By Jay Moore, M.D.
In short, surprise billing is the phenomenon that occurs when a patient ends up with a bill they weren’t expecting after a visit to the hospital. Hence the name.
But there’s a lot more to it. And there are steps insurance companies and others that work with hospitals can take to eliminate some of this unnecessary patient pain.
The Impact of Surprise Medical Bills
The story is usually something like this: A person goes to the emergency room because of a genuine health concern like chest pain or shortness of breath. They do their homework and make sure that the hospital is part of their insurance network and will be covered. They are evaluated by the doctor and admitted for an overnight stay. The next day, their cardiologist comes to see them and schedules them for a procedure. The procedure goes well, and the patient goes home.
A few weeks later, the bills come in. The first one from the hospital is expected. A second one from the cardiologist shows up a few days later. But then, bills start rolling in from the emergency room doctor, the radiologist, and the anesthesiologist. Worse yet, some of these bills are not covered by insurance.
What’s going on?
The answer is that some of the doctors who work in the hospital are part of independent medical groups and are not employed by the hospital. These groups have their own contracts with insurance providers. The end result is a confusing mix of in-network and out-of-network medical bills that makes the patient’s head spin.
While the hospital bills were covered, the services from these doctors were not. This doesn’t seem fair to the patient, and it’s not! They did the work to make sure the hospital they chose was covered. They had no choice about which ER doctor was working that day or which radiologist looked at their chest X-ray. These surprise bills are infuriating — and often financially devastating.
Common Surprise Billing Culprits
When I worked for an insurance carrier, we had an acronym we used to describe the doctor groups that were most likely to generate surprise medical bills. The abbreviation was ERAP, though I’d probably add an H to the end of this acronym. ERAPH stands for:
- Emergency Room (the doctors who work in the ER).
- Radiology (the doctors who read your X-rays and MRI scans).
- Anesthesiologists (the doctors who put you to sleep for surgeries and manage your pain).
- Pathology (the doctors who run the hospital’s lab and examine tissue samples).
- Hospitalists (the doctors who contract with the hospital to manage patients there).
When insurance companies contract with a hospital, they also like to have a contract with the medical groups the hospital works with to cover these services. These doctors are contracted by the hospital to provide services for patients who are seen there, and patients typically have no choice in their doctor for these services.
While other specialists who see patients in the hospital also might not be contracted with a given insurance carrier, the key difference is that a medical specialist like a cardiologist or neurologist is usually chosen by the patient before they end up in the hospital to manage a chronic illness. There are some situations where that’s not the case — and where patients can face surprise medical bills — but they’re far less common.
Taking the Shock Out of Surprise Medical Bills
Insurance companies and others that work with hospitals need to pay special attention to these ERAPH providers. When we partner with hospitals, the Paytient team also reaches out to the doctors who provide these services in the hospitals. We know that our partnership with a hospital is only successful if the patient experience is excellent.
When members go to any of our partner hospitals, they can rest easy knowing that their Paytient card will work with these providers the same way it does with the hospital itself. This is just one of many ways we work with healthcare providers to give their patients a superior product.
If you’re interested in learning more about how Paytient partners with hospitals and physician groups, please reach out! We’re eager to work together to help eliminate surprise billing — and deliver solutions that help patients get the care they need without breaking the bank.
Jay Moore, M.D., is Paytient’s chief clinical officer. He did a combined internal medicine and pediatric residency at the University of Missouri, and he maintains board certification in internal medicine. Jay has worked as a hospital administrator and an insurance executive, where he managed a team of physicians and evaluated startups for partnership opportunities. He lives in St. Louis with his wife and a way-too-large collection of hobby games.