In-Network Emergency Room, Out-of-Network Doctor Could Equal a Big Bill

Balance billing often surprises patients in their pocketbook after a visit to the hospital

A North Texas woman is outraged after receiving a big bill from an out-of-network ER doctor who treated her at an in-network emergency room.

It's a common practice called balance billing.

"It's not a phrase we're familiar with, not a concept we're familiar with. But when you explain it to somebody, they say, 'Oh that happened to me," said Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities, an Austin-based nonprofit.

The same thing happened to Melinda Allen, who went to the emergency room last summer at Texas Harris Methodist Hospital in Fort Worth.

"I woke up on a Saturday morning, just in incredible abdominal pain, and thought maybe it was appendicitis. So my husband took me to the ER," Allen said.

It was a hospital she knew was in-network with UnitedHealthcare, the second largest health insurer in the state of Texas. After a battery of tests, Allen was diagnosed with a large ovarian tumor. She was discharged that same day and had surgery to remove the benign tumor two days later.

Allen said she paid upward of $5,000 out-of-pocket for her treatment, and that's on top of her $1,500 monthly premium. But later she got a bill for $669.85 from the emergency room doctor.

"I thought, 'OK, that's a mistake,'" said Allen.

But it wasn't.

The reason, while Harris Methodist is in-network with UnitedHealthcare, the emergency room doctor who treated her was not in UnitedHeathcare's network. So she was stuck in the middle and responsible for the balance of the bill, which United did not pay.

"I was floored and I was angry," Allen said. "I'm angry with Harris. I'm angry with the doctor and I'm angry with my insurance company. I'm angry with all of them."

"There are a lot of families in Texas that could find those bills and pay them and keep going. But there are a lot of families in Texas who would get a balance bill of a few hundred dollars or a few thousand dollars, and that means they can't make their mortgage, they can't pay for child care, they can't fix their car," said Pogue. "The scope of what these balance bills can cost coming out of an emergency room can be really big."

In Allen's case the emergency room doctor charged what was deemed an appropriate rate for her situation, which was $947. UnitedHealthcare reimbursed what it thought was appropriate, $277.15. She was left to pay the remaining $669.85.

"It just is not fair," Allen said.

"Bill charges aren't pegged to anything. It's not like when you go into the grocery store and you pick a product and you can compare a couple of different types of peanut butter. And you know you're paying more for organic one than your nonorganic one. ealth care is not like that. The variation in what is billed is enormous," Pogue said.

That makes comparing prices difficult. From a consumer standpoint the compromise seems simple.

"Perhaps if the ER doctor had charged half as much and the insurance company had paid twice as much," Allen explained, "Then, me, the consumer, wouldn't be getting screwed in this."

But in the world of health care, the solution is far from simple.

NBC Investigates Consumer Unit contacted Texas Health Resources.

Spokesman Wendell Watson said via email the hospital doesn't mandate doctors contract with insurance companies.

"Leadership does strongly encourage physicians to contract with insurance plans reflecting those with which the hospital has contracts. However, the decision on contracts is up to the independent physician practice," Watson wrote. "Texas Health Resources does not exercise control of a physicians medical staff privileges or impose sanctions on a physician based on their insurance contracts."

The hospital does have financial counselors to help consumers with billing questions about the hospital's portion of the bill and to help patients understand what they need to ask their insurance companies. But, Watson said, the hospital stays out of disputes.

"The hospital does not get involved in disputes between a patient and their physician or their insurance company," wrote Watson.

Allen told NBC 5 Investigates Consumer Unit that the doctor never mentioned he may be out of her insurance network.

That's because he can't. By law, emergency room doctors cannot ask about insurance and they must treat all patients regardless of their ability to pay.

Watson said patients at Harris Methodist are notified that they may be balance billed with a booklet that they sign.

Pogue contended that in an emergency, paperwork is not a priority.

"People really are vulnerable when they go into an emergency room," Pogue said.

Often too, like in Allen's case, the emergency physicians are not hospital staff. At Harris Methodist, emergency doctors are contracted by a private company called Emergency Medicine Consultants. Their doctors are in-network with one insurer, but not United Healthcare.

"The emergency doctors are not opposed to being in-network with commercial carriers whatsoever," said Ben Stolz, executive director of Emergency Medicine Consultants.

But contracts are a sticking point.

"Simply, we're not offered emergency medicine rates and contracts," Stolz said. "Everything that we have been offered to this point has been lumped into other specialties. And any emergency doctor knows that the skills and the attributes that you need in your most emergent times are very different from that of other specialties."

Stolz also believes the rates for ER doctors should be higher because of the round-the-clock nature of emergency care. And he said the billing rates charged by Emergency Medicine Consultants, which services 18 North Texas Hospitals, are fair for the region based on FAIR Health, a nonprofit that tracks heath costs.

Still, Stolz said his company often fields calls from customers complaining about balance bills; but there's no "perfect solution."

"We work with every single one of our patients to try and come up with a favorable outcome in this horribly complicated billing system," he said.

But he also said another issue is that reimbursement rates from insurers vary.

"Most of the times the insurance compensates or reimburses what we believe is a fair rate and sometimes they don't. And we really don't know. There's no rhyme or reason as to why. So sometimes there's a larger balance than others," he said.

"UnitedHealthcare uses rates determined by Medicare Centers for Medicare and Medicaid (CMS) Fee Schedules to process claims," said Kim Whitaker, spokeswoman for UnitedHealthcare.

Whitaker said in Texas, UnitedHealthcare has 51,101 providers and 505 hospitals under contract. That includes physicians who specialize in emergency, radiology, anesthesiology, pathology and neonatology.

"If a member contacts UnitedHealthcare about a large balance bill, we check to see if the member is responsible for the balance of payment on the claim. Recommend that they discuss the bill with their physician/hospital to negotiate payment amount and terms," she said.

That often means the consumer, who is sick or recovering, is left in the middle to deal with the doctors, hospital and insurance company.

"It's unfortunate, again, that we're put in that position because insurance companies and doctors can't decide what is appropriate reimbursement," said Pogue.

"The doctors are saying, 'Oh poor us we're not getting paid,' and the insurance companies are saying, 'Oh poor us we're having to pay too much.' Somebody is making money here," said Allen.

Allen and the NBC 5 Investigates Consumer Unit both made a lot of telephone calls. In the end, Emergency Medicine Consultants dropped her bill because it said she was unaware the doctor was out of network. Also during the course of NBC 5's investigation, UnitedHealthcare and Emergency Medicine Consultants are in late-stage negotiations to bring the practice in-network.

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