Insurance May Not Cover ER Doctors

By Jodie Tillman, Condensed from the Tampa Bay Times. 

Even with in-network hospital, insurance may not cover ER physicians.

When her husband, Charles, showed signs of heart trouble in January, Donna Baker didn’t hesitate to drive him to the emergency department at nearby Mease Countryside Hospital.

Only later did the Bakers learn that, while Mease Countryside is part of their health insurance network, the physician who treated him there is not. The ER doctors are employed by a separate company that doesn’t accept their United HealthCare plan. The result? The Bakers got stuck with a $1,235 doctor’s bill.

Surprised as they were, it’s increasingly common for even careful consumers to get socked with high bills after unknowingly being treated by out-of-network providers. Consumer advocates cite the problem as a key driver of medical debt as patients are getting squeezed between fee-seeking physician practices and cost-cutting insurers.

Such fights mean higher bills for patients. When emergency rooms and the doctors who work there aren’t on the same plans, even diligent consumers don’t stand a chance, said Karen Pollitz, a senior researcher with the Kaiser Family Foundation. “There’s nothing you can do as a consumer. I mean, how can you possibly shop?” she said. “This notion of consumer choice just falls apart when it comes to emergency services.”

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When a medical provider agrees to be within an insurance network, fees are negotiated in advance. Medical providers who are outside a patient’s insurance network may receive some payment from the insurer — but then can “balance bill” the consumer for more.

Patients routinely go to in-network hospitals for a procedure or a test only to learn later that treating physicians — often an anesthesiologist or radiologist — were not in their network’s plans. Though it isn’t always easy, checking ahead to discover the insurance status of everyone involved in scheduled care is at least possible in theory. That’s not at all true in the case of an emergency.

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The Affordable Care Act does prohibit most insurance plans from charging higher copayments or coinsurance amounts for out-of-network emergency services. But it does nothing to stop balance billing by the out-of-network doctors and hospitals. And the law’s new limits on how much consumers must pay out of pocket — $6,350 for an individual and $12,700 for a family this year — apply only to in-network care.

Balance billing of Medicaid patients is prohibited by law, said Cheryl Fish-Parcham, deputy director of health policy at Families USA, a Washington consumer group. And it’s rare for Medicare patients to be balanced billed, though patients enrolled in privately run Medicare Advantage plans sometimes face charges from out-of-network providers.

Florida is one of about a dozen states that do offer additional protections. Under state law, out-of-network medical providers can’t balance bill HMO members for emergency services. Consumers with other types of insurance plans, such as popular PPOs, do not have that same protection.But few HMO members seem aware they’re entitled to the protection, said Steve Burgess, Florida’s consumer advocate for insurance.

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Tampa Bay area patients say that when they call about their bills, the insurers and physician groups typically point fingers at each other. Both insurers and ER contractors say they’re willing to work with patients on their bills. But some patients don’t know that, or figure it isn’t worth trying.

Sept.19, 2014.