Mandating care in the ER but not payment: Why that’s a problem

A recent case from Dayton, OH highlights the tangled mess of emergency department specialty coverage, federal law, and out-of-network insurance benefits.  When these interact, patients, doctors, insurers and hospitals can be left frustrated and perplexed.

Here’s a brief summary.

A 6-year old boy suffered a fingertip injury and the emergency staff called the covering plastic surgeon, who repaired the injury.  The surgeon, who does not participate with insurance, submitted a bill for approximately $8,000.  The insurance company paid 80% of what it determined to be usual and customary charges, leaving the family the remainder, approximately $6,000.  They were unaware the surgeon was out-of-network.  The hospital later changed call coverage, contracting with another group that accepts all insurances.

This case illustrates how current on-call realities can fail all four parties:  patients, hospitals, insurers, and on-call doctors.

First, a few preliminary facts:

  • The Emergency Medical Treatment and Active Labor Act (EMTALA) applies to hospitals accepting federal funds.  It does not allow for a discussion of financial considerations prior to rendering care.  (It is less clear whether this applies to independent physicians or just the hospital).
  • Doctors in private practice are not required to participate with insurance, and do not work for the hospital.
  • Hospitals often do not pay for on-call coverage.  Some hospitals may have other sources of funding for serving the uninsured, but such arrangements may not apply to the covering doctors.
  • Insurers may send payment directly to patients for out-of-network care.  When this happens, doctors try to recover from the patient, often receiving nothing.
  • On-call doctors summoned by the emergency department cannot refuse, and as noted above can’t discuss financial considerations, such as their insurance participation status.
  • In specialties such as plastic surgery, on-call doctors are sometimes called in for non-emergencies.

When these factors intersect as in this case, there can be confusion and finger-pointing.  The doctor may be upset at being inappropriately called (not so in this case), or not paid.  Patients may be surprised by a large bill despite having insurance.  Hospitals risk a public-relations problem if patients complain.  Insurers limit their out-of-network liabilities or risk being overcharged.  All of these positions have some validity.

The essence of the problem is not the emergency department’s behavior, the out-of-network status of the doctor, or the insurance company’s payment policy.

The problem is that under EMTALA, care is mandated but payment is not, and no cost discussions are permitted.  Hospitals and doctors know this, but all too often nothing is done to plan for the inevitable misunderstandings.

The solution lies with hospital executives meeting with each specialty, and figuring out how get patients the emergency care they need, that specialists are available and billing surprises do not occur.  There are many options, such as paying for call, providing for payment if patients are uninsured, or an agreement that there will be a limiting charge in emergency situations.  Some hospitals may decide that hiring specialists meets their needs.   Plenty of options are possible though they need vetting for legal correctness.

As the healthcare delivery system evolves, creative on-call solutions may be required.  What works in one community may not be optimal for another.  But with an open approach, and all stakeholders working together, collaborative solutions are possible.

Thomas Pane is a plastic surgeon.

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  • southerndoc1

    Don’t let the insurers off the hook.
    Frequently this situation arises because insurers intentionally do not contract with specialists, forcing their patients to go out of network. If an insurer has a network of physicians, it is their responsibility to make sure that contracted physicians for all specialties are available at every hospital in their plan.

  • karen3

    Easy solution. If you are on call, you participate for all on call work. Period. If the hospital does not hire participating providers, they pay the difference. Patients have a reasonable expectation that when they go to a participating hospital, they get participating care. It’s an issue between the provider, the hospital and the insurer.

    • John Henry

      No, not such an easy solution. First, many patients do not have insurance yet seek care for non-emergencies at emergency rooms, knowing they cannot generally be refused before being evaluated and treated, and expecting to deadbeat their charges from the hospital and any treating doctors who see them there. Second, many doctors, and particularly many of the specialists on hospital medical staffs are not employees of the hospital. The hospital cannot require doctors they do not employ to accept any particular insurance, and doctors are generally free to decide for themselves which insurers they want to contract with. Patients do not have any right to impose an obligation by a treating doctor to accept payment from their insurer as satisfactory payment for their services, even though some states, California in particular, have made billing above the insurance company allowable limit illegal in that state for services obtained in emergency rooms. Patients really have no more reason to expect every doctor on a hospital to accept their insurance than they do to expect every doctor in their community to do the same.

  • jim kirby

    Docs and hospitals who do not publish their prices for all to see deserved to be stiffed from time to time. Indeed, the patient who shows up in an emergency is incompetent to contract because of duress and stress. Therefore, the doc deserves no more than the “quantum meruit” fee, which is of course totally opaque to the public, since docs and hospitals conspire to hide all relevant pricing information from the consumer.

    • Natedawg44

      If a doctor posts their prices they would be thrown in jail. That is considered collusion by the federal government and a big no no, so your blame is misplaced. It isn’t the docs or hospitals hiding from the consumer.

  • Jack Sawyer

    Dayton needs more In Network doctors. I’m curious who the major health insurer is in that area? The hospital should not use a surgeon that will end up slapping a huge bill on the patient. Must have been an off day for them. It shouldn’t be hard to have participating surgeons around.

    • John Henry

      If the hospital relies on its medical staff for coverage (and most hospitals must) who are not employees but are self-employed or in private groups, the decisions as to which carriers are accepted or not is not the hospital’s to make. Imposing that decision would be considered collusion, and illegal. Different groups may elect to participate differently in private contracts with insurers. Patients cannot reasonably expect someone (and who, exactly?) to organize their hospital consultations so that they never have to see a doctor that doesn’t accept whatever insurance they have. In most cases, specialties are covered by whatever doctors are available and on a rotating basis. In an emergency, you may not have a choice, or doctors you might wish to choose instead may be unavailable.

      This is really the responsibility of the insurance company and the agreements they have with their insured members. Pretending it is somehow the doctors’ responsibility makes no sense.

      • southerndoc1

        Exactly.
        One larger insurer in our area refers patients to a “preferred” hospital where none of the radiologists, anesthesiologists, pathologists, and few of the general surgeons are in-network.
        Does the insurer tell its subscribers that their network has more holes than a slice of Swiss cheese? No, they just take the premiums.

  • Rebecca

    There is a lot of middle ground between denying care due to inability to pay, and having a discussion with a patient about the financial implications of care. Particularly if the patient has been examined and does not need emergency care and/or has been stabilized, it would be completely appropriate to discuss the financial implications of the services being ordered with the patient. That would allow the patient to make an informed decision rather than ending up in significant financial debt without understanding how they got there.

    Rebecca
    CoPatient, Inc.