Free-standing ERs’ coverage still confusing
Fifteen months after Texas enacted a law to bring transparency to the state’s for-profit free-standing emergency rooms, many of them continue to send mixed messages about insurance coverage that could expose unsuspecting patients to surprise medical bills.
A statewide report by AARP Texas, to be released today at a state Senate committee hearing, found that 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-ofnetwork.
“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 Austinbased Center for Public Policy Priorities. “They do not tell the rest of the story.”
Some of the websites included a notice — sometimes under pull-down tabs or at the bottom of a
page — that the facilities are outside the networks of insurers but offered reassurance that under the Texas insurance code, network status does not matter in emergency treatment, implying that patients needn’t worry about coverage.
What the sites failed 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.
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 Texas-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 hairsplitting distinction, but it can carry high costs, health policy experts said.
Free-standing ER websites are technically correct when they cite state insurance code requiring insurers to cover emergencies regardless of network status, said Jamie Dudensing, CEO of Texas Association of Health Plans, the state’s insurance trade group. That provision is in place to make sure that a patient experiencing a lifethreatening 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. Innetwork 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.”
The for-profit freestanding emergency room has 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 free-standing emergency rooms now account for more than a quarter of all emergency visits in Texas, according to a report by insurer UnitedHealthCare.
Stream of complaints
Patients have complained for years about exorbitant bills from the facilities after believing that they were in-network and that treatment would be paid by insurance. Sometimes, they were confused because the facilities, typically located in retail centers, look like nearby — and usually 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 freestanding 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 around the 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 the care may bill separately from the facility.
The legislation passed easily and went into effect Sept. 1, 2017. The industry says it had until Jan. 1, 2018, to comply with website posting regulations.
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 pull-down 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 policy 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.
Not an emergency
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 measure to add heightened scrutiny to outof-network emergency claims in its health maintenance organization 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 Freestanding 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
Rep. Oliverson said he thought the law he sponsored would prompt the industry to police itself and 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 as a model a New York measure considered one of the strongest in the nation for consumer protection. Under that law, patients are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services or on balance bills.
“We need to solve out-ofnetwork balance billing once and for all,” Oliverson said.