Study: Nearly 1 in 4 patients unknowingly treated by out-of-network ER doc

Doctor and nurses wheeling patient in gurney through hospital corridor
Getty/Sam Edwards

Nearly a quarter of patients who receive emergency care at an in-network hospital are surprised to learn that they were treated by an out-of-network physician, according to a new study. And they may be even more surprised once they receive their bill.

In the study, published in the New England Journal of Medicine, researchers analyzed claims data from a large commercial insurer. Of the 99 percent of ED visits by patients younger than 65 between January 2014 and September 2015 that occurred at in-network facilities, 22 percent of them involved out-of-network physicians.

In areas of Texas, surprise billing rates reached 89 percent, while patients in Colorado and Indiana almost never received a surprise bill. By combining enrollment data and claims data, researchers found that surprise billing rates across the country ranged from 18.6 percent to 24.4 percent.  

Patients who were billed for out-of-network physicians were charged $622 on average, although researchers noted that the maximum bill was nearly $20,000.

Balance billing has become more common with the rising popularity of narrow network plans. However, the study notes that surprise bills for emergency services are particularly problematic since patients have no way of knowing whether a physician at an in-network hospital is excluded from their plan.

“It’s the equivalent of going to a restaurant, paying the check and getting a bill six months later from one of the cooks,” Zack Cooper, an assistant professor of public health and economics at Yale and the study’s co-author, told the Wall Street Journal. The researchers noted that the problems associated with balance billing could be resolved by requiring hospitals to sell bundled ED packages that would include the cost of physician services.

Emergency physicians have warned of a loophole within the Affordable Care Act that allows providers to balance bill patients for any costs the insurer doesn’t cover. Last year, New York implemented what is believed to be the most comprehensive law protecting patients from balance billing, leading some experts to wonder if other states would follow suit.

The American College of Emergency Physicians (ACEP) roundly criticized the NEJM study, arguing that the data pulled from an unidentified private insurer was skewed and that balance billing rates are actually far lower.

“The data do not make sense, and in some cases, border on preposterous,” ACEP President Rebecca Parker, M.D., said in a statement, singling out the $19,600 surprise charge referenced in the study. She added that surprise billing research should use the independent Fair Health database