Even with in-network hospital, insurance may not cover ER physicians

When her husband, Charles, showed signs of heart trouble in January, Donna Baker didn't hesitate to drive him to the emergency department at nearby Mease Countryside Hospital.

Only later did the Bakers learn that while Mease Countryside is part of their health insurance network, the physician who treated him there is not. The ER doctors are employed by a separate company that doesn't accept their United HealthCare plan.

The result? The Bakers got stuck with a $1,235 doctor's bill.

Surprised as they were, it's increasingly common for even careful consumers to get socked with high bills after unknowingly being treated by out-of-network providers. Consumer advocates cite the problem as a key driver of medical debt as patients are getting squeezed between fee-seeking physician practices and cost-cutting insurers.

Consider EmCare, the nation's largest emergency room contractor. It has affiliates operating in Tampa Bay hospitals, including Mease Countryside, Mease Dunedin Hospital, Medical Center of Trinity and Bayfront Health Brooksville.

Several major insurers — including United, Cigna, Humana and Aetna — don't include EmCare affiliates in their networks in Florida, saying it demands rates that are too high.

United spokeswoman Elizabeth Calzadilla-Fiallo said EmCare has requested that United pay 600 percent of the Medicare rate. "We cannot contract at rates that are utterly unsustainable and drive up costs while unfairly burdening local businesses and consumers," she said.

EmCare spokesman Ron Cunningham would not comment on rate requests.

"We have the best emergency care system in the world, and it's not cheap to keep it open and treating people at all times," he said. Insurers "want to negotiate a rate that's so low it doesn't pay our service."

Such fights mean higher bills for patients like Charles Baker, who suffered a painful and dangerous hematoma after tearing a blood vessel in his shoulder. His wife wants United to pay the bill.

"I get panic attacks thinking, 'What if we have to go again?' " she said.

When emergency rooms and the doctors who work there aren't on the same plans, even diligent consumers don't stand a chance, said Karen Pollitz, a senior researcher with the Kaiser Family Foundation.

"There's nothing you can do as a consumer. I mean, how can you possibly shop?" she said. "This notion of consumer choice just falls apart when it comes to emergency services."

• • •

When a medical provider agrees to be within an insurance network, fees are negotiated in advance. Medical providers who are outside a patient's insurance network may receive some payment from the insurer — but then can "balance bill'' the consumer for more.

Patients routinely go to in-network hospitals for a procedure or a test only to learn later that treating physicians — often an anesthesiologist or radiologist — were not in their network's plans. Though it isn't always easy, checking ahead to discover the insurance status of everyone involved in scheduled care is at least possible in theory.

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That's not at all true in the case of an emergency.

The day after he moved to Brooksville from New York last October, Michael Coe got sick and couldn't stop vomiting. He and wife Michele didn't know any area doctors at that point, so they decided to go to the closest emergency room, at Bayfront Health Brooksville. Before they left, Michele checked the hospital's web site and saw it accepted both her Blue Cross/Blue Shield plan and a separate plan that her husband has through his union.

The hospital was covered, but then they got a $985 bill from Quality Drive Emergency Physicians, which is affiliated with EmCare, according to state records. The couple said the physician spent less than five minutes with them.

Later, Michele Coe called the Brooksville hospital and asked what plans the ER doctors group does take. No one could give her a clear answer.

• • •

The Affordable Care Act does prohibit most insurance plans from charging higher copayments or coinsurance amounts for out-of-network emergency services. But it does nothing to stop balance billing by the out-of-network doctors and hospitals.

And the law's new limits on how much consumers must pay out of pocket — $6,350 for an individual and $12,700 for a family this year — apply only to in-network care.

"The ACA did a little bit, but it didn't do that much," said Adam Crowther, a researcher with consumer group Public Citizen and author of an April report calling for reforms to help curb balance billing.

Balance billing of Medicaid patients is prohibited by law, said Cheryl Fish-Parcham, deputy director of health policy at Families USA, a Washington consumer group. And it's rare for Medicare patients to be balanced billed, though patients enrolled in privately run Medicare Advantage plans sometimes face charges from out-of-network providers.

Florida is one of about a dozen states that do offer additional protections. Under state law, out-of-network medical providers can't balance bill HMO members for emergency services. Consumers with other types of insurance plans, such as popular PPOs, do not have that same protection.

But few HMO members seem aware they're entitled to the protection, said Steve Burgess, Florida's consumer advocate for insurance.

"We can help people who call us," he said. "But we don't know how many people get a bill and just pay it."

• • •

Tampa Bay area patients say that when they call about their bills, the insurers and physician groups typically point fingers at each other.

Donna Baker said a United representative even suggested she lodge a complaint with the state insurance office against EmCare affiliate Coastline Emergency Physicians Group.

EmCare operates in more than 1,000 hospitals nationwide and is a subsidiary of Envision Healthcare, a publicly traded medical outsourcing company that reported $3.7 billion in revenue last year. In the fiscal quarter that ended in June, its revenues grew by 20 percent.

That growth gives it bargaining ability that small physician groups don't have. And EmCare often is the only provider of certain services at hospitals, said Mark Slitt, a spokesman for insurer Cigna.

"This provides EmCare with leverage to demand higher-than-market rates from insurers that drive up the cost of care, which is a disservice to Cigna's clients," Slitt said.

EmCare isn't the only big ER player in the Tampa Bay area. Tampa General Hospital, for instance, contracts with EmCare's rival, Team Health, a Tennessee-based company that also owns a large chain of pediatric urgent care centers. A Team Health spokeswoman said the practice is included in the networks of most major insurers.

Glenn Waters, president of BayCare's hospital division, said hospitals don't want to insist that contractors get into the networks because insurers "would have no incentives to negotiate fair rates.''

Both insurers and ER contractors say they're willing to work with patients on their bills. But some patients don't know that, or figure it isn't worth trying.

Steve Quilty, a Wesley Chapel resident, was playing second base at an April softball game when he got hit in the face by a line drive. An ambulance took him to the closest hospital, Trinity Medical Center, which was in his United network.

His insurer got the hospital charges down to $3,300, which Quilty paid since he hadn't yet met his deductible. He assumed he was finished until he got a bill from Baxley Emergency Physicians, the EmCare-affiliated company staffing the ER.

The charge: $2,255.

Quilty was floored. But, in the end, he didn't haggle.

He just paid the bill.

Contact Jodie Tillman at jtillman@tampabay.com or (813) 226-3374. Follow @JTillmanTimes.