Patients who go to hospitals covered by their medical plans often receive a bill from a doctor who was not in the insurer’s network.
Doug Moore was out of town at a Florida conference on information technology in October 2015 when he was struck with terrible abdominal pain. He tried to go to an urgent care center and called several local doctors. No one could see him. So he headed to the nearest emergency room. On the way, he called his insurance company to make sure the visit would be covered.
Once he got to the Palms of Pasadena Hospital emergency room, a doctor gave him some medication and tests, and let him go. A month later, feeling better and back at home in Baton Rouge, Louisiana, Moore, 34, received an out-of-network bill from the doctor who treated him — for $1,620.
“That really makes me mad, and kind of breaks my heart,” he said.
When people go to the emergency room, they are often stunned to discover that doctors who treated them are not employed by the hospital and bill their insurance company separately. These doctors negotiate separate deals with insurance companies for payment. If the doctor and the insurance company never strike a deal, the visit is billed at much higher out-of-network rates.
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While the insurance company sometimes pays the higher amount, unlucky patients like Moore can be caught in the crossfire. They receive care and have no idea what it will end up costing them.
New research published in The New England Journal of Medicine Wednesday found that more than 1 in 5 patients visiting the emergency room may face the same financial shock. The study looked at billing data from one large national insurer and found that 22 percent of the time, patients who went to a hospital covered by their plan still received a bill from a doctor who was not in the insurance company’s network.
The average such bill cost more than $900, though there was a wide range; the highest was for more than $19,000. This is not the first time researchers have examined surprise medical bills, but it is the broadest analysis to date of the problem nationwide.
The study found wide variation across the country over the likelihood that someone would get a surprise medical bill. In McAllen, Texas, for example, the rates of surprise billing were 89 percent, compared with Boulder, Colorado, where it was near zero.
Once patients get to the emergency room, they have little choice over who treats them. “To put it in very, very blunt terms: This is the health equivalent of a carjacking,” said Zack Cooper, an assistant professor of health policy and economics at Yale University, and a co-author of the paper. Cooper argues that the problem could be solved by Congress, which could make the visit a package that includes both the doctor and hospital.
Consumer advocates, and scholars like Cooper, see the surprise bill as unfair. It is nearly impossible for patients to uncover the contract arrangements of individual physicians once they walk into an emergency room — or are brought by ambulance.
“People are, by and large, not aware that they’re playing that type of financial roulette,” said Chuck Bell, the programs director at Consumers Union, an advocacy group that has been urging states and Congress to help solve the problem. “They follow the rules, and they go to the in-network hospital, and then it’s just like a bait-and-switch.”
Several states have passed legislation aimed at tackling the problem, including New York, Florida and California, where a law recently went into effect. But the state laws affect only a fraction of insurance customers. Insurance offered by large companies, like Moore’s employer, is regulated under federal law. And most of the laws work by setting up a dispute resolution system for patients, which means they need to know they can go to state authorities to fight a big bill.
Rep. Lloyd Doggett, D-Texas, introduced legislation last year to tackle the practice nationwide, but he said he experienced “a healthy dose of indifference” from his colleagues on the Ways and Means Committee. Doggett had heard complaints of surprise bills from constituents, and it turns out that the new study found that Texas is a hot spot for the practice.
Doggett said he would introduce the legislation again next year. “I think that there’s got to be a way to get consumers out of this trap,” he said.
President Barack Obama included proposals to limit out-of-network emergency room bills in his budget proposal, and recent regulations have made it more difficult for doctors to collect certain bills, though those rules are being fought in court by physicians. The acting administrator for the Centers for Medicare and Medicaid Services has said that surprise bills are a policy priority for him.
The data in the study come from one large commercial insurer, but the researchers agreed not to name it in exchange for access. Cooper said there was only a little difference in the share of surprise bills in places where the insurance company had a lot of customers, compared with those where it did less business.
Emergency room doctors criticized the study’s findings and were quick to blame the insurers. The American College of Emergency Physicians, the medical society that represents the doctors, said patients are much less likely to face large unexpected bills than the study suggested, citing an analysis the group did in Florida of patients who were “balance billed,” or asked to make up the difference between what the insurer pays and what the doctor bills.
“Our balance bills are less than a couple of hundred dollars, on average,” said Dr. Rebecca Parker, the group’s president. She said that most doctors want to be included in networks but that they are not being offered reasonable fees.
“This is insurance company bad behavior,” said Parker, whose group this week put out a parody video that accuses the insurers of paying too little for their work.
Insurance companies like to blame the physicians, arguing that while they can reach a deal with the hospitals, there are many doctors who refuse to be part of the network they offer under a plan.
And the insurers argue hospitals have a responsibility to make sure the outside doctors they use to staff their emergency rooms sign contracts with the same health plans they do. “This would go a long way to reduce and prevent consumers from receiving a big surprise balance bill,” Kristine Grow, a spokeswoman for America’s Health Insurance Plans, a trade group, said in an email. The new paper’s authors agree.
When Moore received his doctor’s bill, he tried appealing the charge to his insurance company. “We understand that you went to a preferred provider facility and did not have a choice of the emergency room physician who treated you,” his insurer wrote back — but denied the claim. Then he went to the private practice that had sent him the bill. It was willing to negotiate.
“They knocked off half the bill,” he said. “Which is great. It’s like, would you rather get punched four times or two times? I guess two times is better.”