Emergency room ‘surprise bills’ hurt patients, need policy solution


The rapidly rising costs of insurance premiums emerged as a dominant focus after the presidential election. However, there is another major problem in the health care financing infrastructure that does not seem to get enough policy discussion: “surprise bills” sent directly to patients following care by physicians who may be working at an in-network facility but who are not actually in the patient’s insurance network.

Imagine going to your local emergency room, knowing that the hospital is considered in-network by your insurance company, then a few weeks later receiving a bill for thousands of dollars to pay the out-of-network physician. You might think it was a mistake. You would be wrong.

Hospitals generally contract with a group of emergency physicians to staff their emergency departments and also contract with insurance companies to provide in-network coverage in their emergency departments. The emergency physicians themselves, however, contract individually with the insurance companies, resulting in gaps of in-network coverage where the emergency room visit itself is covered, but the physician providing care is not. Patients only discover this gap by receiving a bill for the care provided by the out-of-network emergency physician.

According to one study, 22 percent – more than 1 in 5 – of emergency department visits at an in-network facility involved out-of-network physicians. In McAllen, 89 percent received “surprise bills.” In other places, such as South Bend, Indiana, almost nobody received surprise bills.

In 2014, Texas studied this problem, finding that among the three largest health insurers by market share in the state, between 41 and 68 percent of dollars billed at in-network facilities were billed as out-of-network emergency room physician services. In addition, between 21 and 59 percent of in-network hospitals had no in-network emergency room physicians, meaning that for some insured patients in Texas, a visit to more than half of the emergency rooms in their network would likely result in a bill for out-of-network care.

But before we start laying all of the blame at the feet of emergency physicians, emergency room departments are required by law to see and treat everybody in need, thanks to the Emergency Medical Treatment and Active Labor Act, which guarantees access to emergency medical care, but not specifically requiring insurers to pay for that care. Insurers know this, thus making it difficult for emergency physicians to negotiate effectively with insurers. The concern is that without the option of “balance billing,” these physicians will be subjected to increasingly predatory pricing from insurance companies who will hold all of the leverage.

But bankrupting patients cannot be the solution. That is unacceptable and should not be tolerated.

Insurers point the finger at physicians and hospitals, while physicians point it right back at insurers. Though there is not just one villain here who can take all of the blame, there is also a lack of heroes in this story.

Out-of-network emergency department billing is not a problem that can be solved on its own or by any one group within the health care financial system. This is the type of problem that requires policy.

A recent New York Times article pointed to U.S. Rep. Lloyd Doggett of Austin, who introduced legislation in 2015 to help address the issue but was met with indifference from his colleagues, despite Texas’ being one of the worst offending states. It is up to all of us to now replace that apathy with a distinct call to arms that catches the attention of our representatives.

California has already passed a bipartisan bill to protect patients against surprise out-of-network medical bills. Patients who receive care from in-network facilities in that state would only have to pay in-network cost sharing. A few other states, such as Florida, have similar laws.

Texas allows patients to participate in a mediation process to reduce balance bills by working with physicians and insurers, but the process is limited to certain types of bills and plan types, and the billed amount must exceed $500 per provider to be eligible. The system is underutilized and does not protect patients as well as it could.

Texans cannot remain at risk of unexpectedly getting stuck with a surprise out-of-network physician bill after visiting an emergency department. This threat should now be considered an emergency.

Dr. Christopher Moriates is the assistant dean for health care value at the Dell Medical School at the University of Texas. Dr. Victoria Valencia is the assistant director for health care value at the Dell Medical School at the University of Texas.


Reader Comments ...


Next Up in Opinion

Herman: Paxton opines on freedom for the jennets of Fannin County
Herman: Paxton opines on freedom for the jennets of Fannin County

From time to time, state Attorney General Ken Paxton has to officially opine. People covet opinions from attorneys general, which makes them different from columnists. Attorney general opinions matter, and they touch on all matters of life in Texas. From way up in Almost Oklahoma came a request for the attorney general’s opinion (certified mail...
Commentary: Texas-size signage fuels duel among businesses, gun groups
Commentary: Texas-size signage fuels duel among businesses, gun groups

Gun extremists appear to have developed a pattern of targeting small businesses in Texas that legally elect to prohibit guns on their property. Bee Cave patisserie Baguette et Chocolat legally opted out of Texas’ concealed and open handgun carry laws by posting visible and compliant signage prohibiting the open and concealed carry of handguns...
Letters to the editor: Sept. 22, 2017

Re: Sept. 16 article, “Round Rock boy selling soap to help Hurricane Harvey survivors.” What an inspirational young man Ezekiel is! In the midst of hurricane tragedy, I hope that survivors will hear the story about Ezekiel’s compassion for them and how it led him to selfless action on their behalf. They aren’t just getting soap...
Commentary: Let’s debunk falsehoods about school choice and special ed
Commentary: Let’s debunk falsehoods about school choice and special ed

As kids begin a new school year, it’s deeply unfortunate that some of the most disadvantaged students in Texas still lack access to a quality education. When the special session for the Texas Legislature abruptly ended, the move killed two bills that would have created a tax-credit scholarship program for students with special needs. This common-sense...
Commentary: Senate health care plan creates ‘haves’ and ‘have-nots’
Commentary: Senate health care plan creates ‘haves’ and ‘have-nots’

Sixteen words from my doctor changed my life: “What worries me is that I think you are in the early stages of Parkinson’s disease.” I was 48 years old. Recently, I stopped by my local Walgreen’s pharmacy to pick up my Parkinson’s medication. As I waited in line, a woman told the pharmacy tech, “I absolutely have...
More Stories