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Anthem asks Missourians to think twice before going to the emergency room – St. Louis American

(St. Louis Public Radio) – Anthem Blue Cross Blue Shield, one of Missouris largest insurers, no longer covers emergency room visits that it deems unnecessary.

The policy aims to save costs and direct low-risk patients to primary care physicians and urgent care clinics. But doctors say patients may avoid going to a hospital when they really need it, if they fear a large bill.

Theyre forcing the lay public to make a medical determination, said Dr. Doug Char, a Washington University emergency physician. Theyre basically telling people you have to decide if this chest pain youre having is indigestion or a heart attack.

An emergency room is the most expensive place to see a doctor, and insurers are balking at the cost. Between 15 percent and 30 percent of emergency room visits in the St. Louis region are avoidable, according to a study by the nonprofit Midwest Health Initiative. Missouri hospitals charge an average of $372 for emergency room visits for minor issues, but some charge as much as $1,300, according to data compiled by the Missouri Hospital Association.

“Most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics of 24/7 telehealth services,” Anthem’s Missouri spokesperson, Scott Golden, wrote in an email. “The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis.”

In mid-May, Anthem sent letters to Missouri enrollees to alert them that from June 1, it would no longer cover emergency room services for non-emergencies. In such cases, people who have health insurance could still be stuck with the full cost of their visit, if the insurer determines that their symptoms did not reach the level of requiring emergency care.

Anthem enforces the same guidelines in Kentucky, and put the rule in place for Georgia policyholders this month. Its officials say there are several exceptions, such as if a patient is under 14, the visit occurs on a Sunday or there are no urgent-care centers within 15 miles.

The American College of Emergency Physicians raised a red flag when Anthem sent out a spreadsheet of 1,908 conditions that it may not deem not worthy of coverage in an emergency room. Some of the listed symptoms could indicate a life-threatening emergency, said Dr. Jonathan Heidt, president of Missouris ACEP chapter.

To have them under that threat of not having their bills paid if theyre wrong about what their diagnosis is, its really going to harm patients in the long run, Heidt said. Our patients have a right to seek emergency care.

The doctors argue that Anthems policy, and similar rules set up by state Medicaid programs, violate the federal Affordable Care Acts prudent layperson standard. The rule asserts that a person with average knowledge of health and medicine should be able to anticipate serious impairment to his or her health in an emergency, and that laws should not assume that a person will know more than that. Anthem contends that it reviews claims using this standard already.

Though Anthem began enforcing the Missouri rule at the beginning of June, patients who visit the emergency room for non-emergencies likely will receive bills in the coming months. Heidt said that if Anthem does not reconsider its policy, ACEP may weigh legal action against the insurer.

Were still a little bit early for that,” Heidt said. “But at this time, all of our options are on the table.

According to the Missouri Department of Insurance, Financial Institutions & Professional Registration, the rule is based on previously filed language that was approved by the regulator. Other plans have similar provisions.

“If a consumer believes a claim has been improperly denied, or has questions about how a claim has been handled by their insurer, they can contact the Department’s Consumer Affairs Hotline at 800-726-7390 or they can file a complaint online,” said Grady Martin, the agency’s director of administration.

Republished with permission of St. Louis Public Radio: http://news.stlpublicradio.org/post/anthem-asks-missourians-think-twice-going-emergency-room

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Belleville OKs Clara Maass emergency room expansion – NorthJersey.com

A rendering of the proposed Emergency Department renovations at Clara Maass Medical Center in Belleville.(Photo: Mollie Shauger/NorthJersey.com)

The Belleville Zoning Board of Adjustment has given its go-ahead for Clara Maass Medical Center to expand its Emergency Services department.

As previously reported, the hospital was seeking approval for a 1,400-square-foot addition and renovations to its Emergency Department and an 8,000-square-foot courtyard between the ER and a recently built Intensive Care Unit. The application included four variances.

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Domenic Segalla, the chief operating officer and chief financial officer of Clara Maass, appeared before the board on Thursday, July 6, to explain the reasons for the upgrades. Segallasaid Clara Maass is looking to expand the current Emergency Room by adding more space and to segregate pediatrics andbehavioral health treatment areas. Right now, the two areas are commingled, he said.

“Our whole goal isto createand help to expand and create a need that is here for the community, and how do we serve that need. We feel very strongly that right now we don’t have the capacity to provide this need for the community,” Segalla said.

“We’ve spend a lot of time over the last sixmonths trying to become as efficient as we can, and even thoughwe’ve made a lot of progress, it’s still a small setting for the volume we continue to see,” he added.

The hospital sees about 20,000 pediatric visits a year, and about 10,000 behavioral health visits, he said.

As a result of the the Affordable Care Act, more patients are being treated in an outpatient setting, he noted, and some with behavioral health issues don’t necessarily need to be admitted to the hospital.

Clara Maass intends to addmore observation beds for these patients tobe treated and cared for in a safer and more efficient way, but not necessarily admitted to the hospital, he explained.

Also, these treatmentareashave special requirements in that they cannot contain furnishings and other items that a patient could potentially use for committing suicide, he said.

A map shows where the additional construction would occur at Clara Maass.(Photo: Mollie Shauger/NorthJersey.com)

The expansion would also include the addition of 10 pediatric treatment rooms on top of 13, for patients to be examined,he said.

The Zoning Boardbecame hung up on the aspect of parking, as the hospital had proposed eliminating a small number of spaces to enhancethe drop-off area to the Emergency Department.

Board ChairA.J. Del Guercio and Vice ChairWilliam Villanoexpressedconcernthat patients in distress or those who have physical ailments may not be able to walk from another lot 250 feet away from the ER.

The application had proposed a loss of 16 parking spaces overall. However the applicants agreed to provide four additional parking spots at the drop-off area, and to reserve seven in a nearby employee lot for Emergency Room visitors, and not to refuse other ER visitors from parking in the lot.

Email: gray@northjersey.com

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Summer months bring rise in emergency room visits – Florida Times-Union

Summertime in Florida brings warm weather, beach trips and outdoor activities as children are out of school and families enjoy vacations.

All can be fun, but also have inherent risks and increases in injuries.

Close to 20 percent of adults and more than 17 percent of children every year visit an emergency room.

About 27 percent of visits are in the summer months, according to the Centers for Disease Control and Prevention.

In Florida, we are faced with a unique set of problems that can result in drownings from rip currents in the ocean to heat-related illnesses and dangerous sunburns.

Some other common injuries and illnesses seen in emergency rooms in the summer include motor vehicle accidents, watersports-related injuries, snake bites, shark bites, bug bites, spinal injuries and other traumatic injuries.

But there are many ways to stay safe while enjoying all the fun summer has to offer.

Wear sunscreen that is SPF 30 or higher and reapply frequently

Limit your time in the extreme heat and direct sun and wear sun protective clothing

The suns rays are most harmful between 10 a.m. and 4 p.m. If youre out during these times, seek shade under a tree, shelter or an umbrella.

Stay hydrated throughout the day

Learn CPR and other life-saving techniques

Be sure to wear your seatbelt at all times

In the summer, the temperature inside a parked car can reach 140 degrees. Never leave a child or a pet inside a parked car even if the windows are cracked or the car is parked in the shade.

Water safety is also essential. The CDC reports that from 2005 to 2014 there were an average of 3,536 fatal unintentional drownings (non-boating related) annually in the United States about ten deaths per day. An additional 332 people died each year from drowning in boating-related incidents.

Drowning is the leading cause of death among children between 1 and 4 and the second leading injury-related cause of death in older children, with nearly 800 children drowning each year nationally, according to Safe Kids Northeast Florida, led by THE PLAYERS Center for Child Health at Wolfson Childrens Hospital. More than half are under age 5.

More than 5,000 children nationally are seen in emergency rooms for injuries from near-drowning incidents.

According to Safe Kids Northeast Florida, studies show that although 90 percent of parents say they supervise their children while swimming, many acknowledge that they engage in other distracting activities at the same time like talking, eating, reading or taking care of another child. Even a near-drowning can have lifelong consequences.

With all the water activities in Florida, its important to also know that Floridas drowning death rate of children ages 1 to 4 has historically been the highest in the nation.

Children need to be watched carefully and at a close distance while also avoiding any distractions. Use life jackets when boating and ensure that yourself and children know basic swimming skills. If you have a pool, be sure it is fenced off and safeguards are in place to protect children from getting inside unsupervised.

When it comes to the outdoors, children and adults also need to be careful where they walk and play because they may come face-to-face with critters, including snakes.

Summer is snake season and Florida is especially dangerous with several poisonous snakes commonly roaming the area.

Avoid high-brush areas and if you see a snake, do not approach or pick it up.

If you are bitten, seek help immediately. Do not apply a tourniquet and do not attempt to suck venom from the wound. Often times, people try to capture and bring in the snake when they go to the emergency room. But that is actually more dangerous and does not help with treatment. Instead, remember the snakes color and shape to describe to medical personnel.

The key to summer fun is to just be cautious and take necessary precautions to keep you and your family safe.

Brandi Gilchrist, MD, is board-certified as an emergency medical specialist. She is medical director of Baptist Emergency at Town Center and assistant medical director of the emergency department at Baptist Medical Center Beaches, 1350 13th Avenue South, Jacksonville Beach, FL 32250.

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Entry to Leesburg hospital ER moving as part of $27 million expansion – Orlando Sentinel

LEESBURG The entrance to Leesburg Regional Medical Centers emergency room, which will grow in size as part of a $27 million expansion, will close Thursday as part of the construction, hospital officials said.

Starting then, patients will be required to access to the ER through the hospitals main entrance, officials said. Signage and extra security will be in place to help guide patients and family members. Additional parking spaces have been added to the east and west lots to accommodate patients and visitors.

The expansion will increase the hospitals east side by almost 48,000 square feet of space, adding 24 beds to the ER and including a fast-track unit to handle pediatric patients, three or four trauma-sized rooms for critical-care treatment, a spacious waiting room and an atrium-like lobby.

Its the first increase in the ERs capacity since it was built more than 50 years ago, according to Don Henderson, president and CEO of Central Florida Health, LRMCs nonprofit parent company. The expansion is due to be completed in spring of 2018.

jfallstrom@orlandosentinel.com or 352-742-5916

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Anthem asks Missourians to think twice before going to the emergency room – KBIA

Anthem Blue Cross Blue Shield, one of Missouris largest insurers, no longer covers emergency room visits that it deems unnecessary.

The policy aims to save costs and direct low-risk patients to primary care physicians and urgent care clinics. But doctors say patients may avoid going to a hospital when they really need it, if they fear a large bill.

Theyre forcing the lay public to make a medical determination, said Dr. Doug Char, a Washington University emergency physician. Theyre basically telling people you have to decide if this chest pain youre having is indigestion or a heart attack.

An emergency room is the most expensive place to see a doctor, and insurers are balking at the cost. Between 15 percent and 30 percent of emergency room visits in the St. Louis region are avoidable, according to a study by the nonprofit Midwest Health Initiative. Missouri hospitals charge an average of $372 for emergency room visits for minor issues, but some charge as much as $1,300, according to data compiled by the Missouri Hospital Association.

“Most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics of 24/7 telehealth services,” Anthem’s Missouri spokesperson, Scott Golden, wrote in an email. “The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis.”

In mid-May, Anthem sent letters to Missouri enrollees to alert them that from June 1, it would no longer cover emergency room services for non-emergencies. In such cases, people who have health insurance could still be stuck with the full cost of their visit, if the insurer determines that their symptoms did not reach the level of requiring emergency care.

Anthem enforces the same guidelines in Kentucky, and put the rule in place for Georgia policyholders this month. Its officials say there are several exceptions, such as if a patient is under 14, the visit occurs on a Sunday or there are no urgent-care centers within 15 miles.

The American College of Emergency Physicians raised a red flag when Anthem sent out a spreadsheet of 1,908 conditions that it may not deem not worthy of coverage in an emergency room. Some of the listed symptoms could indicate a life-threatening emergency, said Dr. Jonathan Heidt, president of Missouris ACEP chapter.

To have them under that threat of not having their bills paid if theyre wrong about what their diagnosis is, its really going to harm patients in the long run, Heidt said. Our patients have a right to seek emergency care.

The doctors argue that Anthems policy, and similar rules set up by state Medicaid programs, violate the federal Affordable Care Acts prudent layperson standard. The rule asserts that a person with average knowledge of health and medicine should be able to anticipate serious impairment to his or her health in an emergency, and that laws should not assume that a person will know more than that. Anthem contends that it reviews claims using this standard already.

Though Anthem began enforcing the Missouri rule at the beginning of June, patients who visit the emergency room for non-emergencies likely will receive bills in the coming months. Heidt said that if Anthem does not reconsider its policy, ACEP may weigh legal action against the insurer.

Were still a little bit early for that,” Heidt said. “But at this time, all of our options are on the table.

According to the Missouri Department of Insurance, Financial Institutions & Professional Registration, the rule is based on previously filed language that was approved by the regulator. Other plans have similar provisions.

“If a consumer believes a claim has been improperly denied, or has questions about how a claim has been handled by their insurer, they can contact the Department’s Consumer Affairs Hotline at 800-726-7390 or they can file a complaint online,” said Grady Martin, the agency’s director of administration.

Follow Durrie on Twitter: @durrieB

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Emergency room patients shouldn’t have to worry about coverage – STLtoday.com

In the wake of Anthem Blue Cross/Blue Shield notifying Missouri plan participants that non-urgent emergency room visits would no longer be covered, the Post-Dispatch published an article (June 23) asserting that St. Louis residents use the ER too often for unnecessary care. Unfortunately, there were serious methodological flaws in their study. This policy from Blue Cross/Blue Shield may violate federal law regarding the national “prudent layperson” standard.

This standard requires insurance coverage be based on a patients symptoms, not final diagnosis. Anyone seeking emergency care suffering from symptoms that appear to be an emergency should not be denied coverage.

Burning in the chest may be heartburn; however as emergency physicians, we know not infrequently it actually ends up being a heart attack.

If you have an Anthem Blue Cross/Blue Shield health insurance plan in Missouri, be aware that nearly 2,000 diagnoses which the company consider to be non-urgent would not be covered in the emergency room. Heart disease, cancer, asthma, stroke, diabetes, influenza and pneumonia are among the top eight causes of death in the United States. All of these illnesses can cause life-threatening conditions that require emergency care.

Missouri participants need to fight for their right to have access to emergency care as protected by the “prudent layperson” standard.

Patients should be able to seek emergency care immediately without wondering if insurance will cover the ER visit. The vast majority of patients who come to the emergency department seek care appropriately.

Dr. Kristen Mueller St. Louis

Member, Missouri College of Emergency Physicians

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My Night in the Emergency Room – Aish

I was in my kitchen following directions for a new muffin recipe when the immersion blender got stuffed with the dried ingredients, clogging the sharp blades. For a second I thought to myself, let me unplug the machine, but somehow I didnt.

I know. Big mistake.

I put my finger in to scoop out the thickened flour and before I knew it the machine went swirling. I screamed out for my husband to call Hatzalah, the emergency volunteer corp. Grabbing a towel, I wrapped it tightly around my finger. We ran outside, my hand lifted, pointed to the sky.

A few moments later we heard the sound of sirens. My husband and I climbed into the ambulance. I was afraid to look and turned away as my finger was examined. No doubt about it, I needed to get to a hospital. I kept giving my husband a brave smile but the truth is, I had no idea about how much damage was done. I was frightened and scared. And yes, it was painful.

The Hatzalah volunteers raced us to a nearby hospital. They brought us in to the emergency room and reassured us that all will be all right.

All around me there were people waiting to be helped. Police were clustered around a room where they were guarding a crime victim with a gunshot wound. Some lay moaning on their stretchers. This is going to be a really long night, I thought to myself.

The Hatzalah crew took care of getting me checked in and quickly returned with news.

The doctor on call tonight is a wonderful plastic surgeon. Hes part of the local community and guess what his specialty is? Hands!

I was overwhelmed with gratitude.

I cant believe it, my husband added. I know him. We grew up together and went to the same shul as kids.

Even more unbelievable because the shul is in Sao Paulo, Brazil.

I was settled on a stretcher still holding up my heavily bandaged finger while we waited for the doctor who was treating another patient.

My husband began pacing. Is the pain terrible? he asked.

Its ok. I gave a thin smile.

So many thoughts were going through my head. Why didnt I just unplug that machine? What was I thinking? Who knows what this will involve? And wow, does this ever hurt!

Then I remembered something my mother taught me years ago. When Joseph was sold by his brothers and taken down to Egypt, he was put into a caravan. Normally, there would be smelly tar taken as the caravans cargo but to spare Joseph the awful stench, God arranged that on this journey there would be fragrant spices instead. When Joseph would smell the spices hed realize that he was not forgotten. This would be a personal sign to him. Even in the midst of his pain and suffering, he was receiving a comforting message from Above.

At this moment I truly got it.

In the midst of your pain, look for a sign and seek a token of something good. Try to smell the sweet spices and youll get through your challenge feeling loved despite the pain.

Here we are in this emergency room, I said to my husband. Its the middle of the night, were both exhausted and I have no idea how this will turn out. But with it all, I feel comforted. The doctor here is a plastic surgeon hand specialist whom you grew up with! What are the odds? I am smelling the sweet spices. I am feeling the Almighty watching over me.

A short while later the doctor treated me and thank God I my hand will heal without lasting damage. We were finally ready to return home.

It had been a difficult day. That morning we had stood in the cemetery for the unveiling of my beloved mother, Rebbetzin Esther Jungreis. Prayers were recited and tears were shed. Even though the distance from that tragic moment of loss grows wider, the searing pain remains. I yearn for another conversation, another laugh, another Shabbos meal shared, another blessing that will never be.

But if we can hold onto the lessons that a parent has given us, then the soul is forever with us, guiding us, inspiring us, and infusing us with strength. That is the parents legacy.

That night my mothers words echoed to me in the night, bringing me comfort and soothing my soul.

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Tough question for hospitals: Who’s too risky to release? – Auburn Citizen

NEW YORK Four days before Alexander Bonds ambushed and killed a New York City police officer, he was in a hospital emergency room getting a psychiatric evaluation. The hospital released him the same day.

Now the hospital’s actions are under a state review ordered by the governor. St. Barnabas Hospital says it handled Bonds appropriately and welcomes the inquiry.

The decision was one psychiatrists across the country make regularly: whether patients pose enough danger to themselves or others to require hospitalization. Practitioners say that it’s often a difficult call to make and that even an experienced evaluator can’t predict someone’s behavior.

“Most of the time, it’s very complicated. You’re trying to make an assessment: Is the person going to a home? Is there family? Are they reliable? What was the specific reason they were brought in? Is that likely to occur again?” said Bea Grause, president of the statewide hospital and health system association HANYS and a former emergency room nurse.

Bonds, 34, evidently had a history of mental health problems. There were antidepressant and anti-psychotic medications in his apartment, and his girlfriend told officers she took him to St. Barnabas for the psychiatric evaluation July 1, police said.

He was observed for seven to eight hours in the emergency room, where he was seen by a physician and then a psychiatrist, hospital spokesman Steven Clark said.

“We believe the proper protocols and standards were met,” he said.

By the night of July 4, Bonds’ paranoid, erratic behavior worried his girlfriend enough that she called police to look for him. They didn’t find him before he marched up to a parked police vehicle and shot through the window just after midnight, striking Officer Miosotis Familia in the head. Soon after, officers shot and killed him after they say he drew a weapon on them.

The state Health Department said it plans to interview St. Barnabas staffers, conduct inspections and examine records to review Bonds’ case and the hospital’s policies and prescribing practices.

Under state law, people can be involuntarily hospitalized for at least 48 hours if they pose a substantial risk of causing serious injury to themselves or others.

“If you’re making a determination that someone’s a danger to themselves or others, you better be pretty clear about it. Because you’re taking away their liberties,” said Grause, whose association represents hospitals and nursing homes.

Psychiatrists caution that the risk can be difficult to pinpoint.

“While psychiatrists can often identify circumstances associated with an increased likelihood of violent behavior, they cannot predict dangerousness with definitive accuracy,” the American Psychiatric Association said in a 2012 position statement.

Doctors and other hospital staffers can encounter agitated emergency room patients they’ve never seen before.

While paying close attention to what patients say and do, doctors also might test to determine whether a medical problem or medication might be spurring the behavior. They consider whether the cause could be alcohol or illegal drugs, a clue sometimes illuminated by observing patients for hours. They may look into whether someone has dementia.

Some patients arrive clearly violent, and others are just having a bad drug reaction that will wear off. But “there’s this vast gray area in the middle that takes a lot of experience, a lot of knowledge and balancing all of the factors that go into a good assessment,” said Dr. Vivian Pender, a New York City psychiatrist and public affairs representative for the New York County Psychiatric Society.

Police have been working to determine Bonds’ motive in shooting Familia. Bonds, who had served prison time for a 2005 armed robbery, had railed about police and prison officers in a Facebook video last September.

Familia, 48, was a 12-year New York Police Department veteran and a mother of three. She was selfless, “incredibly funny” and full of warmth and wisdom, her 20-year-old daughter, Genesis Villella, said Friday.

She “went to work every day proud to do her job, to protect us,” Villella said.

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Patient, BBB seek change with Emergency Room "hidden charges" – FOX 46 Charlotte

CHARLOTTE, NC (FOX 46 WJZY) – Hidden charges at emergency rooms are causing transparency questions to be raised.

“Any other form of purchasing, people know what they’re paying,” patient Steve Komito said. “Somehow if you’re in the emergency room, you don’t have to know and I’m saying that’s wrong.”

Komito took his son to the Carolinas Healthcare Systems Emergency Room in Waxhaw this past Spring. X-rays were done but when Komito received his bill, he noticed a “room charge” for $1,244.44. Komito said, had he known about that charge up front, he would have taken his son elsewhere — adding, the X-rays were not even conducted in that general service room and they could have waited elsewhere.

“I guess my mission at this point is transparency,” Komito said.

Komito said, during his visit, someone with the E.R. told him they will not give pricing ahead of a visit because if the patient determines it’s too expensive and leaves — the E.R. will be held liable if something were to happen with their health.

The Better Business Bureau said it receives roughly 1,000 complaints a year for situations like this in the Greater Charlotte region.

“It’s not like going into a fast-food restaurant and seeing prices up on the board,” BBB’s Tom Bartholomy said.

FOX 46 Charlotte reached out to Carolinas Healthcare Systems earlier this Spring with a list of billing questions that have still not been answered. We sent them an email again on Friday and are waiting for a response. Here’s a portion of the email…

1.Will Carolinas Healthcare System give pricing information prior to service at the Emergency Room, upon request?

2.Does CHS stand behind this standard room charge and policy? When did this charge go into effect?

3.Weve heard talks about Level 3 and Level 4 E.R. room visit cases. What are the specific levels and what determines one of these levels?

4.What goes into the room charge? Is there a time limit a person has to be in there for a charge? A specific procedure? Does a doctor have to physically examine them? What warrants this charge?

5.Does CHS maintain that it will not release pricing prior to an E.R. patient being seen because it can be held negligent if the patients decides the cost is too high, and leaves without treatment?

FOX 46 Charlotte has now reached out to State Senator Tommy Tucker (Komito’s district) to see if he would be interested in any sort of legislation surrounding hospital charges being disclosed up front. Here’s a portion of that email…

Would Sen. Tucker support legislation demanding immediate transparency of ER pricing? As these bills are broken down into “Levels” — why can’t a patient know ahead of time the approximate costs of his service?

*This obviously does not include any additional testing that may be ordered or needed. But again, these prices – all pricing – is slotted ahead of time.

The Better Business Bureau told FOX 46 Charlotte there needs to be more transparency between E.R.’s and patients.

“If there’s going to be a basic charge for you for being in that emergency room no matter what you’re there for, then, yeah, why not?” Bartholomy added.

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The ER, an out-of-network provider and then ‘surprise!’ – mySanAntonio.com

Christopher Moriates and Victoria Valencia, For the Express-News

Photo: Mayra Beltran /Houston Chronicle

The ER, an out-of-network provider and then surprise!

Is there anything more emblematic of our troubled health care system than a patient receiving a surprise bill in the mail after getting emergency care?

The most egregious form of surprise medical bills, also known as balance bills, happens when an out-of-network provider bills a patient despite having delivered care at an in-network facility. Often this occurs when a patient goes to an emergency department or hospital that accepts that persons insurance, but then is seen by a physician who is not contracted with that insurance group.

As writer and physician Elizabeth Rosenthal recently wrote, Imagine if you paid for an airplane ticket and then got separate and inscrutable bills from the airline, the pilot, the co-pilot and the flight attendants. Even worse, the co-pilot could then tell you he is out of network and is going to bill you the full amount.

This practice of medical surprise out-of-network bills should be illegal. At this point, only the Legislature can solve the problem of surprise bills.

In 2009, Texas led the way by being the first state to put a mediation system in place for surprise bills. This past year, Senate Bill 507 was expanded to include mediation eligibility for bills of more than $500 from any provider type; facility bills from emergency care, including those from free-standing ERs; and to patients covered by the Teacher Retirement System, or TRS, health plan and the self-funded TRS ActiveCare program. This last change granted an estimated 680,000 additional individuals eligibility for the mediation process.

Prior to these changes, only bills from certain specialty providers were eligible for mediation, and ER facility bills were not eligible.

We should all thank our representatives for this bipartisan legislation, but it is nowhere near enough.

One indication the system is inadequate is how rarely it is used. A 2015 Consumer Reports survey found that 1 in 14 privately insured adult Texans reported getting a surprise, out-of-network bill within the previous two years, totaling about 250,000 Texans. However, according to the Department of Insurance, only 3,824 Texans have used the mediation process from its implementation in September 2009 through the end of last year.

Clearly, the system is not as accessible as it needs to be.

One major reason it is the responsibility of the patient to start the mediation process. This puts the onus on the patient to gather information, submit paperwork, make phone calls and attend at least one formal phone meeting. And that assumes the patient recognizes the bill is eligible for the process. Senate Bill 507 now specifies that when surprise bills are sent to patients, the sender must include language indicating the bill is the balance for out-of-network services and that it may be eligible for mediation. It is possible, however, that this language will be lost in all the other fine print on the mostly indecipherable bills.

Other states have passed much stronger protections than has Texas. New York passed a law in 2015 that requires hospitals negotiate directly with the insurer for all out-of-network payments, across all health care settings. This is how it should be.

Making the problem worse for patients, emergency departments in Texas can essentially charge whatever they want for services. Prices vary without any logic or reasonable guardrails. According to a recent study, emergency physicians reading an EKG (electrocardiogram) of your heart a mostly simple task performed many times each day charge patients anywhere from $18 to $317, which is 20 times the rate that Medicare would pay. If the doctor who read that EKG happens not to be in your network, guess who will be billed that full $317?

The Texas Legislature should consider capping all charges at a reasonable level above Medicare-allowable fees. There would still be variation in charges, but patients would no longer be subject to extreme markups.

Texas should lead once again in protecting patients from surprise medical bills.

Christopher Moriates, M.D., is assistant dean for health care value in the Dell Medical School at the University of Texas at Austin. Victoria Valencia is the assistant director for health care value in the Dell Medical School.

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