Rural Health News Service<\/p>\n
Surprise medical bills spell big trouble for consumers, especially those who find themselves in an emergency room. Such surprises have surfaced as a major patient problem, but because of entrenched healthcare interests, a solution is not likely soon.<\/p>\n
Here\u2019s what happens. Patients arrive at the emergency room of a hospital that is in their insurer\u2019s provider network. However, the physician who treats them is out of network.<\/p>\n
Because ER docs are usually assured a steady stream of patients, many believe they don\u2019t need to accept potentially lower fees from insurers in exchange for any new patients they might attract by belonging to a network. That\u2019s not the case for other specialists who may rely on insurer networks for more business.<\/p>\n
Whatever the reason, emergency room patients may be stuck with huge bills their insurance company may not cover, or it will pay less than if patients had used in-network doctors.<\/p>\n
If you think this is unfair, it is.<\/p>\n
A study by Yale researchers of more than 2 million emergency room visits across the country was just published in the New England Journal of Medicine. It found that out-of-network doctors treated 22 percent of the patients who visited emergency departments; the departments themselves were part of their insurers\u2019 networks.<\/p>\n
The average bill patients incurred was $623. The highest bill was more than $19,000. To put that number in perspective, this year the Federal Reserve reported that 46 percent of Americans were unable to pay a $400 expense without running up credit card debt or selling assets.<\/p>\n
Not surprisingly, researchers found out-of-network ER doctors ended up getting paid a lot more than those who were part of a network. \u201cThe fact this type of price gouging has become routine operating procedure in so many emergency departments is shameful and appalling,\u201d says Chuck Bell, programs director for Consumers Union.<\/p>\n
A recent study in Texas by the Center for Public Policy Priorities shows how prevalent out-of-network ER doctors are. Using a 2013 report from the Texas Department of Insurance, the Center found that 45 percent of in-network hospitals in the state used by United Healthcare had no in-network ER doctors. Fifty-six percent of Humana\u2019s hospitals had none. \u201cConsumers would be astonished to see how poor the odds are of getting an in-network doctor in the emergency room.\u201d Bell added.<\/p>\n
The odds of getting redress are also low. Too many consumers don\u2019t contest their bills. Only about 25 percent of those getting surprise bills do, Bell told me. Of those who do protest to their insurer, only half get their bill forgiven or reduced.<\/p>\n
Surprise bills are a variation of what\u2019s called balance billing, the gap between what insurance, including Medicare, pays and what a doctor charges. It\u2019s been around for decades, but in the late 1980s, the outcry from Medicare beneficiaries became so loud that Congress did something about it.<\/p>\n
For doctors who accept Medicare\u2019s payment in full, there is no balance billing \u2013 called \u201cexcess charges\u201d in Medicare speak. Doctors, including ER physicians who don\u2019t accept that payment, can sock beneficiaries with excess charges. But Medicare limits what they can charge.<\/p>\n
Beneficiaries can protect themselves from these excess charges should they use a doctor who doesn\u2019t accept Medicare\u2019s fee schedule by buying Medigap policies Plan F and Plan G. For those with Medicare Advantage plans, there\u2019s no protection until the beneficiary reaches the plan\u2019s out-of-pocket spending limit. After that, the doctor can\u2019t balance bill separately.<\/p>\n
There\u2019s no similar help for those not on Medicare.<\/p>\n
Many consumers are unaware that an out-of-network doctor is treating them.<\/p>\n
The standard advice \u2013 to ask if your doctor is in the network \u2013 is silly when it comes to care in the ER. What patient having a heart attack is going to look up and say, \u201cHey doc, are you with Aetna?\u201d<\/p>\n
A few states \u2013 New York, California, Illinois, Connecticut, and Florida \u2013 hold patients harmless if they find themselves with a surprise bill or require outside arbitration to decide a case. But Bell says it will take an act of Congress to solve this problem. Public outrage will have to get much louder if that\u2019s to happen.<\/p>\n
Because chances are high you\u2019ll find yourself with such a bill, think twice before you choose to go to the ER for a problem that can wait until you see your regular doctor.<\/p>\n
Although Obamacare was supposed to cut down on emergency room use, that hasn\u2019t happened. People are still going to ERs for less serious conditions, many being enticed by hospitals themselves that advertise their ER wait times on billboards.<\/p>\n
Our healthcare system is all about making money. And balance billing, its causes and consequences, is another sorry example.<\/p>\n