Wed 22 Mar 2006
So, to continue from The Emergency Room Trick - Part I - Beware… I’d spoken to the Insurance Commissioner’s consumer hotline and the gentleman there brought up a point I hadn’t thought of. Even if the hospital had told me that all the ER doctors didn’t take Blue Cross, was I in a position at that time to go somewhere else?
The answer is… not really. I mean, I wasn’t going to die if I didn’t get seen immediately, but did I have the stamina and presence of mind to go home, get on the internet, go on the Blue Cross web site and figure out how to tell which hospitals had ER staffs that took Blue Cross, then drive to the other hospital? And what about the people who come in by ambulance? Are they really in a position to comparison shop at that time? The answer to those questions is a resounding “NO”.
So what is the solution? Do we lobby our states for laws to make ER docs take every insurance? In theory, it sounds good. But in practice, the insurance companies would have too much power over doctors because if the insurance companies came up with outrageously low rates, the doctors wouldn’t have the legal power to say no to them. Plus, you know the medical lobby would spend millions to try to defeat laws like that.
Okay, then do we legislate that your health insurance must give you full coverage on Emergency Room fees to the extent that you pay the same percentages whether the doctor takes your insurance or not? Once again, it’s that same problem. Now the doctors are free to bill whatever they want and the insurance companies are taking the beating. And, therefore, the insurance lobby would spend millions to try to defeat laws like that.
With each proposal, you give one group (doctors or insurance companies) an ability to set unfair rates and remove the other group’s ability to refuse them. Despite the fact that both are rich groups that piss us off, giving one that much power to stomp on the other would end up being bad for everyone in the long run.
The solution, in my opinion, is in three parts…
1: More proactive disclosure. Hospitals cannot just put some vague language about third parties in their paperwork that you sign. They have to provide you with a personalized list of their doctors and departments that do or do not take your insurance before you sign the forms to let them treat you.
Remember Part I, where I said I could build them a database for generating forms like this in a day? It is neither difficult or expensive for them to do this. Only when you come in via ambulance, and this really shouldn’t be a distraction from your care, is there an exemption from this.
2: We, as consumers, need to be prepared. Even if item 1 was implemented, if you’re in the Emergency Room, you’re not really ready to get up and leave when you get that list, especially if you’re in great pain. But, if you know ahead of time which Emergency Rooms have doctors that take your insurance, and you’re not in a situation where a few extra minutes could mean the difference between life and death, you can save a lot of money by going to the right Emergency Room for you.
And how should you prepare yourself? Call your insurance company and ask. Why not go online? That takes us to…
3: Provider directories that make sense. Finding out which hospital emergency rooms take your insurance is more difficult than it seems. According to my health insurance’s online provider directory, the hospital took my insurance. I assumed that meant that all doctors and departments there did too. That wasn’t the case.
To find out which hospital emergency rooms I could go to, I had to do a search for “Emergency Medicine” facilities, not “Hospital” facilities. But even then, the facilities were named by the doctors’ group that did the billing. At three out of seven facilities within 40 miles, including the closest one, the names of the doctors’ groups didn’t include the name of the hospital. I actually had to check their addresses on Google to see if they were “doc-in-a-box” urgent care centers or at hospitals.
This is why I tell you to call customer service, rather than try to navigate this maze yourself. Call your insurer and ask which hospitals near you have Emergency Room docs that take your insurance. And do it every few months, because that information can change.
As I’ve noted before, I’ve built database-driven sites and I know how they work. The online provider directory doesn’t have to be confusing. If the insurance companies designed the database behind their online provider directory better and had the web site ask it the right questions, then when you looked up a hospital it would not only tell you whether the hospital accepted your insurance, but also which of its departments did (i.e. Oncology, Emergency Medicine, Radiology, etc.).
And the cool thing about calling… Calling them costs them a lot more than if you use their web site. Hopefully, when they see their call center costs rise, they’ll actually try to figure out why and not just outsource their call centers to India. If they do analyze the types of calls, they’ll make the directories make more sense, which would probably be cheaper over the long haul than a call center in Bangalore.
Still, all of this only applies to when the medical issue isn’t so critical that you have the option to decide where you go. If you don’t have the option (i.e. you’ve been rushed there in an ambulance, you’re stuck). How do we solve that? I really don’t know. But this blog does allow comments, so you’re welcome to post your suggestions.
Read the previous post: The Emergency Room Trick - Part I - Beware
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March 27th, 2006 at 2:01 pm
Having access to an updated web site is of little value in an emergency. Same can be said if you are going to have multiple procedures (lab, scans, etc.).
These hidden providers (as they are referred to in the industry) are simply folks who are (generally) not part of ANY network.
ER docs are just some of the few. And you will find hospitals with staff docs (who are in network) and on-call docs (who may not be).
Other hidden providers can include pathologists, radiologists, medical transport companies, labs, free standing scanning facilities, anesthesiologists . . . the list goes on.
As for the outsourcing comment, you do realize that HIPAA does not apply outside of the U.S. While some medical records are already transcribed in Asian countries so far customer service is not rerouted there . . . yet.
May 9th, 2006 at 10:52 pm
This may be a tad off topic.
It is getting to a point where it is probably better to just eliminate all ID from your pockets,take with you an amount of cash that you think is fair for the sevices you are seeking and identify yourself as “John Doe” when you go to an emergency room for minor stuff. Pay them then split!
I pulled that recently on Hoag after I sliced my hand open working on my truck and needed stitches. They weren’t too thrilled about it but took my $300 and I went on my way. I plucked the stitches myself at the prescribed removal time just in case they have the “Billing Police” waiting for me to return.
I have no medical insurance and usually count on my PHD buddy for most of my medical needs. I do work on his office building for free and he works on me for free. Unfortunately this happend on the weekend and he wasn’t around.
Some years before I broke my little toe slipping on carpet and jamming it into a post. I’ve broken toes before and I know there is not much a Dr. can do that I can’t. I usually just set it, tape it up and stay off of it as much as possible until it heals. This time it was a bit different. I had some immediate bruising and it felt like the bone may have shattered. I was concerned that it might be a compound fracture and may not heal right. I went to Hoag with cash and like a dummy filled out all their BS paperwork. All I wanted was an X-Ray and a Dr. to take a look at it so we could make decisions from there. Turned out the injury wasn’t severe all he did was tape it up and tell me to stay off it as much as possible. I payed my bill $385 and left.
Then the mail starts arriving. $250 for radiology,$180 for a consuting PHD of whom I never saw or noticed the attending PHD consulting with,$192 for an orthopedic sandal which I could have purchased at the drug store for $12 and even the temp agency that provides the candy stripers who work for free tried to hit me up for another $50.
After a few failed attempts to negotiate with them rationally over the phone without them getting nasty with me I got an attorney involved and they reduced the fee down to the price of the sandal which I was willing to pay just to be done with it. By that time I had learned that one of my co-workers had a brother that worked in Hoag’s IT department. For the price of a 12pack he made my whole account dissapear.
Pardon my French but “F-em”!
Good luck folks.
Rant off!
May 10th, 2006 at 2:14 am
This is kind of long, but very useful, it can save you big headaches by just knowing the following:
If you have an HMO plan in California, or a multiteared plan HMO/PPO(must include the HMO tier) and have a legitimate emergency room visit to a contracted hospital(in some cases non contracted hospitals) then whether or not the drs in that er are contracted, the insurance company has to honor the bill, minus your regular copayment and/or coinsurance.
If the ER orders radiologic services or lab services during your visit, whether or not the radiologic provider or lab provider is contracted, the insurance company is still responsible, minus your regular copayment and/or coinsurance.
Its important to understand that most hospitals, ER physicians, and ancillary providers are separate entities. Each entity bills for themselves. Typically, you will receive at least 2 different bills for an ER visit and possibly more.
1.) facilty(hospital) charge
2.) ER physician’s charge
3.)laboratory charges (if lab services rendered, such as blood tests)
4.) radiologic charges (if radiologic services, such as xrays, mri, etc. are rendered)
Many times what happens is the facility(hospital)gets your insurance billing information and does NOT forward that information to the ER physicians group or the radiologic and lab groups.
You will probably receive bills from all involved..the hospital bill will typically advise that your insurance has been billed. The ER physicians and others will send you a bill, I recommend that you call the billing parties, give them your insurance billing info have them bill due to important info often needed by insurance carrier that only the billing party can provide. The providers will normally agree to bill and allow time for payment. I would not pay provider direct unless absolutely necessary, due to delays of reimbursement.
Your insurance co. will send you and EOB(explanation of benefits) advising you how the bill was paid or advising of denial.
If denied or partial payment made-because provider was not contracted, call the insurance company, request full payment(if denied) or balance payment(if partial payment) advising you went to contracted hospital(facility)and drs and providers of services during visit in not in your control.
WARNING: If you are within your contracted hospital’s area and need urgent care, but the contracted urgent care facility is closed and you can’t wait for services, be sure to go to your contracted hospital and to be safe contact your insurance carrier and primary care physician as soon as possible after services.
If you have an extreme emergency and have to get to nearest hospital,contracted or not, that too should be paid by insurer, minus regular copay and/or coinsurance.
If ER physicians refer or suggest ANY FOLLOWUP SERVICES once your ER visit is over, PLEASE, PLEASE contact your primary care physician or your insurance co for authorization or to determine is services will be covered. Since most ER physicians are not contracted, they have no responsiblity in sending you to other contracted providers. It is your responsiblity to verify if the followup services will be covered. Better safe than sorry.
May 22nd, 2006 at 10:00 am
My mother has Regence and they are not contracted with them either. I called North Sound ER Physicans group and told them I am choosing a plan for open enrollment and wanted to know what plans they are contracted with. They told me that they couldn’t tell me that because it is “HIPAA” protected. HIPAA is a privacy law that protect patient information. I think that’s total bull that they couldn’t tell me. I don’t think they are contracted with any insurance company in WA. The Everett and Monroe hospitals need to find a new ER physician group.
April 18th, 2007 at 11:52 am
HIPAA is a privacy law that SUPPOSEDLY protects patient information, but if you actually read it, you will see that it is a law that allows everybody to snoop into your medical record except your spouse and next door neighbor, who must be given special permission. It gives all governments everywhere, including foreign, the right to see your medical records, which is why they really passed it and hid its true meaning under phony statements about protecting your privacy. So easy to fool the public!
When you called North Sound ER Physicians Group, you must have talked to some stupid clerk who doesn’t know what she is talking about. It is so hard to get past these clerks. Due to the name of the ER group, it sounds like they are probably a private physicians group, but most ER groups these days are not. (See my comment on Emergency Room Tricks, Part I.)
June 3rd, 2008 at 9:33 am
So here it comes, straight from the horse’s mouth. I’m an ER DOC. I’m residency trained, and have been boarded for over 12 years. I’ve worked everywhere from small 8 bed ER’s to large centers with over 65 beds.
First, understand that most EM Groups contract with the hospital. IOW, a group of EM Docs signs a contract with the hospital to provide 24 hour coverage in the ER. Then that group sub-contracts out to various ER Docs that actually take care of patients. As such, the ER Group does it’s own coding, but may or may not use the hospital’s billing service. There are all kinds of laws, but often the hospital wants to keep control of the billing to not risk federal Medicare fines for inaccurate billing.
With all that said, most ER Docs could care less about insurance! We didn’t go into Emergency Medicine to make money nor expect to be caring for patients that even say “thank you doc.” We take care of everyone that walks through the door, regardless of ability to pay, color of skin, who they have intimate relations with, or how bad their breath or feet smell. It’s part of our speciality - and it’s how we train our young ER Docs to think. We regularly get cussed at, spit at, or violently attacked. In a recent study, over two-thirds of us had been hit by a patient in the past 5 years. Do you know of any other job where employees getting struck is tolerated? ER folks have a special relationship with the cops for a reason.
Consequently, ER Docs really don’t know much about how health insurance works. If we did, it would cause us to do a “double-take” on our recommendations for best treatment and care. We would be constantly thinking, “Yeah, but can this patient afford this care?” The ripple effect of that would be catastrophic! Emergency medicine would become a negotiating practice - “So here’s what my extensive training thinks we should do, but since you can’t afford it, well, try soap, water, and green tea extract.”
The ER I currently work in (In the Northwest) sees over 30% of patients that are underinsured, or have no insurance at all. Do you know of any other business in the country that willingly accepts that 1/3 of it’s customers won’t pay for services or sales? I don’t……
So my advice to you is the following:
1. Don’t get yourselves into an unhealthy situation! Don’t smoke. Drink moderately and socially (but don’t drive!). Watch how much and what you eat. Use safety equipment. Teach your kids and yourself safe sex. And most importantly, start taking care of your body - it’s a magnificant and incredible gift from your higher power. Don’t abuse it! As I teach young physicians going into Emergency Medicine: “Drugs, alcohol, stupidity, and violence keep us employed.”
2. If you are sick or injured, most of the time you can care for yourself at home. Soap and water, clean dressings, ice, motrin, rest and chicken soup are mainstays of my treatment. They should be mainstays of your home treatment as well. Most people, with some common sense, know what’s lifethreatening or not. If you’re unsure, CALL YOUR DOCTOR FIRST (or whomever is oncall) and ask them. Often they will tell you, “Go to the ER.” Ask them why? What do you think the ER is going to do for me? If I’ve sprained my ankle, can’t I wait until tomorrow to see you in the office? If I’ve cut myself, the bleeding is controlled, and the wound edges come back together with simple bandaids, then why do I need to see the ER? If your kid is over 3 mos of age, fully immunized, and suffering from a fever, call your pediatrician. Ask them, “Do I really need to go to the ER now - or can you see me first thing in the morning?”
3. If you find yourself at an ER, without insurance or significant cash to pay your bill, then TELL US! I’ve had patients tell me, “Hey, I am paying cash and can’t really afford alot.” Let me work with you. We may be able to forgo an xray or treatment - if you accept the medical legal risk of doing so! I had a patient the other day who was paying cash and had a severe headache. He asked if he could forgo an $500 CT Scan (special xray of the brain). He and I discussed the risks of his decision-making process. He left the ER with pain medication feeling better. I called him the next day to see how he was doing. He was much better and very appreciative of my understanding. Medical-legally, I was protected. It was a win-win situation. I’ve had patients try to sue me for pity s–t! I can tell you, ALL DOCTORS will protect ourselves from lawyers and fraudulant malpractice suits. We’re tired of constantly having to look at every patient as a potential legal event!
4. Understand, I have bills to pay just as you do. My malpractice runs $45,000 / year. For anyone, that’s a significant chunk of change. My state license is $800/year. Continuous medical education is $2500/year. Office overhead is $8000/year. My taxes were $54,000 last year. My college and medical school tuition was around $250,000! You do the math. If all I’m asking is $300-500 for making sure you don’t die, lose a limb, eyesight, or provide an early diagnosis of cancer, than fork it over! Hell, plumbers get that much for servicing your toilet.
June 3rd, 2008 at 9:51 pm
Wow, that last post was amazing. And for all of you who like to complain over and over about how expensive all this stuff is and work on strategies to “stick it to the hospital”, you’re only making it more expensive for the people that do pay. Aren’t you special?
June 5th, 2008 at 4:29 pm
I don’t know what Hospital you work at
MDfor911. My wife was hit from behind
in a auto wreck and someone called the
ambulance for her as she was dizzy and
disoriented. She was taken to a nearby
hospital here in Sacramento, CA and they
did two CT scans head and neck. The put
one of those collars on her and sent her
home three hours later. Since we hadn’t
yet received a bill (3 months) we went in
to see what was going on. They were billing
her health provider 23,000 dollars for
their services. We informed them about
the other drivers auto insurance so they
will be billing them, however, if they have
the state minimum it will only cover 15,000.
Since she is covered by the VA for medical,
which I don’t think covers auto accidents,
we will be on the hook for about 10,000.
Their charges for the CT scans totalled
8500 bucks and the charge for the ER was
15,000 dollars. On what planet do either
of these charges make sense? Actually the
the doctor’s charge was 900 which is the
only charge near reasonable. I think
hospitals should be made to inform you of
their fixed charges. I would have gotten
her off the gurney and I would have driven
her to the VA.
Grog
October 8th, 2008 at 3:51 pm
I worked for an Emergency billing service. A group that supplies the ER doctors. I did claims. Here is one hint. If it was a true emergency. You did not have a choice which hospital to go to. When you get billed because the ER MD was not contracted with your insurance, call the medical billing company. Tell them it was a true emergency. You had no choice which ER doctor saw you. 9 times out of 10, they will credit your account and take whatever the isurance is paying. I did this. I know it works. It also works for ambulances. You have no choice in a live and death situation which ambulance picks you up but your insurance may be contracted with a specific one. Again call them. 9 times out of 10 they will credit the account. Don’t forget to always check you EOB’s (thats explanations of benefits) from your insurance for what is called double billing. Only pay what your insurance tells you your responsibility is to pay. You will be amazed how many doctor’s offices, ect will try to collect the portion that the insurance did not pay even though they are contracted. This is called double billing. Could save you thousands of dollars. Could go on and on about what I learned working in insurance & billing that could save you thousands of dollars.