Emergency Room Bill from In-Network Facility May Include Out-of-Network Care

In an era of rapidly increasing medical costs, it is not unheard of for an insured patient to receive an astronomical post-care emergency room bill.

The high emergency room bill reflects a growing reality that many hospitals staff this area of their facility through contracts with outside physician groups.

This situation isn’t intuitive for the consumer—particularly one in the midst of a medical crisis who later receives a high emergency room bill. 

Negotiating the current medical insurance landscape is difficult in the best of circumstances. Theoretically, a patient should be able to do a quick internet search to discover what individual providers and what facilities are in their insurer’s network.

In-network providers, clinics, and hospitals are entities that have agreed to provide care for reimbursement within a pre-contracted expense range with an insurance company.

The unexpectedly high emergency room bill that can come after a patient seeks urgent medical attention at an in-network hospital is known as balance billing. The care provided is often not by in-network physicians and the insurance will only pay the pre-negotiated in-network rate.

This leaves the remainder of the emergency room bill to be paid by the consumer who thought he or she had done their insurance homework.

According to a recent online article by The Inquirer, this was the case with Steve Z., a patient that sought care at Riddle Hospital in Media, Pa. in early May. Steve was in severe pain with a kidney stone—although the diagnosis was unbeknownst to him at the time.

He presented himself at the hospital which technically was in his Blue Cross Blue Shield (BCBS) network.

Upon arrival, Steve was given a full battery of tests without regard to his insurance—which is the protocol of emergency rooms in general. Being in pain and having looked up the facility to make sure it was in-network ahead of time gave Steve a false sense of security during his physical work-up.

A few weeks later, he was sent a balance emergency room bill  for $666 from the out-of-network doctor that treated him. This was what remained after his insurance had paid their portion at the in-network rate.

Contracted physician groups which are forming these business relationships with hospitals are quickly gaining the reputation of providing services at a steep markup well beyond what would be considered reasonable. The truth is that because they do not have the same relationship to insurance companies, they don’t have to be reasonable.

The era of the surprisingly high balance emergency room bill might be coming to an end, however, as more people come forward to share their economic horror stories. One such woman shared her story by filing a California class action lawsuit against EmCare and EDS Practices 1 of California—two such physician groups that staff hospital emergency rooms—in 2017.

This plaintiff was treated at an in-network hospital emergency room by an out-of-network physician that didn’t disclose this status. She was later presented with a $4,000 emergency room bill for all the care she received there. The rate for services was close to double what the in-network charge would have been.

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