Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

The Real Surprise in Emergency Department Surprise Billing

A recent article by the New York Times highlighted the issue of surprise bills for patients seen in the emergency department. According to the article, research published in The New England Journal of Medicine recently found that more than one in five emergency department patients received an unexpected bill for out-of-network services when the hospital they were treated in was in-network.

According to Times reporters Reed Abelson and Margot Sanger-Katz, consumer advocates believe surprise bills unfair for patients. “It’s nearly impossible for patients to uncover the contract arrangements of individual physicians once they walk into an emergency room — or are brought by ambulance.”

Of course a physician’s or practice’s reasons for remaining out of network, though complex, often boil down to failed negotiations with the insurance company for fair compensation. Physicians who operate independently from the hospital will then remain out of network rather than accept below-market reimbursement.

Responding to the Times article in a round-up piece for Emergency Physicians Monthly, Seth Trueger, MD, MPH, Assistant Professor of Emergency Medicine at Northwestern University’s Feinberg School of Medicine, said the main issue in these negotiations is that insurers take advantage of emergency physicians’ EMTALA (Emergency Medical Treatment and Labor Act) obligation.

According to Trueger, “[we have] to see patients regardless of whether or not we get paid, so [insurers] are free to walk. And because of the structural divide between many hospitals and physicians, insurers still get to list our ERs as ‘in network.’ Insurers have done a great job of labeling this a ‘surprise bill’ problem rather than a ‘surprise lack of coverage.’”

This was the point the American College of Emergency Physicians (ACEP) was making in their response video poking fun at a recent Cigna commercial. The ACEP parody highlights the “lack of fair coverage for value in emergency medical care.” According to ACEP, “Cigna, and others like them, are exploiting federal law [EMTALA] to reduce coverage for emergency care knowing emergency departments have a federal mandate to care for all patients, regardless of their ability to pay.”

That federal law may also be contributing more to the “surprise” element of surprise billing than initially meets the eye. In an article on the NPR Shots blog this week, Kaiser Health News reporter Michelle Andrews talks about the healthcare trend of requiring payment before service.

“At many doctors offices and hospitals, a routine part of doing business these days is estimating patients’ out-of-pocket payments and trying to collect the money up front,” she writes. In fact, as many as 75 percent of health care and hospital systems ask for payment prior to or at the time of service.

In many practices, including primary care physicians and specialists, these cost estimates mean patients know exactly what they will be charged and often have to prepay at least a portion of their bill before the visit, procedure, or surgery is ever performed. The balance, for which they are later billed, is no surprise because they were required to sign a printed estimate.

That’s not the case for emergency physicians who have to stabilize and treat patients in emergency situations regardless of the their ability to pay.

“I just don’t think there’s a market mechanism to fix this,” Dr. Trueger said, “and unfortunately the truly unfortunate stories of patients being hit with huge bills, particularly in other settings … might lead to a heavy-handed legislative ban on balance billing.”

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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