By using this site, you agree to the Privacy Policy and Terms of Use.
Accept
Health Works CollectiveHealth Works CollectiveHealth Works Collective
  • Health
    • Mental Health
    Health
    Healthcare organizations are operating on slimmer profit margins than ever. One report in August showed that they are even lower than the beginning of the…
    Show More
    Top News
    How Not to Become a Victim of Medical Scams
    How Not to Become a Victim of Medical Scams
    December 22, 2021
    11 Ways You Can Care for Your Elder Family Members Health
    11 Ways You Can Care for Your Elder Family Members Health
    April 6, 2022
    How Can Brain Injury Lead To Dangerous Long-Term Effects?
    How Can Brain Injury Lead To Dangerous Long-Term Effects?
    August 30, 2022
    Latest News
    Medicare Helps Seniors, and People with Disabilities & ESRD
    November 27, 2023
    The Link Between Allergies and Sinusitis & Strategies for Relief
    November 27, 2023
    What Health Complications Can a Sunburn Cause?
    November 22, 2023
    From Mountains to Metropolis: A Guide to First Aid Approaches
    November 20, 2023
  • Policy and Law
    • Global Healthcare
    • Medical Ethics
    Policy and Law
    Get the latest updates about Insurance policies and Laws in the Healthcare industry for different geographical locations.
    Show More
    Top News
    The Hidden Dangers of Working as a Health Care Professional
    May 5, 2016
    Inpatient vs. Outpatient Drug Recovery — Which One Works?
    September 28, 2020
    accident injuries healthworkscollective
    Beyond the Fender Bender: Accident Injuries, Actions, and Recovery
    February 5, 2021
    Latest News
    Automation in Pharmacovigilance: A Double-Edged Sword
    November 15, 2023
    What Does Science Say About Modern Health Practices?
    November 12, 2023
    Harnessing the Power of Email Marketing in Healthcare
    October 26, 2023
    10 Proven Strategies to Level Up Your Health Business
    October 25, 2023
  • Medical Innovations
  • News
  • Wellness
  • Tech
Search
© 2023 HealthWorks Collective. All Rights Reserved.
Reading: Fingertip Injury Points Out Emergency Care Billing Conundrum
Share
Sign In
Notification Show More
Font ResizerAa
Health Works CollectiveHealth Works Collective
Font ResizerAa
Search
Have an existing account? Sign In
Follow US
  • About
  • Contact
  • Privacy
© 2023 HealthWorks Collective. All Rights Reserved.
Health Works Collective > Policy & Law > Fingertip Injury Points Out Emergency Care Billing Conundrum
Policy & Law

Fingertip Injury Points Out Emergency Care Billing Conundrum

Thomas Pane
Last updated: 2012/08/08 at 8:57 AM
Thomas Pane
Share
5 Min Read
The emergency department entrance at Mayo Clin...
SHARE
The emergency department entrance at Mayo Clin...

The emergency department entrance at Mayo Clinic’s Saint Marys Hospital.

The emergency department entrance at Mayo Clin...

The emergency department entrance at Mayo Clinic’s Saint Marys Hospital. (Photo credit: Wikipedia)

A recent case from Dayton, OH highlights the tangled mess of emergency department specialty coverage, federal law, and out-of-network insurance benefits.  When these interact, patients, doctors, insurers and hospitals can be left frustrated and perplexed.

Here’s a brief summary:

A 6 yr old boy suffered a fingertip injury and the emergency staff called the covering plastic surgeon, who repaired the injury.  The surgeon, who does not participate with insurance, submitted a bill for approximately $8000.  The insurance company paid 80% of what it determined to be usual and customary charges, leaving the family the remainder, approximately $6000.  They were unaware the surgeon was out-of-network.  The hospital later changed call coverage, contracting with another group that accepts all insurances.

This case illustrates how current on-call realities can fail all four parties:  patients, hospitals, insurers, and on-call doctors.

First, a few preliminary facts:

  • The Emergency Medical Treatment and Active Labor Act (EMTALA) applies to hospitals accepting federal funds.  It does not allow for a discussion of financial considerations prior to rendering care.  (It is less clear whether this applies to independent physicians or just the hospital).
  • Doctors in private practice are not required to participate with insurance, and do not work for the hospital.
  • Hospitals often do not pay for on-call coverage.  Some hospitals may have other sources of funding for serving the uninsured, but such arrangements may not apply to the covering doctors.
  • Insurers may send payment directly to patients for out-of-network care.  When this happens, doctors try to recover from the patient, often receiving nothing.
  • On-call doctors summoned by the Emergency Department cannot refuse, and as noted above can’t discuss financial considerations, such as their insurance participation status.
  • In specialties such as plastic surgery, on-call doctors are sometimes called in for non-emergencies.

When these factors intersect as in this case, there can be confusion and finger-pointing.  The doctor may be upset at being inappropriately called (not so in this case), or not paid.  Patients may be surprised by a large bill despite having insurance.  Hospitals risk a public-relations problem if patients complain.  Insurers limit their out-of-network liabilities or risk being overcharged.  All of these positions have some validity.

The essence of the problem is not the Emergency Department’s behavior, the out-of-network status of the doctor, or the insurance company’s payment policy.

The problem is that under EMTALA, care is mandated but payment is not, and no cost discussions are permitted.  Hospitals and doctors know this, but all too often nothing is done to plan for the inevitable misunderstandings.

The solution lies with hospital executives meeting with each specialty, and figuring out how get patients the emergency care they need, that specialists are available and billing surprises do not occur.  There are many options, such as paying for call, providing for payment if patients are uninsured, or an agreement that there will be a limiting charge in emergency situations.  Some hospitals may decide that hiring specialists meets their needs.   Plenty of options are possible though they need vetting for legal correctness.

As the healthcare delivery system evolves, creative on-call solutions may be required.  What works in one community may not be optimal for another.  But with an open approach, and all stakeholders working together, collaborative solutions are possible.

Related articles
  • ER overcrowding hurts minorities in California (eurekalert.org)
  • Children’s Hospital Boston testing three innovative telemedicine pilots (medcitynews.com)
  • Health Insurance Definitions: What the Terms Mean (health.usnews.com)

TAGGED: ED, insurance

Sign Up For Daily Newsletter

Be keep up! Get the latest breaking news delivered straight to your inbox.
By signing up, you agree to our Terms of Use and acknowledge the data practices in our Privacy Policy. You may unsubscribe at any time.
Thomas Pane August 8, 2012 August 8, 2012
Share This Article
Facebook Twitter Copy Link Print
Share
Previous Article Too Much Hype in the Mobile Health App World?
Next Article Metabolic Surgery for Treatment of Obesity

Stay Connected

1.5k Followers Like
4.5k Followers Follow
2.8k Followers Pin
136k Subscribers Subscribe

Latest News

Unlocking a Healthier You: Shedding Unwanted Pounds
Weight Loss November 29, 2023
hearing aids
Navigating the World of Hearing Aids with Confidence
Wellness November 29, 2023
find affordable hearing aids
Finding Quality Affordable Hearing Aids That Fit Your Lifestyle
Wellness November 29, 2023
Rhinoplasty
Rhinoplasty 101: 6 Factors To Consider Before Going Under The Knife
Surgery November 29, 2023

You Might also Like

AI in pharmaceutical industry
Pharmaceuticals

Automation in Pharmacovigilance: A Double-Edged Sword

November 15, 2023
Modern Health Practices
Medical Innovations

What Does Science Say About Modern Health Practices?

November 12, 2023
email marketing in healthcare
Marketing

Harnessing the Power of Email Marketing in Healthcare

October 26, 2023
healthcare business tips
BusinessHealth care

10 Proven Strategies to Level Up Your Health Business

October 25, 2023
Subscribe

Subscribe to our newsletter to get our newest articles instantly!

Follow US
© 2008-2023 HealthWorks Collective. All Rights Reserved.
  • About
  • Contact
  • Privacy
Welcome Back!

Sign in to your account

Lost your password?