Fearing a gallbladder attack or worse, Jane Popick of St. Petersburg went to the emergency room at highly rated Largo Medical Center in November suffering stabbing pain under her breast. When providers diagnosed her with costochondritis, an inflammation of the cartilage that connects ribs to the sternum, Popick felt relieved the problem wasn’t more severe. Then she got the bill. Though she’d gone to a hospital in her health plan’s network, Popick says doctors she saw weren’t covered, and she owed them $2,200. “I was on the hook for money I didn’t have,” she says. “I thought it was a mistake.”
Benefits experts say the billing surprise Popick encountered is all too common. Because hospitals don’t employ most doctors who practice under their roofs, they can’t compel them to accept the same health plans they do, and often ER doctor, anesthesiology, radiology and lab groups remain out-of-network when they don’t find plan terms acceptable. That leaves some patients to pay more out of pocket, sometimes thousands of dollars.
“We fight this all the time,” says patient advocate Anna Inglett, owner of Putnam Health Advocates in Tampa, who charged Popick $300 to take her case. Popick says Inglett eventually negotiated her bill with an emergency provider group from Dallas-based clinical outsourcing company EmCare to about $800. EmCare didn’t respond to calls for comment.
Consultant Stephen J. Dresnick, founder of Dresnick Healthcare Advisors in South Miami, says Florida hospitals, which are mostly for-profit, have historically relied more on outsourcing ER staffing than hospitals in other states for financial reasons, because of limited in-state emergency medicine residency programs, and to care for a growing patient population. A national leader in clinical outsourcing, Knoxville, Tenn.-based TeamHealth has an office in Tampa, and spokeswoman Tracy Young says it saves hospitals on doctor-related overhead costs, including paying for recruitment and malpractice insurance.
Young says TeamHealth usually honors hospitals’ requests that its physicians accept the same insurance plans hospital customers are in because the firm’s size allows it to negotiate favorable doctor reimbursement rates with most insurers. But, she speculates, smaller outsourcing firms and independent physician groups with less leverage have more motivation to reject plans, and remain out-of-network.
Largo Medical Center spokeswoman Tammy Robiconti declined comment on Popick’s case, but says the hospital encourages patients to understand their insurance coverage and educates them about hospital, physician and consulting fees, upon admission. Popick lauded her care and doesn’t regret her decision to visit the ER, but thinks patients should be better informed about possible out-of-pocket costs.
Besides avoiding the ER in non-emergencies, billing advocates suggest patients request their insurers reprocess claims for out-of-network providers as in-network when they go to an in-network facility. Request the insurer send payment directly to you, says Pat Palmer, founder of Salem, Va.,-based Medical Billing Advocates of America. Then negotiate directly with the provider, and request a discount for cash payment.
For non-emergency cases, including elective surgeries, check in advance to make sure all involved in care — from anesthesiologists to outpatient surgery centers — are in-network. And read your policy’s fine print. “Know exactly what’s in your plan, and what it will and won’t pay for,” Inglett says.