Just by looking at the title, you can almost hear the “ER” theme. Imagine Doug Ross running down the halls of the Los Angeles County General. This show defined a generation’s understanding of trauma. But leave the drama at the door. The reality of modern emergency medicine is that billing codes and online contracts mean more than charismatic doctors and romantic backstories.
This is an obvious fact. You may end up in a hospital that is covered by your insurance, but the doctor treating you may not be.
This is not always the case. In the past, hospitals employed their own emergency staff directly. Billing is easy. You go in, you come out with a bill. The doctor’s work is included in the facility usage fee. This is, of course, confusing. This is also predictable.
This model has almost disappeared. Emergency medicine is now its own specialty. Hospitals often do not have the cash flow or human resources infrastructure to hire these professionals full-time. That’s why you hire a staffing agency. These groups have medical contracts with hospitals.
The numbers don’t lie. About 65% of hospitals currently outsource their emergency providers. This creates a significant difference between institutions and clinicians. You go to an “in-network” hospital. You trust the sign on the door. But what about those testing for chest pain? They work for third party companies. It may not be in your insurance network. Some may not accept insurance at all.
Network Trap
This is the “surprise bill” phenomenon.
Most insurance plans define their network by hospitals rather than individual providers in the network. If you’re having a heart attack, you don’t google your network status during cardiac arrest. You call 911 and go to the nearest emergency room.
If that ER is in your network, you think you’re safe. you are not.
The doctor in the room was probably a contract worker. If you are out-of-network, your insurance company may pay only a portion of the cost or none at all. The doctor then bills the “balance”. This is called balance billing.
Consider a simple fracture. Casting and facility fees are paid by the insurance. It covers 80 percent of them. But what about the radiologist reading the images? Or an emergency doctor fixing bones? If they are out-of-network, you may be charged for professional services. You end up paying twice. Once you’ve passed the hospital, via copays and deductibles. Again to the doctor.
How does the law try to solve this problem?
This approach is a disaster for consumers. This creates a contradiction. Going to the most convenient and nearest hospital can lead to financial ruin.
The Affordable Care Act (ACA) intervened but did not eliminate staffing models. It does not force hospitals to hire their own doctors. Instead, billing practices are targeted.
The law prohibits out-of-network service providers from charging a balance for emergency services offered in in-network facilities. Insurers must pay service providers the same prices as doctors in the network. You only pay the standard in-network cost sharing (copayments or deductibles).
This is important consumer protection. This closes loopholes that allow contractors to exploit gaps between facility and supplier networks.
Reality check
Even with these protections in place, the system is complex. You may still be confused. You may also receive an invoice that appears to be incorrect. But thanks to federal regulations, the days of in-network hospitals charging full price for out-of-network emergency room care are virtually over.
Still, the personnel models continue. Hospitals continue to contract. The doctor continues to work at the institution. There is a structural difference between where care is sought and who treats you. It is built as part of the health economy.
The next time you end up in the emergency room, you don’t have to worry about whether the doctor is in your network. Legally, they are treated as if they are. Your invoice must show in-network benefits.
But check the benefits description anyway. Errors happen. Unlike Doug Ross, these billing mistakes are rarely resolved with a romantic kiss at the end of the episode. You have to fight for them.
