Beware standalone ER sticker shock

Accepting ‘all insurance’ doesn’t mean ‘in-network’

For Texas patients getting stuck with surprise bills, out-of-network emergency departments and stand-alone emergency rooms (also called freestanding emergency rooms or FSERs) should serve as buyer-beware cautionary tales.

It is no surprise to health insurers and other health care experts that these business models are hugely profitable and that they continue to pop up across the state, as recently detailed in Houston Chronicle reporter Jenny Deam’s “Blindsided” report and a Chris Tomlinson column, “ER docs, hospitals fleecing patients.”

In 2009, FSERs began proliferating in Texas, where more than half of all such facilities in the United States are located. FSERs are not attached to hospitals, and, in most instances, are not a part of a hospital’s network of services or providers.

Research shows that these types of ER facilities typically are built in affluent neighborhoods where there is already a wide selection of health-care options, including hospitalbased emergency rooms, urgent care centers and doctor offices.

How have FSERs developed so quickly?

These facilities succeed under a low-volume, highper-capita-income model — meaning they see just a few patients per day who pay a lot of money. Because of this, most FSERs choose to stay out-of-network.

In 2016, Blue Cross and Blue Shield of Texas reached out to all known out-of-network FSERs in Texas hoping to negotiate in-network agreements. Not a single FSER contacted would agree to a negotiated rate, many before even looking at the rates being offered.

Patients often are unaware that many of these facilities are classified as out-of-network by most insurance companies.

Additionally, because of location and appearances, they can easily be confused with the more affordable urgent care centers.

Moreover, some FSERs use marketing materials that can be confusing to patients, such as advertising that that they accept all insurance plans. However, this is not the same as being in-network, which can leave consumers much larger bill than they expected.

Texas has one of the highest rates of surprise medical billing in the nation. The risk of surprise billing is even greater at FSERs — nearly 70 percent of out-of-network claims for Texas emergency rooms occur at freestanding ERs.

These facilities can charge up to 10 times more than urgent care centers for the same services. The average cost to treat bronchitis at a Texas FSERs is around $3,000, compared to $136 at a traditional doctor’s office or $167 at an urgent care center. In many cases, consumers are left confused and angry when they get a big bill for care they thought was covered.

There’s hope. Two bills passed in the last legislative session that will help protect Texas consumers from the outrageous costs and confusion associated with FSERs. Senate Bill 507, authored by Sen. Kelly Hancock, expands mediation protections to include FSERs and other out-of-network emergency providers to all PPO insurance plan holders. The reform empowers PPO plan holders to challenge inordinately expensive bills received after a visit to one of these facilities.

House Bill 3276, authored by Rep. Tom Oliverson, requires independent FSERs to be more transparent when it comes to their insurance network status to lessen the confusion about the cost of services these facilities cover and what’s considered in-network.

As a physician, I understand that many people find it difficult to determine if they are experiencing a true medical emergency. If you have, or think you have, a true medical emergency then seek care in the nearest emergency facility or by calling 911. However, if your need for care is urgent but not lifethreatening, I encourage you to consider your options. This decision is critical to avoiding potentially exorbitant outof-pocket emergency costs. Where you go for care does matter, and going to a freestanding emergency room can be costly.