The hospital ER you visit may be in your insurance network, but your ER doctor may not be, and that could cost you big money

You go to the emergency room of a hospital, choosing it because it’s in the network of your health insurer. But then you get a big bill because the ER doctor who treated you isn’t in the network.

“Such ‘surprises’ have surfaced as a major patient problem, but because of entrenched healthcare interests, a solution is not likely anytime soon,” Trudy Lieberman writes in her “Thinking About Health” column for Rural Health News Service.

“Because ER docs are usually assured a steady stream of patients, many believe they don’t need to accept potentially lower fees from insurers in exchange for any new patients they might attract by belonging to a network,” Lieberman writes. “That’s not the case for other specialists who may rely on insurer networks for more business.
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.”

A Yale University study published in the New England Journal of Medicine “found that out-of-network doctors treated 22 percent of the patients who visited emergency departments,” Lieberman reports. “The average bill patients incurred was $623. The highest bill was more than $19,000. . . . Not surprisingly, researchers found out-of-network ER doctors ended up getting paid a lot more than those who were part of a network.”

Chuck Bell, programs director for Consumers Union, told Lieberman, “Consumers would be astonished to see how poor the odds are of getting an in-network doctor in the emergency room. . . . The fact this type of price gouging has become routine operating procedure in so many emergency departments is shameful and appalling.”

A Texas study by the liberal Center for Public Policy Priorities found that 45 percent of in-network hospitals in the state used by United Healthcare, and 56 percent of Humana Inc.‘s hospitals, had no in-network ER doctors.

“The odds of getting redress are also low,” Lieberman reports. “Too many consumers don’t 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.” Medicare patients “can protect themselves from these excess charges should they use a doctor who doesn’t accept Medicare’s fee schedule by buying Medigap policies Plan F and Plan G. For those with Medicare Advantage plans, there’s no protection until the beneficiary reaches the plan’s out-of-pocket spending limit.”

“The standard advice, to ask if your doctor is in the network, is silly when it comes to care in the ER. What patient having a heart attack is going to look up and say, ‘Hey, Doc, are you with Aetna?’ . . . Bell says it will take an act of Congress to solve this problem. Public outrage will have to get much louder if that’s to happen.”

Meanwhile, “Think twice before you choose to go to the ER for a problem that can wait until you see your regular doctor,” Lieberman advises. “Although Obamacare was supposed to cut down on emergency-room use … people are still going to ERs for less serious conditions, many being enticed by hospitals themselves that advertise their ER wait times on billboards.”

Been faced with surprise billing? Tell Trudy at trudy.lieberman@gmail.com.

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