Visit to emergency room brought a separate bill

Lynn Johnson was confused when she got a $195 medical bill.

Johnson had gone to the emergency room at Johnston Medical Center in Smithfield last April and was treated by a physician assistant for a knee injury. She figured her coverage through Blue Cross Blue Shield would pay for her care because the hospital was a network provider.

Blue Cross did pay the $398 bill from Johnston Medical Center, but then, Johnston was left with a bill from the medical group that employed the physician assistant.

As Johnson discovered, emergency-room doctors may not be employed by the hospital. Some hospitals have contracts with physicians' groups that staff their emergency rooms, an arrangement that can create extra paperwork and, in some cases, extra out-of-pocket costs for patients. The reason: Some physicians groups aren't part of some major insurance networks.

Johnson, a former state and federal employee, said when she went to the emergency room last April, she didn't have the chance to find out if the medical worker who examined her was in her insurance carrier's network.

"You have no choices, and you really cannot check beforehand," Johnson said.

And even if she had, she said, her options were limited; she couldn't wait to see a family doctor. "It was 8 o'clock on a Friday night," she said. "There's no other place to go."

Blue Cross and Blue Shield of North Carolina insures nearly 3.8 million people across the state, said spokesman Lew Borman. Most of the physicians' groups are in the company's network, he said.

Pay the bill

In cases when patients with Blue Cross and Blue Shield go to emergency rooms and see a doctor in the network, claims are filed as usual. But if the medical worker isn't in the network, the patient will probably get a bill from the doctors' group, Borman said.

When that happens, he said, patients should pay the bill and wait for reimbursement from Blue Cross and Blue Shield. But the company will pay based on out-of-network rates, which could leave the patient responsible for the difference.

"It really does not happen all that often, but occasionally it does," he said. "And folks raise questions."

Raleigh Emergency Medicine Associates is a doctors' group that staffs the emergency room at Rex Hospital. The group does not have a contract with Blue Cross Blue Shield and some other major insurers, said Dr. Colleen Casey, group president.

Patients who go to emergency rooms that contract with out-of-network doctors' groups will be seen and treated as usual. The only difference is what happens after patients receive the care.

"We never want patients searching emergency rooms, finding who they're covered by and who they're not covered by," said Dr. Jim Palombaro, president of Wake Emergency Physicians. His group, which is in the Blue Cross and Blue Shield network, staffs the emergency rooms at Wake Med and Johnston Medical Center in Clayton.

At Duke University Medical Center and Duke Raleigh, most emergency-room doctors are Duke employees, a spokeswoman said. Durham Regional's emergency room contracts with Durham Emergency Physicians, which is in the Blue Cross network but not a network provider for some other big carriers.

Insurance companies tend to complicate things, Palombaro said. Some have a history of sending checks to patients, who are then supposed to send the money to the doctors' group that provided care, he said. That system is flawed, Palombaro said, because some patients keep the money for themselves.

"Unfortunately, the patients are put in the middle sometimes by the insurance companies," he said.

Johnson hasn't paid her bill. She didn't get a check from Blue Cross Blue Shield, and she told the doctors' group she's not paying until she gets the money from her insurance company. Borman said Johnson's case is especially complicated because she has coverage through both the state and federal employee programs.

Casey said seeing emergency-room doctors is like being treated by specialists. Patients might get a separate bill, and insurance companies might say they won't reimburse the full costs if they decide the treatment wasn't necessary.

But there are options, Casey said. Patients can appeal.

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