. In between, I’ve had a recurring case of bronchitis that has required five doctor’s visits and 40 days of antibiotics and counting. (And, of course, I’ve had the annual pleasure of changing insurance companies due to yet another cancelled plan). I loathe our current “system”.

And as time permits, I will expand on what I’ve learned at each step of the way. Most of it is not good. While I have earned scorn for insurance companies, I’ve lost my sense of humor with hospitals, pharmacies, and most any bureaucrat associated with this system. I’ve concluded it is dysfunctional by design. To quote a line from the movie Operation Petticoat, “In confusion, there is opportunity.” There are many taking advantage of the bloat in this system, and it is patient care that is suffering. We continue to pay more and get less.

With that long preamble out of the way, today I’ll start not with a personal anecdote from the above list, but on a bill that is currently proposed before the Georgia General Assembly. 11Alive’s Doug Richard’s provides the details:

It was for some respiratory distress,” said Dan Harrison, recalling his visit last spring to a metro Atlanta emergency room with his six year old daughter. The hospital, he says, was in his insurance network.

“It was like a $50 co-pay. And then right about the same time, I got a bill for physician services,” Harrison said.

It turned out the physician was not in the same insurance network as the hospital. Harrison says he was blindsided by a bill of $780. “I’m not sure that anyone should expect to say (while with doctors in an emergency room), are you in network? Or are you contracted? I mean that just doesn’t happen in an emergency room situation,” Harrison said.

To end “surprise bills,” a Senate proposal would forbid ER doctors from billing above the amount that they’d bill if they were in the hospital’s insurance network. The measure would also provide for dispute resolution.

But the proposal could drain hospitals of its ER doctors, says retired emergency physician Chip Pettigrew.

If you click the link above you can watch the package or read the full text. Essentially, we now have a situation where hospitals negotiate with insurance companies over reimbursement rates for medical care. These negotiations have grown contentious, with some insurers briefly pulling out of contracts with some hospitals (similar to the same negotiations we often see with cable companies and individual channels). Everyone is trying to keep costs down while protecting their individual revenue streams. That’s how a competitive market is supposed to work.

The problem with healthcare is that it’s not a competitive market. In much of Georgia, you’re limited to one hospital and one insurance company. Even in Atlanta, when you need an emergency room, you’re not exactly about to comparison shop. The closest one is most often the ER of choice.

As such, it makes little sense for a hospital to negotiate one price for an in-network ER visit, then to hire doctors that can’t match that price. It’s hard to tell patients – the actual customers, the ones that actually pay for ER visits – that they have to pay above their required healthcare plan rates when they know that many of the people they’re sitting in the waiting room with are there because it’s the one place that the non-paying patients can get treated for free.

Hospitals are pointing fingers at insurance companies. Insurance companies point back. And patients currently lose.

The best way to avoid new regulations is to have the stakeholders fix the problems so that regulations aren’t needed. But in the lack of a competitive market, this problem screams for a legislative fix. Either a hospital’s ER is in network or it’s not. Anything less is a bait and switch, and if the hospitals and insurers can’t figure out how to fix that, the legislature should.

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FreeDuckNoParty4MeGeorge ChidiGregsbethebalance Recent comment authors
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bethebalance
bethebalance

It sucks that the system adds insult to injury. The proposed bill appears to shift more negotiating power to the insurance companies, because it in essence forces doctors to agree to a certain contract price, which is not only anti-competitive, but it will incentivize doctors to leave hospitals. Perhaps incentivize smaller Energency Care practice groups. Instead of regulating doctors’ contracts with the hosital, though, the state is in a better position to regulate insurance providers. We have an Insurance Commissioner and everything. Why not simply state that if an insurer puts the hospital in a plan network, that the hospital… Read more »

bethebalance
bethebalance

actually, a quick read of HB71 indicates that the idea floated in my above post is already part of that bill, with the insurer requirement to kick in January 2018.

Gregs
Gregs

I’ve been a victim of this type of surprise billing before. I visited my local ER in 2012 for complications from a colonoscopy, I received 5 surprise bills from labs and doctors that I don’t remember seeing etc. My total unreimbursed expenses exceeded $1200 for a 24 hours stay.

When you’re sick or injured you’re in no position to negotiate or make inquiries about the final cost for your treatment. The $100 dollars you pay when you’re admitted should be the final cost for you. The hospital, doctors and insurance company must fix this or the legislature should act.

George Chidi
George Chidi

Even the threat of legislation is likely to bring parties to the table. But the problem is the system, the competing interests coupled with the moral hazard of the principal-agent problem inherent in any private healthcare setup. My main complaint with the Affordable Care Act was that it did almost nothing to contain costs directly, which is what ultimately caused it to break. That was predictable — hell, it was predicted — and pilloried as an intentional flaw meant to create the conditions for socialized medicine. But the plain truth is that no one wanted to go up against the… Read more »

NoParty4Me
NoParty4Me

This scam has been going on for years. Not just in the ER. Hospital and providers use third party x-ray, anesthesiologists, lab, diagnostics, etc. Many of these may be out-of-network. If you go to an in-network hospital, it is reasonable to expect all services to be in-network. You don’t expect your doctor to bring in an unexpected, out-of-network chum to make a few bucks when you are under the knife. (Yes, this has happened. Well documented.) Insurance companies should pay for all services for an in-network facility billed by the facility. Most reputable Insurance companies will pay for ER services… Read more »

FreeDuck
FreeDuck

I have more experience with this than I would like. I hate the distributed billing itself. If I have to go to the hospital (and I have, and so have my kids) then from my perspective I’m paying the hospital for that care. I should get one bill. Let the hospital pay the doctor, and for the MRI, and the lab. There is no doubt that it’s very easy to double bill by splitting it up and those of us who have day jobs and families to feed don’t have the time to figure out if we actually did use… Read more »