Out of network ER physicians

[Looking4Ward]

So I've been hammering BCBS over the last several weeks to tell me which Emergency Rooms in my area are considered "In Network". After much back-and-forth, they finally provided a list of facilities. So I then moved on to my next question, which of those facilities have ER Physicians who are in-network as well?

Here was their answer:

"Unfortunately we cannot verify if all ER physicians at these locations are in network as we do not have a listing of their ER physicians. You would need to contact the Facility directly to verify if their ER physicians are in network. We regret any inconvenience."

Evidently the burden is back on the patient to double/triple check everything, even when unconscious and being transported by EMS.

But wait - there appears to be some protection and increased movement towards a solution, at least in Texas. I found this interesting tidbit of information in regards to HMO's from the Center for Public Policy Priorities out of Austin:

"For Health Maintenance Organizations (HMOs), the Texas Department of Insurance (TDI) has long maintained that in an emergency or when an in-network provider is not reasonably available, consumers should have to pay no more for out-of-network care than they would have for in-network care. In other words, consumers are not liable for balance bills, and the HMO has the responsibility of fully reimbursing the provider. This protection on paper, however, may not always translate into practice. State law does not prohibit an out-of-network provider from sending a balance bill to a consumer enrolled in an HMO, even though the HMO should be on the hook to resolve it. HMOs must instruct consumers to call the HMO if they get bills for out-of-network services, but neither HMO disclosures nor provider bills are required to explicitly say that the HMO, not the consumer, is liable for balance bills resulting from emergency care. Due to the convoluted nature of these protections, consumers in HMOs could receive balance bills stemming from emergencies and pay them, never knowing they are not technically responsible for the bill. TDI plans to amend state HMO rules soon and will have the opportunity to make existing “hold harmless” consumer protections explicit, so that they are meaningful for consumers."

Full document here:

Surprise medical bills take advantage of Texans

 

[sengsational]

I wouldn't trust an insurance company as far as I could throw them, but according to what I've read, if it is an emergent situation, the charges should be treated as in-network, no matter where the ambulance takes you. I would imagine, though, that you'd have to get transferred as soon as possible to an in-network facility and demand only in-network doctors as soon as you could utter a word.

 

[bizlady]

My understanding is that in a true emergency, out of network will be covered as if it is in network. I too was concerned about this, in case of emergency while traveling.

 

[photoguy]

The plan we picked has an explicit out of network deductible and max OOP (one of the reasons we chose it). This is about 50% higher than the in-network. I believe this would cover the non-emergency cases where one cannot confirm ahead of time that all docs will be in-network.

I don't know if they must be met separately. E.g., if one has expensive surgery with in and out of network, are we liable for the 6k in network and 9k out of network for a total of 15k?

 

[MichaelB]

My understanding is

1) The in-network deductible and co-pay apply, even if the ER not in the network

2) If out of network the insurer must offer to pay a "fair rate" to the ER, which could be their typical reimbursement rate or the average reimbursement rate for that region, and

3) Unless prohibited by state law, the ER can balance-bill for the expense not covered by insurance.

 

[Brat]

In my community a central dispatch office determines which emergency room will receive a patient based on the availability of beds and staff (things such as is a neurosurgeon available when that service is indicated). Medics connect the patient to vital signs transmission equipment, the dispatch medical staff talk give it a look, talk to the medics, then direct the ambulance (and the vital signs transmission) to an emergency room. We have two Level I trauma centers one of which has a burn unit, several Level IIs.

Rarely does the patient have a choice.

 

[heeyy_joe]

One more reason why we are headed towards a single payer system.

 

[ERhoosier]

My understanding is

1) The in-network deductible and co-pay apply, even if the ER not in the network

2) If out of network the insurer must offer to pay a "fair rate" to the ER, which could be their typical reimbursement rate or the average reimbursement rate for that region, and

3) Unless prohibited by state law, the ER can balance-bill for the expense not covered by insurance.

Some of these issues are subject to state law/regulation, but generally (in US)-

1) True ONLY if it is a true emergency. Under most all HI contracts, non-emergency care in the ER is termed "not a covered benefit" or something similar. Going to the ER for the sniffles of a common cold or a routine blood pressure check up will likely NOT be covered whether in-network or not. IMHO- A good thing. ER is a VERY expensive place to deliver routine care. And do you want the ER jammed with minor stuff when (God forbid) you are rushed in with crushing chest pain or serious bleeding/broken bones from a wreck?
2) Out of network true emergency care is typically reimbursed at that HI company's in-network rates, which may be quite different from that ER's typical rate or a regional ave. Whether that is "fair" or not is a value judgement based on one's POV -patient, HI company, or ER
3) Balance billing for true emergency care varies a lot by state and insurance. Medicaid often prohibits balance billing, and Medicare has some limits. Private HI generally limits in-network charges to their contracted fee structure. Uninsured (& non-emergency out-of-network) are the ones most likely to get those HUGE unreasonable bills we've all read stories about.

 

[explanade]

There was a NY Times piece a few weeks ago which got a lot of attention about surgeries and even ER patients being hit with unanticipated out-of-network bills.

Insurers are looking to reduce reimbursement rates and a lot of providers are opting out of networks. But they're able to do "drive-by" doctoring where they consult for a few minutes and are able to charge large fees, often maybe saying hello to the patient after the fact.

Despite lower reimbursement rates, average ER doctor pay has increased from $247k to $311k from 2010 to 2014:

http://www.nytimes.com/2014/09/29/u...-but-the-doctors-are-not.html?ref=health&_r=2

Here's the companion piece about out-of-network doctors being brought in without the patient's knowledge and sometimes against the will of the primary doctor:

http://www.nytimes.com/2014/09/21/us/dr ... -well&_r=1

 

[MichaelB]

Some of these issues are subject to state law/regulation, but generally (in US)-

1) True ONLY if it is a true emergency. Under most all HI contracts, non-emergency care in the ER is termed "not a covered benefit" or something similar. Going to the ER for the sniffles of a common cold or a routine blood pressure check up will likely NOT be covered whether in-network or not. IMHO- A good thing. ER is a VERY expensive place to deliver routine care. And do you want the ER jammed with minor stuff when (God forbid) you are rushed in with crushing chest pain or serious bleeding/broken bones from a wreck?
2) Out of network true emergency care is typically reimbursed at that HI company's in-network rates, which may be quite different from that ER's typical rate or a regional ave. Whether that is "fair" or not is a value judgement based on one's POV -patient, HI company, or ER
3) Balance billing for true emergency care varies a lot by state and insurance. Medicaid often prohibits balance billing, and Medicare has some limits. Private HI generally limits in-network charges to their contracted fee structure. Uninsured (& non-emergency out-of-network) are the ones most likely to get those HUGE unreasonable bills we've all read stories about.

My previous points 1 and 2 are mandated by the ACA and apply to all ACA compliant plans. Point 3, balance billing, applies specifically to individuals with private health care insurance receiving emergency room treatment in a facility not in the insurers network. Unless specifically prohibited by state law the hospital is free to bill the patient for charges not reimbursed by the insurer.

Here's a link to a KFF section on state protections on balance billing: http://kff.org/private-insurance/st...iders-balance-billing-managed-care-enrollees/

 

[ERhoosier]

My previous points 1 and 2 are mandated by the ACA and apply to all ACA compliant plans. Point 3, balance billing, applies specifically to individuals with private health care insurance receiving emergency room treatment in a facility not in the insurers network. Unless specifically prohibited by state law the hospital is free to bill the patient for charges not reimbursed by the insurer.

Here's a link to a KFF section on state protections on balance billing: State Restriction Against Providers Balance Billing Managed Care Enrollees | The Henry J. Kaiser Family Foundation

As KFF link states, (in comments under main table), according to ACA insurers must pay OON providers their in-network rates for emergency services provided to OON patients. It appears to make no difference under ACA if those in-network payments are typical or ave for the region.
ACA does NOT require all care delivered in ER to be paid for, only true "emergency services". In practice, true emergency service is normally defined by the HI carriers. IOW- ACA is not a blank check to use the ER as a primary care clinic. Going to ER for non-emergency care can still be $$$$$$ whether in or out of network.

KFF link is useful reference for state specific OON billing reg's, but data is current as of ~18mo ago. State HC laws, reg's, and court rulings are constantly changing the landscape. Always good to check for the latest in your area, particularly considering the potential $$$ involved.

FWIW- I have read of many having success negotiating unreasonable OON ER balance billings down to whatever the person's in-network charges/payments would have been. The person might call the involved billing office, ask for a supervisor, and offer to pay up to that in-network amount...and only that amount. Such an offer may well be accepted by the billing office. After all, the alternative could be the patient delaying/refusing to pay, the bill getting sent to collection agency (if allowed in that state), and the ER eventually receiving pennies on the dollar after lots of extra paper work and many months of delay. As in any other business, payment in hand is worth more than hollow numbers in the 'accounts receivable' spreadsheet