What's that? Your arm just fell off? Naturally your first reaction might be something along the lines of, "Thank goodness I'm insured!" Your next reaction might be to scream in agony, but instead you might want to suck it up, save your breath and tell the ambulance driver not to take you to Baylor University Medical Center.
Don't misunderstand -- Baylor doctors will probably patch you up just fine. But according to a new report, even insured patients are more likely to be saddled with horrendous bills after visiting the emergency room at Baylor or dozens of other ERs across the state. On Monday, the Center for Public Policy Priorities outlined "balance billing" problems in Texas. That's the bill insured patients are saddled with after they unknowingly accept care from an out-of-network physician.
The report focused on emergency room care, and cited Baylor as one major in-network hospital that works with the three largest state providers -- Humana, BlueCross BlueShield and United Healthcare -- but does not have any in-network emergency room doctors.
"Balance billing" is also referred to as "surprise billing," because patients are often unaware of the added charges they'll incur by receiving services from certain physicians. Although Baylor accepts several different insurance providers, the physicians themselves might not be part of the insurers' networks, which negotiate lower fees with doctors. If a patient is seen by an anesthesiologist, a surgeon, and an ER physician, that's four different bills, including the hospital bill, that patients have to hope their insurance covers at the lower network rates.
"If you're having a heart attack, you might be rushed to a hospital that you know is under your insurance. And you might expect that everyone who touches you under that roof is under that network is as well," says Stacey Pogue, a policy analyst who authored the study. "In a hospital that's not how it happens. The physicians who care for you are allowed to practice in the hospital, so it's entirely possible for you to go to an in-network hospital but every other bill you get will be for out-of-network services. And that will lead to really high costs."
Pogue says there's much less of an incentive for emergency room physicians to list popular insurance providers in their network. While primary care physicians need to work with popular providers in order to attract patients and drive business, emergency room doctors don't need insurance to keep up their volume and bring in patients.
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And that quickly adds up to hundreds and thousands of dollars of out-of-pocket bills. "When you get to the emergency room, you don't get to say I want a doctor in my network," says Pogue. "The data shows that so many more emergency room services are out-of-network. It means that you're nearly guaranteed to have to pay a balance bill. Even if you have the most popular insurance provider in Texas, you're almost guaranteed to have to pay someone out of network."
Patients do have the option to find out if on-call physicians are in their network. But even if patients anticipate their emergencies, it's extremely difficult to find out emergency room doctors' networks ahead of time. Between frequent on-call rotations and the sheer panic that typically comes with medical emergencies, most people never find out if their ER doctor is in their network.
"People ask all the right questions, but the trick is you can't find out your, say, anesthesiologist until the day of or day before. So even very diligent consumers can't get the information they need," says Pogue. "The Legislature has emphasized transparency. But what we found having looked at the data is that transparency can't be a solution in emergencies. You can't expect someone in the back of an ambulance to get on their iPhone and pull data up."
Then again, you probably won't care very much about the bill if your arm has just fallen off.