Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

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

Thomas Pane, MD, MBA
Physician
August 16, 2012
46 Shares
Share
Tweet
Share

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.

Prev

Why must medical care be provided for free?

August 16, 2012 Kevin 38
…
Next

Real health reform cannot happen without a primary care foundation

August 16, 2012 Kevin 13
…

Tagged as: Emergency Medicine, Pediatrics

Post navigation

< Previous Post
Why must medical care be provided for free?
Next Post >
Real health reform cannot happen without a primary care foundation

More by Thomas Pane, MD, MBA

  • a desk with keyboard and ipad with the kevinmd logo

    Residency directors and board certification can work together

    Thomas Pane, MD, MBA

More in Physician

  • Decoding name displays in health care: Privacy, identification, and compliance unveiled

    Deepak Gupta, MD
  • Master time management with 7 productivity strategies for optimal results

    Farzana Hoque, MD
  • The tragic story of Mr. G: a painful journey towards understanding suicide

    William Lynes, MD
  • The escalating violence in health care workplaces: a critical problem facing the nation’s health care system

    Harry Severance, MD
  • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

    Howard Smith, MD
  • Why allowing yourself to embrace discomfort is necessary for personal growth

    Jillian Rigert, MD, DMD
  • Most Popular

  • Past Week

    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
    • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

      Harvey Castro, MD, MBA | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
  • Past 6 Months

    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
  • Recent Posts

    • Decoding name displays in health care: Privacy, identification, and compliance unveiled

      Deepak Gupta, MD | Physician
    • Empowering Black nurses for lasting change [PODCAST]

      The Podcast by KevinMD | Podcast
    • Master time management with 7 productivity strategies for optimal results

      Farzana Hoque, MD | Physician
    • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

      Hoag Memorial Hospital Presbyterian | Conditions
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 9 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Novel Anti-HER2 Drugs 'Impressive' in Advanced Biliary Cancer
  • What Was Tied to Lower Long COVID Risk?
  • Chemo-Free Approach Works in Subset of Patients With HER2+ Early Breast Cancer
  • Two-Drug Combo Wins for Refractory Gout
  • First-in-Class Sjogren's Drug Passes Mid-Stage Test

Meeting Coverage

  • Novel Anti-HER2 Drugs 'Impressive' in Advanced Biliary Cancer
  • Chemo-Free Approach Works in Subset of Patients With HER2+ Early Breast Cancer
  • Two-Drug Combo Wins for Refractory Gout
  • First-in-Class Sjogren's Drug Passes Mid-Stage Test
  • Pricey Drug Combo Boosts PFS in First-Line Advanced Ovarian Cancer
  • Most Popular

  • Past Week

    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
    • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

      Harvey Castro, MD, MBA | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
  • Past 6 Months

    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
  • Recent Posts

    • Decoding name displays in health care: Privacy, identification, and compliance unveiled

      Deepak Gupta, MD | Physician
    • Empowering Black nurses for lasting change [PODCAST]

      The Podcast by KevinMD | Podcast
    • Master time management with 7 productivity strategies for optimal results

      Farzana Hoque, MD | Physician
    • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

      Hoag Memorial Hospital Presbyterian | Conditions
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

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

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...