If you have an emergency, you often don’t have a choice about which provider treats you. HMOs offer in-network coverage only. High deductible health plans (HDHPs) may or may not have out-of-network options.
Hospitals need to set the tone. When an emergency department hires non-contracted providers, they must accept the insurance carriers with which the hospital is contracted. If the providers do not accept, they should not be hired.
Emergency departments are supposed to be a safe haven. Hospital administrators should take responsibility for ensuring all providers are contracted with the same insurers for which the hospital is in-network. They should not be allowed to surprise someone with a $10,000 or $50,000 bill after an emergency. That’s not acceptable.
If someone seeking care in an emergency room has insurance from their fully-insured employer, the insurer eats these balance bills or negotiates with the hospital and provider on the side.
However, if that individual’s employer is self-funded, it’s up to the third-party administrator (TPA) to negotiate with the provider, and they may not always have the power to do so. The balance bill then falls back on the employer and employee, creating more hardship than the initial emergency.