Billing at free-standing ERs still confuses

State law forces facilities’ websites to disclose insurance coverage, but ‘accepting’ plans doesn’t mean all is paid

Fifteen months after Texas enacted a law to bring transparency to the state’s for-profit free-standing emergency rooms, many of the facilities continue to send mixed messages about insurance coverage that could expose unsuspecting patients to surprise medical bills.

A Houston Chronicle review of websites representing the 52 free-standing emergency rooms in the Houston area shows a pattern in which many of the facilities prominently advertise that they “accept” all major private insurance. Some even list the insurers’ names and logos.

But often tucked under pull-down tabs or at the bottom of the page is a notice that the facilities are outside the networks of those insurers, followed by a reassurance that under the Texas insurance code, network status does not matter in emergency treatment, implying patients needn’t worry about coverage.

What the websites fail to disclose is that out-of-network status can result in insurance reimbursements far below the charges, leaving patients on the hook for the remainder of the bill — sometimes thousands of dollars.

“The word ‘accept’ means something very different to them than to the consumer, and they know that when they write their websites,” said Stacey Pogue, senior health policy analyst at the Austin-based Center for Public Policy Priorities. “They do not tell the rest of the story.”

For example, many of the Houston-area facilities advertise that they accept Blue Cross and Blue Shield of Texas, the state’s largest insurer. But the Chronicle’s review found that only five — about 10 percent — are in that insurer’s network.

Those findings are consistent with a statewide report by AARP Texas, to be released Monday at a state Senate committee hearing, that found 77 percent of the state’s 215 free-standing emergency rooms said they “take” or “accept” Blue Cross and Blue Shield insurance, but were out-of-network.

Free-standing emergency rooms defend their websites, describing concerns raised by advocacy groups and Texas lawmakers as manufactured outrage.

“I don’t see a problem with saying they ‘accept,’ ” said Dr. Carrie de Moor, CEO of Code 3 Emergency Partners, a Frisco-based network of free-standing emergency rooms, urgent care clinics and a telemedicine program. She insisted that patients understand that accepting someone’s insurance is different from being in that company’s network.

It may seem like a hair-splitting distinction, but it can carry high costs, health policy experts said.

Free-standing websites are technically correct when they cite state insurance code requiring insurers to cover emergencies regardless of network status, said Jamie Dudensing, CEO of the Texas Association of Health Plans, the state’s insurance trade group. That provision is in place to make sure a patient experiencing a life-threatening emergency does not have to worry about finding an in-network doctor or facility.

But she cautions that covering emergency treatment is not always the same as footing the entire bill. A facility outside an insurance network is not bound by the negotiated reimbursement rates and has no limit on how much it can bill.

Further, under a practice know as balanced billing, out-of-network providers can charge some patients for the portion of a bill not paid by insurers. In-network providers are prohibited from balanced billing.

“They are twisting the language to make it seem like patients are always protected,” Dudensing said of the websites. “They are not.”

Stream of complaints

The for-profit, free-standing emergency room got its start in Houston nearly a decade ago and ballooned into a health care phenomenon. The idea was to offer patients easy access to a fully equipped emergency room in their neighborhood and avoid lengthy waits at hospitals. Visits to freestanding emergency rooms now account for more than a quarter of all emergency visits in Texas, according to a report by the insurer UnitedHealthCare.

Patients have complained for years about exorbitant bills from the facilities after believing they were in-network and treatment would be paid by insurance. Sometimes, they were confused because the facilities, typically located in retail centers, look like the nearby — and often in-network — urgent care centers. Often, they found out too late that the cost difference can be staggering.

Consider a case of strep throat. A UnitedHealthCare analysis of claims found that in Texas the average cost billed at a free-standing emergency room was $2,732, or 21 times higher than the $128 average cost at a physician’s office. At an urgent care clinic, the average cost was $159, the analysis found.

The free-standing emergency room cost was even higher than a traditional hospital emergency room, which would have charged on average $1,784, the insurance analysis said.

The free-standing industry defends its fees and billing practices because the facilities must be staffed with physicians aroundthe-clock, see all patients and offer the same level of treatment and testing as a hospital emergency room. Sometimes patients may not know all that goes into their treatment, particularly when it involves expensive tests to rule out a more serious ailment, the industry says.

The volume of consumer outrage led state Rep. Tom Oliverson, a Harris County Republican and anesthesiologist, last year to introduce House Bill 3276, which required free standing-emergency room websites to properly identify the facility, disclose network status, and include a warning that physicians providing care may bill separately from the facility.

The legislation passed easily and went into effect Sept. 1, 2017.

Nearly a year later, though, murkiness remains.

Take, for instance, the prominent graphic on the website for Clear Creek Emergency and Urgent Care that touts “No Wait No Worries. All private insurance accepted.”

But only after opening a pulldown tab for “patient resources” does this statement appear: “For most insurance providers, we are considered out-of-network. However, we honor all in-network deductibles and benefits.” The website then adds: “If your health insurance company attempts to treat your classified medical emergency as out-of-network, you can consider it a violation of the law and take action by contacting your billing company or your insurance agent.”

“Reading all of that together,” said Pogue, the health analyst for the Center for Public Policy Priorities, “there is no way for a consumer to make heads or tails of it.”

The company did not respond to requests for comment.

Network, schmetwork

Other websites seem to downplay the importance of network status altogether.

Elite Care Emergency Center in League Center, for example, offers this message: “Some of our hospital-based competitors make much of the fact they are contracted and thus ‘in-network’ with most of the major health insurance plans. When you see this marketing message, you can assume that it really means that they do not have much else good to say about themselves.”

Chad Bush, managing director for Elite Care, acknowledged in an emailed statement: “We do not give a lot of credibility to in-network status as it specifically relates to emergency care” because of protections in place. Still, he said the website’s “bold language” may need to be reviewed.

Another unaddressed issue occurs when a patient’s out-of-network emergency room visit is later determined not to be a true emergency. In August, Blue Cross and Blue Shield of Texas launched a controversial measure to add heightened scrutiny to out-of-network emergency claims in its health maintenance organization (HMO) plans. The company has said that if an after-the-fact review determines that the patient should have sought treatment at a less-expensive option, the insurer may not pay the claim.

Free-standing emergency officials say insurers are tricking patients, not them.

“We have seen an alarming increase in the efforts made by insurance companies to confuse patients about where they can and should go for medical care in emergencies,” said Brad Shields, executive director of Texas Association of Free-Standing Emergency Centers. “The reality is simple: In-network and out-of-network are irrelevant concepts when it comes to emergency care.”

Blake Hutson, associate state director of AARP, says the dizzying finger-pointing between insurers and providers only further confuses patients.

“People want to understand their health insurance, to have an explanation of how they’re going to be covered and their cost,” he said. “At free-standing emergency rooms in Texas, that all breaks down.”

Try, try again

Oliverson said he thought the law he sponsored would prompt the industry to police itself and to clearly inform patients.

“Some have done a good job, others I’m not so happy with,” he said. “The whole point of the law was to make it more plain that ‘accept’ is not the same as ‘in-network.’ ”

He vowed to introduce additional legislation in the 2019 session. He is considering modeling a New York measure, which is one of the strongest in the nation for consumer protection. Under the New York law, when a patient receives a surprise bill, the insurer and provider are forced to the table to fight it out and the consumer is removed from the middle. In Texas, it is up to patients to initiate a state-sponsored mediation.

“We need to solve out-of-network balance billing once and for all,” Oliverson said.