North Sound, the corporation, I was told, was left with no option but to stop accepting Blue Cross insurance after negotiations failed between NSEM and Blue Cross. An agreement was reached 1 1/2 years ago and NSEM does accept Blue Cross at this time. Emergency medicine, payment for services, insurance compensation, billing charges, are all very complex. I certainly understand all the concerns.

I also know that North Sound has been contracted Providence hospital in Everett for 35 years. Many of the original MD’s still work with the group and have never had any other job. Though many have retired it is a group committed to the health needs of Everett. The group that started in the spirit of the 60’s by young physicians. I know there is no profit skimming, as someone noted above. I know that no one working with the group gets paid unless they work.

It is easy to make inflammatory statements and allegations in this kind of forum. But, in the very difficult world of Emergency Medicine, where 35% of the patient care is provided free to people who can not pay, and where patient demand for services often outstrips a facility’s funding for staffing to meet those needs, there are many sides to this story.

An eye opener… if you have ever seen medical care in other countries, you would be glad to have American medicine standards in your own back yard. We have the best system, it all just needs to be made better… and people are working on it. In a country of 300 million, change will take some time.

1. Know your insurance plan BEFORE an emergency occurs. The can tell you what hospitals AND physician groups they contract with. Call the ER and ASK what physician GROUP hnadles their ER. ***DO NOT WAIT*** until you have an emergency to find out. It is prohibited by a law called EMTALA to discuss insurance before you are triaged.

2. Often it isnt the hospital that controls that situation but the physicial billing group.

Most EDs are managed by the doctors themselves and are legally separate. They have a contract with the hospital to manage the ED, much as a retailer leases space in a mall. If the doctors don’t have a contract with the managed care plan, then the bill is the patient’s responsibility to the extent the patient’s (non-contracted) insurer fails to pay the entire bill.

In the great majority of cases, the reason why the doctors may not have a contract with an insurer is because the insurer was not willing to contract to pay an adequate amount. The message is, if at all possible first check to find out if the emergency department has a contract with your managed care insurer. Managed care plans should - but usually do not - include this information in their lists of hospitals and doctors.

Grog

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.

I went to Evergreen ER in 2006 on-plan with United Healthcare and later when the bills came found out that their ER doctors were not on-plan. So had a bill over $300 over what the insurance paid. I found out that the ER docs were on-plan for the affiliated network on my card (check those as many plans have them like Multi-care) but said they weren’t and wouldn’t take the discount. With tenacity and the help of the Benefits Advocate at work finally after 9 months they did take the discount. BTW, I went to Evergreens ER again in 2008 on-plan with a different insurance, Guardian/PHCS, and the ER doctors WERE on-plan and no balance due; easy breezy!

In mid-2007, I went to the Swedish ER on-plan with Guardian/PHCS and later when the bills came found out that their ER doctors were not on-plan. They were not part of the affiliated network either. The bill was not very much, about $40, but I called and asked them to review it and see if since the insurance paid at the “higher in-network rate” if they would take the discount. It took a few months but they did so I didn’t have to pay anything.

In late 2007, I went to Overlake ER on-plan with Guardian/PHCS and later when the bills came found out that their ER doctors were not on-plan. So had a bill over $200 over what the insurance paid. They were not part of the affiliated network so no hope of working that again. After months of talking to the physicians billing and my insurance, the insurance company saying they paid at in-network rates and we were responsible for the balance billing, the insurance commission saying the same thing, and feeling taken, I found out that the Physicians Group was controlled by the ER Director. I called and talked to him, talked about them getting paid the higher in network rate, told him how I chose not to go to his ER when I had to just recently (now 2008) because of the outstanding bill. He looked over my bill and found that one of the codes was no longer being billed separately due to some Medicare issue (we don’t have Medicare but apparently that is a factor that determines how the hospitals bill things based on what is required by Medicare ). He wrote off that code with was most of the balance billing. I just had to pay a small fee for “after hours 24 hr facility fee” but since it was so small in comparison I chose to pay it. Now I just have to see if this all dinged my credit report or not.

I asked the Director why people were not told that their ER doctors were not on-plan. He said there was a Federal Law that prevented them from telling patients WHEN AN EMERGENCY IS HAPPENING so that people will go to the nearest emergency room and so there is not lawsuits of “the guy with insurance got seen before the person without insurance” (that is why they don’t do any billing paperwork until you are past triage). BUT THEY CAN TELL YOU IF THEIR ER DOCS ARE ON-PLAN IF YOU ARE CALLING ASKING ‘WHAT IF IN THE FUTURE’ QUESTIONS. Since we just got new insurance through work changing plans, he did tell me that the Overlake ER docs were on-plan with my new insurance.

So do check with your ERs when you are NOT needing them to see if their ER doctors are on-plan so that you have an easier choice choosing which hospital to go to in an emergency. But be prepared that if you don’t have a choice, like in a car accident with ambulance transport, that you WILL get multiple bills from multiple departments and you WILL have to be vigilant to see if you can get write-offs from the billing physicians. I have found that in some cases, it was as simple as ASKING NICELY if they will review and take the write-off. In other cases you really have to stand your ground.

I do think that everyone should talk to their Government Representatives to see if they can somehow make this medical insurance mess easier for people.

I would really like to know what happens when the crack heads and druggies show up at the ER. Who pays their bills?

Seems very likely to me that suckers like us, who actually take bills seriously, are probably making up for all of the folks who simply ignore their bills and don’t pay a dime.