What is a surprise balance bill for ER services? Say you walk in to an ER that is in a hospital that your health insurance plan tells you is in the plan’s network, or you get taken to this ER by ambulance. Your expectation is that the services you receive in the ER will be covered under the ‘in-network’ provisions of your plan, but this may not always be the case. Certainly, the charges for services provided by the hospital, such as the ER facility fee (for using the ER), the fees for CT scans, blood tests, etc, should reflect the ‘in-network’ status of the claim, and your out-of-pocket costs should be based on your deductible, co-pay, and co-insurance provisions of your policy with the insurer. (For a definition of these and related terms, see the FAIR Health website; and for the specific rates and percentages that apply to your costs, read your policy summary or call your agent).
However, not every physician who might treat you in the ER, or charge you for some of the services you received in the ER (for example, the radiologist who interprets your x-ray), is necessarily going to be an in-network provider for your plan. In this case, you might receive one or more surprise balance bills for the difference between the benefit for this service your plan is willing to ‘allow’ and the provider’s full charge. In addition to any deductible or co-insurance payment you owe to the provider, your bill from the physician might also include this ‘unpaid balance’, which you may owe even though you were treated in an in-network hospital.
You might wonder why all of the physicians who work in this hospital are not contracted with your plan. There are many reasons. Some hospitals require emergency physicians, and other specialists who are based in the hospital, to contract with every (major) plan that the hospitals contracts with. Your plan might be a smaller plan that these physicians are not required to join. Many hospitals allow hospital-based physicians to negotiate with the plan for ‘reasonable market rates’, but often the plans are not willing to pay reasonable market rates to these physicians, so the physicians remain ‘out of network’ (OON). Part of the reason for the plan’s reluctance is that these plans know that these doctors are required by a federal law called EMTALA to provide emergency care to every patient who comes to the ER, regardless of insurance status or ability to pay. Thus, the plan can avoid contracting with these doctors and allow whatever deeply reduced benefit they are willing to pay, and shift the burden for paying the unpaid balance on to the shoulders of their enrollees. More profit for them, more out-of-pocket costs for you. Few states require plans to contract with hospital-based physicians, though states do require plans to contract with other physicians; and so-called narrow network plans have even fewer physicians and specialists under contract.
In most ERs, specialists called Emergency Physicians staff the ER, and many, but not all, of these doctors are contracted with the same plans the hospital contracts with. Other specialists, like cardiologists, orthopedic surgeons, or gastroenterologists, serve on ER on-call rosters, and agree to treat ER patients when these specialists are called in to provide their special services. In community hospitals and even in University Medical Centers, most of these physicians are not ‘hospital based’, and have private practices of their own. These specialists may or may not be ‘in-network’ with your plan. In many cases, the ‘on-call’ specialist is the only such specialist available to provide their special services to ER patients in an emergency, so it is not possible for the ER physician to find a specific specialist who is ‘in-network’ for your plan to come in to treat you. You can certainly ask for this when you are in the ER, but it may not be possible to meet this request.
Thus, you may be surprised to learn, when you get the bills that are mailed to you after your visit to the ER, that one or more of the doctors who treated you in the ER are not in your network even though the hospital is in-network, and that these doctors are billing you for the ‘unpaid balance’ in addition to deductibles or co-insurance payments. Surprise! What should you do in this case?
The first thing is to take a close look at the EOB (Explanation Of Benefits) that your plan should also have sent you. Match the EOB to the bill based on the date of service and the doctor’s name. You should know that sometimes plans will tell you that you really don’t owe anything to the physician except the co-insurance payment or deductible, and that any other charges should be ignored because they are ‘not allowed’ or are unreasonable, or some such language. The plan may say this to make you believe you are not responsible for this unpaid balance from the OON provider. This is often FALSE information, meant to take pressure off the plan for failing to have a full network of providers, and to shift the blame to the OON physician by implying that the physician’s charges were unreasonably high. To find out if the physician’s charges really were especially high, you can go to the FAIR Health website and use their cost estimator to see the upper end of charges for 80% of physicians for a particular coded service. This means 8 out of 10 physicians charge at or below this amount in your area. Most physicians’ charges are reasonable, and some plans continue to consider these physicians’ full charges to be reasonable if they are at or below these 80th percentile numbers. In this case, there should be no or a very small ‘unpaid balance’ except for the deductible or co-insurance payment. Plans that arbitrarily allow benefit amounts that are far below most physicians’ usual and customary charges are sticking it to their enrollees; and thus if you get a balance bill from an OON physician at an in-network hospital, the first place you should call to complain is your health plan. The telephone # should be on the EOB. Often, plans will ‘adjust’ their allowable benefit to pay the unpaid balance, or should at least agree to contact the physician to ‘negotiate’ for a payment that both agree to, so as to leave you out of the middle of the dispute over what is the reasonable value of the services you received. You paid for these benefits when you wrote your check for the plan premium, and you should get the benefits you paid for.
Some states prohibit balance billing of certain emergency care claims, but it is very unlikely you will get a balance bill in that circumstance. Other states require plans and providers to address these unpaid balances in a dispute resolution or arbitration process. Either your plan or the physician’s office staff or billing company (see the telephone number on the bill) should be able to tell you how to get this dispute resolved without necessarily holding you accountable. In Part 2 of this post, which should come out in a few days, I will cover the other ways to avoid or address surprise balance bills for emergency care, including dealing with ER referrals to OON specialists; negotiating with your plan or with the physician, or both; accessing your state’s regulations related to balance billing, and options for dealing with balance bills when you go to, or end up in, an out of network hospital ER.