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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