Say you break your leg. Fortunately you have insurance, so you head to an emergency room that’s in your insurance network -- and you think, at least when it comes to your medical bill, you’re all good.
But a new study out of Yale University finds you may not be.
“This is one of the scary parts of American medicine,” said Zack Cooper, an assistant professor of public health and economics at Yale University. “Hospitals and physicians independently negotiate with insurers over network participation. So it’s possible to have a physician inside an in-network hospital who, himself or herself, is out of network.”
According to the U.S. Centers for Disease Control and Prevention, about 40 percent of the U.S. population visits an emergency department each year. To learn more, Cooper’s team obtained data from a major commercial insurer, studying nearly 9 million ER visits between 2011 and 2015.
In his paper released by the National Bureau of Economic Research, he reported surprise out-of-network billing isn’t happening at all hospitals -- it’s just done a lot by a relatively narrow group of providers, about 10 to 15 percent.
“A lot of those hospitals tend to be for-profit,” Cooper said. “And, in many instances, have emergency departments managed by this one single company: EmCare.”
EmCare, a physician outsourcing company, has disputed the study’s methodology, but in a statement, acknowledged out-of-network billing is a “structural issue” in health care.
“The study appropriately identifies out-of-network reimbursement as a source of dissatisfaction for all payors, providers and patients in our current healthcare system,” said Kim Warth, communications director for EmCare’s parent company, in an e-mail. “We agree with the implied recommendation -- which is to advance a shared goal to reengineer the current system in a positive way.”
Cooper said he hopes his work inspires legislators to follow the lead of states like New York, which in 2014 passed a law designed to protect patients who get emergency care from surprise out-of-network bills.
He also wants to examine out-of-network surprise billing in other medical specialities -- like neonatology, anesthesiology, and radiology.
“There are a lot of really complicated problems in health care that can’t be solved,” Cooper said. “This is one of these rare problems, that is incredibly devastating, that we can fix.”