A physician’s first priority is to help those they see in need of medical attention. So, when a doctor working the night shift sees a EMTs rolling a bloodied car accident victim into the emergency room on a gurney, she doesn’t hesitate; she immediately crosses the room to treat her new patient. At that moment, her mind is solely focused on what she needs to do to stabilize the person on the gurney; she doesn’t focus her response on searching for the victim’s insurance card or asking if the injured person is in-network.
She provides medical care first — and in an emergency, who wouldn’t want her to?
However, as grateful as the patient might be for her quick treatment in the moment, the aftermath of that care can pose an entirely kind of pain for the patient. If the treating physician was out of the patient’s coverage network, their insurer might not agree to cover that provider’s out-of-network rate and thereby leave the doctor to bill the patient for the — often significant — difference.
Accidental out-of-network encounters like the one outlined here aren’t uncommon. According to one study published in Medline, 68% of involuntary out-of-network care contacts happened as the result of medical emergencies. Moreover, roughly 40% of all surveyed individuals who used out-of-network physicians did so either because they hadn’t realized the doctor wasn’t in-network, they were in the midst of a medical emergency, or they attempted to find an in-network physician in the treating hospital but failed.
The out-of-network billing conversation is inevitably an awkward one. Patients want the coverage they pay monthly premiums to have, payers want to cover reasonable expenses, and providers want fair compensation for their services. Balance billing — the practice of providers billing patients for the uncovered remainder of their fee — occurs when those three wants don’t align. A patient’s final bill can vary greatly depending on the type of plan they have; P.P.O.’s, for example, typically cover around 70% of out-of-network fees, while H.M.O’s don’t cover any such expenses unless the insurers pre-approved the treatment.
When it comes to settling a balanced bill, those involved rarely emerge from the compensation conversation feeling satisfied.
Physicians, for their part, want to be fairly compensated for the services they provide. However, if a provider’s idea of a fair payment doesn’t match with a payer’s stated — and often discounted — reimbursement rates, they may not be paid in full for their work. While balance billing and uncompensated care do occur in other medical disciplines, it is the worst for emergency providers; ER doctors are, after all, the only specialists with a responsibility to treat every patient regardless of whether they have insurance or can pay for their services. According to statistics provided by the Florida College of Emergency Physicians, the average ER care provider loses out on about $138,000 per year as the result of uncompensated care.
The financial loss for physicians is significant — but so too is the cost to the patients left with the bill.
In 2011, New York’s Department of Financial Services found that the average price of a surprise — i.e., out-of-network or balanced — bill topped $7,000. Of that number, patients paid an average of $3,778. Needless to say, many patients aren’t in a position to pay that amount easily or quickly; some might not be able to pay at all.
Patients can, however, alleviate some of the risks by being proactive about the care they receive and verifying that the hospital and provider they intend to visit are both in-network. If the patient doesn’t check both, they might visit their in-network hospital only to find that their treating physician is an expensive out-of-network contractor. Patients also have the option of negotiating with their insurer and the out-of-network doctor to see if the two can come to a more equitable and less costly agreement.
Patients have the option to negotiate — but they shouldn’t have to. Nor should emergency physicians have to resign themselves to losing out on tens of thousands of dollars in compensation each year. Balance billing is sloppy and frustrating for all those involved, and these solutions — proactive searching, careful negotiation — may resolve individual cases, but they don’t fix the overarching problem.
The healthcare system is in need of a more widespread and systemic change. In the short term, payers, care institutions, and doctors need to increase transparency, facilitate better communication, and empower patients to make affordable choices for their health. In the longer term, those of us in the health sector should consider a shift to a more value-based system, where insurers could delegate the task of curating high-quality and low-cost provider networks to those who have an on-the-ground view of what patients need to the doctors themselves. With clearly-communicated and provider-driven care networks, the disconnect that drives balance billing would all but disappear, leaving expectations between doctors, patients, and payers as they should be: aligned.