By Dylan Deprey
From broken bones to bronchitis, Dr. Lisa Maura had seen many life-threatening situations walk through the doors of Wheaton Franciscan – Saint Joseph Hospital.
A couple weeks ago, a man in his fifties came into Dr. Maura’s ER with chest pain. He had been putting it off for weeks, avoiding the emergency room because of the potentially hefty bill in his future. He tried using Aspirin and other home remedies. Little did he know he was having minor heart attacks and by the time he made it to the ER he was having a full-blown heart attack. To Maura’s surprise, the man was not as concerned about the status of his health as he was the cost.
“One of the first things he asked was if this hospital was in his (insurance) network,” Maura said. “We are seeing it more often.”
According to a study by Marketing General Incorporated, on behalf of the American College of Emergency Physicians (ACEP) found that 8-in-10 emergency physicians have witnessed patients avoid healthcare due to out-of-pocket expenses, deductibles and co-insurance “By waiting that long, it ends up being the worst situation for him (heart attack patient) and the insurance company,” Maura said.
The man with the heart attack, flirting with death, was not the first Maura has seen avoiding the ER due to an impending fear of a bank account draining ER bill.
She said that insurance companies have been misleading patients by offering “affordable” premiums for policies with less coverage.
Maura noted the Emergency Medical Treatment and Labor Act (EMTALA). The EMTLA is a federal law and was enacted in 1986. It stated that “anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay.”
“Insurance companies know the law and how to take advantage of the law,” Maura said.
The ACEP president Dr. Jay Kaplan noted how insurance companies have created small networks of health care providers. This potentially leads insurance companies to higher profits for those patients who have to receive care outside of their network.
“Insurance companies are exploiting federal law [EMTALA] to reduce coverage for emergency care knowing emergency departments have a federal mandate to care for all patients, regardless of their ability to pay,” Kaplan said.
This would mean that when patients visit an out-of-network emergency room the price of the deductible would be exponentially higher because the lack of coverage.
America’s Health Insurance Plans (AHIP) is the national trade association that represents insurance companies throughout the country. From employer-sponsored insurance to public programs like Medicare and Medicaid, AHIP has worked with it.
AHIP Press Secretary, Clare Krusing addressed the statements of insurance companies misleading patients. She noted that health plans are not the sole responsibility for the charges in emergency rooms.
“All stakeholders — hospitals, physicians, health plans — have a responsibility to provide patients with the information they need to make informed choices about their care,” Krusing said.
Krusing added that a solution to the problem could be if hospitals ensured that billing would be balanced between a reasonable number of physicians and specialists.
“That’s why any proposals to address balance billing should address the core issues at hand — lack of transparency and excessive charges billed by certain specialists and doctors who choose to forego participation in health plans’ networks,” Kursing said.
The lack of transparency seen on the insurance company’s end with the inconsistent billing between specialists is not the same lack of transparency Dr. Maura has seen on the health providers’ end.
Maura expressed how insurance companies needed to be upfront with patients on the details of the premiums they are paying for. This is especially to know the coverage out-of-network emergency room situations.
“People need to know that low premiums are not always an affordable plan,” Maura said.