After the ER visit, the financial nightmare begins

Imagine this scenario. A young child is playing in the yard when her pet dog bites her face. Bleeding, the child is rushed to the ER and the doctor offers to suture up the child’s face.

A parent will probably ask for a plastic surgeon to suture the face instead of the emergency room doctor.

As such, the plastic surgeon is called in and sutures up the face beautifully.

The child and family goes home and that’s when the financial nightmare begins.

The plastic surgeon bills the family for $2,000 for services rendered in the emergency room. The plastic surgeon does not participate with their health insurance plan and being a non-participating provider, the bill for care provided is directly sent to the child’s family.

Outrageous?

Unfortunately, it is not unusual and there are lawsuits now pending both against specialist physicians as well as patients regarding who pays the medical bills.

Here is an article portraying a hand surgeon who has sued numerous patients regarding just this scenario. Most specialists will either write-off or accept any amount after being sent to collection.

If a patient has a medical problem, a call to the medical office is made to see the doctor. However, before the appointment is made, both the patient and office checks to ensure the visit will be covered by insurance. If not, a call to a different medical office is made until one that participates with the patient’s insurance is found. However, if the patient decides to see a physician who does not participate with his health insurance company, he will be responsible for the entire bill (the office visit will not be covered by insurance).

The same is true for outside specialists called into the emergency room. These outside medical specialists participate only with certain insurances. As such, if they perform services on a patient whose health insurance does not cover that particular medical specialist, the patient will get the entire bill.

Emergency room care is covered by insurance because it is an “emergency,” but services performed only by the emergency room staff applies. Not services by outside specialists called in.

So what is a patient to do in order to avoid a surprising large bill?

Ideally, have all services performed by emergency room staff and avoid services by outside specialists. If it is not life-threatening (like a facial dog-bite — ugly, but not life-threatening), have the emergency room doctor do all he can. Than follow-up as an outpatient with a specialist who participates with your health insurance plan.

If an outside specialist must be called in, ask whether this specialist participates with your health insurance plan. If not, ask how much the specialist will charge for services rendered. Be aware, if the outside specialist actually comes into the hospital, a consultation fee will be charged (typically around $100 to $200). If a procedure is performed, a procedure charge will be present (hundreds to thousands of dollars).

A patient can request whether there is a different doctor who can be contacted should the specialist on-call not participate with his/her health insurance plan. However, be aware that typically only one doctor per specialty is on-call to the emergency room at any given time and as such, an alternative doctor may not be available.

Once you are aware of the charges, you as the patient needs to decide whether to proceed with specialist care or not.

Be aware that the insurance coverage issues also applies for specialist consultations during a hospitalization and not just in the emergency room.

Simply going to the emergency room does not mean all medical services will be covered by insurance, especially services provided by a medical specialist.

If specialist care is required in the emergency room, just ask whether the specialist participates with your health insurance plan, because if not, be aware that you directly will get a bill.

That’s just how the medical system is currently set up, unfortunately.

Christopher Chang is an otolaryngologist who blogs at Fauquier ENT Consultants blog.

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  • karen3

    Many hospitalss require as either part of the contract or part of the house rules, that specialists on call not balance bill. Many, if not most, insurance companies forbid balance billing. So, if a specialist presents a balance bill, do some close questioning as to the contractual provisions amongst the parties. Usually, balance billing is someone behaving sharkishly.

    • http://www.facebook.com/people/Myles-Riner/100000936260954 Myles Riner

      Karen, you are mistaken – few hospitals prevent on-call physicians from balance billing, and insurance companies can only prohibit balance billing when the physician is contracted with the plan (in-network). California prohibits balance billing of Knox-Keene regulated plan claims, but not most PPO claims. Most health plans use to allow a benefit for out-of-network services based on the lesser of the provider’s full charge or the 70th or 80th percentile of usual and customary charges for the service in question. Thus, these plans would set a benefit for these claims that results in payment of the provider’s full charge 70-80% of the time, meaning no unpaid balance and no (or just a small) balance bill, other than for the coinsurance payment or deductible. Lately, plans around the country have reduced these benefits substantially, thereby shifting the burden for the payment of the ‘unpaid balance’ for these claims on to the backs of their enrollees. Though there are providers and (more often) hospitals that overcharge for services, large balance bills are usually the result of the insurance company behaving ‘sharkishly’ by setting a benefit amount for these claims that is inappropriately low. Plans are supposed to maintain a full cadre of specialists in their networks to ensure that patients can get the care they need from in-network providers, but plans often fail to ensure that these specialists are available to provide 24-7-365 emergency care. In part because of this, the suggestion in the scenario above that if an on-call specialist is required, the patient should try to make sure that this specialist is in-network may be ineffective. An alternative approach is to harass your insurance plan if they leave you with a large unpaid balance by setting an inappropriately low benefit amount. You paid for the policy, you should get the benefit you deserve, especially in an emergency, when you may not be able to select an in-network provider.

  • John Henry

    An insurance company cannot prohibit a physician who does not contract with them from billing the patient. “Balance billing” implies that the doctor has accepted a payment from the insurer (whether contracted or not) and the remainder of the charge, the “balance” has been billed to the patient. In California, for services provided to HMO plan enrolees, that kind of billing was outlawed. It is not illegal in other states. Even in California, a doctor may refuse to accept a payment from the insurer, not bill that insurer and submit a bill directly to the patient. That kind of arrangement is usually by agreement between the patient and doctor, but circumstances in the ED may prevent that, including the lack of availability of alternative specialists participating in the patient’s plan.
    Also, demanding a specialist like a plastic surgeon when the ED staff tells the patient a consultation is not necessary may place the burden of the entire charge on the patient as it would be a demand for non-essential services. Most insurance companies will not pay for that.

  • karen3

    John, you need a short lesson in the legal term, “third party beneficiary.” If you and someone else have a contract and its intended to benefit me, and I fall within the scope of that contract, I am legally entitled to enforce that contract. If the doctor’s contract with the insurer or with the hospital forbid balance billing, the physician cannot balance bill.

    • southerndoc1

      As stated below, very few doctors who cover ERs have contracts with hospitals that prevent balance billing.
      Keep pushing this point, and it will become even more difficult to get specialist coverage for anyone in the ERs.

  • Eruntano

    I work for an insurance company :) For the policies I handle-all national plans offered by employers, if you go to an er, it’s paid as an in-network service, even if the doctor/hospital is out of network. The difference, most of the time, is that if you see an out of network doctor, we reduce the amount that we’ll process down to the reasonable and customary rate- theoretically the average of rates in the area, but the actual rates are determined by some crazy high black magic. That’s where the horror begins, the patient gets a bill for $2000, we call the reasonable rate $500, and start calculating from there. The $1500 difference? That all ends up being the patient’s part of the bill…

  • http://www.facebook.com/valarie.murphy Valarie Murphy

    Medicare and insurance companies pay about 1/3 to 1/2 of what providers charge and somehow, providers accept it and go on. Individuals are charged the full price. All payers, including insurance companies and individuals, should pay the same price for the same procedure performed by the same provider. A huge problem with medical utilization is that no one knows what anything costs.