Texas ER patients: Here’s the truth behind “In-network” vs. “Out-of-network”

By Carrie de Moor, M.D., CEO

Code 3 Emergency Room and Urgent Care & Board Member, Texas Association of Freestanding Emergency Centers (TAFEC)

Texas ER patients: Here’s the truth behind “In-network” vs. “Out-of-network”

By Carrie de Moor, M.D., CEO, Code 3 Emergency Room and Urgent Care & Board Member, Texas Association of Freestanding Emergency Centers (TAFEC)

As a Board Certified Emergency Medicine Physician who owns and operates a Freestanding ER and Urgent Care company in the Dallas-Fort Worth area, my colleagues and I have spent many years treating patients in need and providing life-saving care. We have also spent a considerable amount of time fighting insurance companies so that they will properly cover the care of their policyholders and also reimburse the providers of this care at a fair rate without unfair cost shifting to patients.

As recently reported in the Houston Chronicle:

“Texas has one of the highest incidences of surprise bills in the United States. Health economists have reported a 27 percent likelihood of Texans getting an out-of network bill after out-patient emergency room treatment — nearly double the national average of 14 percent….Network status matters because under a business practice called balance billing, unsuspecting patients can get stuck paying the difference between what an out-of-network doctor or facility charges and what insurers pay. By law, in-network providers cannot balance bill.”

It’s this last sentence that is the key component—“…in-network providers cannot balance bill.”

Surprise billing is simply balance billing that patients weren’t expecting. Insurers are misleading patients about why they’re on the hook for a large bill. In reality, insurers are passing on an increasing amount of ER costs to patients and keeping more of the profits for themselves.

They throw around terms like “in-network” and “out-of-network” in explaining to patients why their bill adds up to what it does, saying “in-network” bills are less and “out-of-network” bills are more, when in fact the exact opposite is often true. The truth that they don’t want you to know or understand is that insurance companies make more money when you and your employer spend more money. They do not want you to have a choice to access less expensive options for emergency care.

Many of us have attempted to go “in-network” with insurance companies, but few of us have succeeded. In fact, a study presented at TEXMED 2017 showed that the majority of independent freestanding ERs actively sought in-network contracts but were forced out-of-network by the insurance carriers (see attached poster).

My company is one of the freestanding ER groups that has managed to contract with a number of carriers, but even as the only access point to emergency care in Rockport, Texas (Hurricane Harvey’s “ground zero”) covering 60 miles of the Texas Coastal Bend in a disaster-declared area, the two largest insurers in Texas continue to force us out-of-network, despite our aggressive advocacy and good faith efforts to get in, purposefully giving their members no choice for access to in-network emergency care.

The good news is that Texas law protects patients in emergencies from these kinds of predatory contracting behaviors.

Your insurance company doesn’t want you to know this, either, and they are trying hard to take that protection away. What patients need to know is that when it comes to “in-network” versus “out-of-network” the differences are essentially irrelevant in the time of a medical emergency. Your care at an ER (hospital-based, hospital-affiliated, or independent freestanding ER) is always required to be covered under your in-network benefits.

And yet, here is something else that might surprise many patients and lawmakers alike. For all the freestanding ERs that are “out-of-network, it doesn’t always mean our prices are more expensive; in fact, they are more often than not, 30 to 40 percent lower.

Look at this comparison of prices to understand the differences…the truth will surely surprise you (see the pricing guide for a detailed side-by-side look).

And let me provide you with an example where out-of-network care for a certain treatment or procedure at our facility was less than what was charged for in-network care at a neighboring hospital-based ER. My son recently had to visit the emergency room for abdominal pain, which actually ended up being appendicitis. The cost of care at our freestanding emergency room, which is theoretically “out-of-network” for my insurance carrier, was 43 percent less expensive on average than each of the four surrounding hospital owned emergency rooms. That means on average, the cost of care at our “out-of-network” facility would have been almost $6,000 less expensive!

In conclusion, in their efforts to deceive you about your rights to seek care when you need it most and to better understand what it might cost, big insurance companies operating in Texas are attempting to play games with your health and your wallet.

But at the end of the day, they cannot escape the truth.

When it comes to emergency care, “in-network” and “out-of-network” don’t necessarily translate to what insurance companies say (i.e. “out-of-network” doesn’t always mean more expensive).

This is a truth that all Texas consumers need to know.