Emergency Room Patients Routinely Overcharged—Greatest Effect on the Uninsured

Emergency Room Patients Routinely Overcharged—Greatest Effect on the Uninsured

A Johns Hopkins study of billing records for more than 12,000 emergency room doctors across the country showed a wide variance in prices. On average, adult patients are charged 340% more than the Medicare rate (amounts Medicare pays each facility for like services, plus the deductible and co-insurance). These rates are lower than in-network health insurance rates—which generally are contracted at 1.6-2.0 times the Medicare allowable rate. The study covered a wide variety of services from CT scans to simple stiches for a small cut.

A very distressing finding of the study was that most hospitals charged minorities and patients that are uninsured substantially higher rates, than commercial insurance and Medicare allowable rates. These huge disparities in emergency room prices poses a serious problem to millions in the U.S.

Surveys of both emergency room physicians and general internal medicine physicians’ charges were analyzed. The resulting service bills’ markup ratios were staggering: Emergency Room doctors had an average markup of 4.4 times Medicare allowable-while the Internists’ charges averaged 2.1 times Medicare allowable; less than half. However, due to a ubiquitous lack of patient-friendly regulation and unfettered and unrestrained greed—some emergency room physicians charged between 1.0-12.6 times what Medicare allows. ($1000-$12,600). This “gap” cannot be attributed solely to the quality of hospital or doctor performance (given the variations within each institution).Besides, who is thinking of that in the ambulance? This disparity cannot be explained by equipment used(a CT machine is a CT machine).Thus, presumably more so than any other hospital department, emergency rooms were guilty for charging up to 12 times more than what Medicare paid for the same services. There is a clear bias, however, toward for-profit hospitals charging more than non-profits.

The population affected most greatly by these practices are more likely to be located in the Southeastern and Midwestern U.S., serving a population of African-Americans and Hispanics that are uninsured. These uninsured patients are often charged FULL CHARGEMASTER rates. It gets worse. Once receiving a bill for services calculated at 12 times Medicare allowable, the billing departments are often aggressive about collecting amounts 8-12 times higher than from most other patients.

Often, the uninsured will receive no discount on their bill. (Several hospitals first seek to have the patient apply for financial assistance—and, if qualified, may receive discounts through that route). Some hospitals are terribly rigid, setting up roadblocks to negotiating reductions to this medical debt. Billing personnel will not even identify their last names. Managers are difficult to identify-generally not listed on the website. A more transparent, interactive approach could go a long way to addressing this problem. Some have a very “quick trigger” as to when to send a patient to collections. The effect that medical debt-particularly debt inflated to 10.0 times the pricing at a comparable facility can have negative life-changing repercussions. The uninsured bear the brunt of such practices –although certainly not alone. Forty-three (43%) percent of the population has medical debt listed on their credit report. Medical debt is the largest driver of individual bankruptcies in the U.S.

 In 2003, the eighty (80) plus hospitals owned by Tenet was the subject of a lawsuit involving this precise topic—that was characterized as “Price-Gouging the Uninsured. To its credit, it softened its policy toward collections against those unable to pay; including discontinuing placing liens on the homes of such patients. Currently, it still offers automatic discounts for the uninsured in certain situations—with payment plans on discounted amounts (although its preference is to do so prior to the patient’s discharge).

The need for state and federal regulation to address hospital rates in order to protect patients becomes more pressing each day. If you have such an experience, write a letter to the hospital Administrator—copy its CEO and the state agency governing hospitals (despite that in some cases, it will not take jurisdiction of billing matters), call your congress person and senators(both state and Federal). Contact NPR and other news organizations. Silence will not result in change. Bringing this to the attention of those with decision-making authority might.

If you think you’ve been overcharged, or otherwise need help with your medical bills and health insurance matters– contact a Board Certified Patient Advocate at Human Health Advocates of Boca Raton, FL. WE ARE HERE TO HELP!

Preparing for an emergency

Preparing for an emergency

Did you know that you can save yourself a lot of time, frustration, and MONEY by being an informed patient? You may be asking yourself “how?” The healthcare system, especially medical billing and health insurance is extremely complex and confusing. However, with a little advance planning, you can reduce or eliminate endless phone calls to medical billing or health insurance representatives that are unwilling or unable to help you resolve your problem. Advance planning is also very likely to help you save money on medical expenses, as well. In a series of blog posts, we will give you many of the tools necessary to help you make informed decisions that ultimately save you money.

Be prepared for an emergency. When you need medical attention quickly, you have to make several decisions at once. Knowing which in-network Hospitals and Urgent Care Centers are closest to your home, workplace, or places you visit most often can save you hundreds, even thousands of dollars.


If possible, start by assessing whether the situation could be handled effectively by an Urgent Care Center, or whether your condition is serious enough to warrant a trip to the emergency room.You could spend a few minutes researching this as part of the planning process. If you are unsure, try calling your primary care physician for help determining which facility you should go to. An Emergency Room visit can cost as much as 10 times that of an Urgent Care Center.


In order to protect yourself from unnecessarily high medical bills, you should know which hospitals and which urgent care centers are in-network with your health insurance plan.

 These simple steps can help you save thousands of dollars:

  1. Locate one or two in-network urgent care centers near your home. Be sure to note the address and hours of each. Remember, some Urgent Care Centers are staffed by MD’s—others not.


  1. Next, locate one or two in-network urgent care centers near your workplace;


  1. Locate one or two in-network hospitals closest to your home. Note the entrance to the Emergency Room.


  1. Finally, locate one or two in-network hospitals near your workplace.Note the entrance to the Emergency Room.


  1. Document the information in a way that you can access it at any time, especially in an emergency.

It’s not always possible to be fully prepared for an emergency. However, knowing which Hospitals and Urgent Care Centers are in-network with your health insurance plan literally can save you thousands of dollars.


Finally, there may be several invoices in connection with an Emergency Room or  Urgent Care Center. Don’t assume that your medical bills or health insurance explanation benefits are correct. Its estimated that 85% of medical bills have erroneous charges or health insurance processing mistakes. If you are having difficulty understanding your medical bills and/or health insurance Explanation of Benefits(“EOB’s”), contact one of our Board-Certified Patient Advocates at Human Health Advocates. We review medical bills and health insurance determinations. We negotiate reductions in medical debt from hospitals and other providers. Get in touch. We can help!

Reduce your out-of-pocket costs by staying In-Network with your health insurance plan

Reduce your out-of-pocket costs by staying In-Network with your health insurance plan

Did you know that you can save yourself a lot of time, frustration, and MONEY by being an
informed patient? You may be asking yourself “how?” The healthcare system, especially the
medical billing and health insurance aspects, are extremely complex and confusing. However, with
a little advance planning, you can reduce or eliminate endless phone calls to representatives that
are unwilling or unable to help you resolve the problem. Advance planning is also very likely to
help you save money on medical expenses. In this series of blog posts, we will give you the
necessary tools to help you make informed decisions and ultimately save you money.

What is a Health Insurance Network and Why Does it Matter?

Every hospital, free-standing facility, and physician has what is called a chargemaster rate. This
rate is typically an inflated amount related to the services that were performed during your visit.
These chargemaster rates are different among the various providers. The chargemaster rate for
an emergency room visit due to the flu might be $1,200 with Hospital A while Hospital B’s rate is
$1,800. Why is this important?

Literally, no one pays the full chargemaster rate. If you are uninsured or underinsured- you are
expected to pay this full rate. However, in most cases, a reduction can be obtained (be on the
lookout for a future blog post to explore this further).

Health Insurance Companies and Providers (hospitals, physicians, facilities, etc.) work together
to negotiate rates for every service, procedure, and supply called “allowed amounts.” This
agreement between a health insurance company and multiple contracted providers is what
creates the NETWORK. Doctors, hospitals, and other providers that do not have a contract with
the insurer are “out-of-network. IF YOU STAY IN-NETWORK amounts billed are radically less
than the chargemaster rate for covered services. Again—that is IF you stay in-network! When
you see a network provider, you are protected by the negotiated rates between the provider and
health insurance company. The provider cannot bill you more than the contracted allowed
amount for services covered by your health insurance plan. This does not apply to non-covered
or exclusionary services.

In some cases, such as having an HMO/EPO plan, out-of-network charges are not paid at all by
the insurance- leaving you with astronomically high medical bills. In other cases, your health
insurance company may make a small payment but, you are left with the remaining balance which can be substantial. Below you will find clear examples of the difference in costs from seeing an in-network vs. out-of-network provider for the same service.


Beth recently received a breast cancer diagnosis. Her primary care physician refers
her to a highly respected oncologist at a local cancer center. Without checking with her
insurance company, Beth schedules an appointment for an initial exam.

Here is an example of difference between the out-of-pocket cost had the oncologist been in-network vs out-of-network:


The Oncologist’s chargemaster rate for Beth’s initial exam: $550.00

The in-network health insurance allowed amount (based on the annual cost-sharing
accumulation): $200.00

The negotiated in-network discount amount: $350.00

The amount you may owe (based on your annual deductible, copay, and out of pocket
maximum): $200.00
**The in-network provider cannot charge you more than the negotiated rate for covered

The out-of-network Oncologist’s chargemaster rate for the initial exam: $550.00

The out-of-network health insurance allowed amount: $100.00

The amount the out-of-network provider may try to collect from you (based on your annual
deductible, copay, and out of pocket maximum): $450.00-$550.00
**The provider is allowed to charge you more than the out-of-network “allowed amount”
as there is no contractual agreement with the health insurer (also known as balance

Beth’s savings by using an in-network provider were $200.00-$300.00


Did you know that using an out-of-network provider is likely the greatest cause of exorbitantly
high medical bills? Providers and patients are not on the same page. Barely a third of doctors
discuss their charges with patients. Unfortunately, it’s the patient’s responsibility to know their
provider’s network status with their health insurance plan. One of the most commonly made
mistakes regarding confirming network status is relying on just the hospital or physician’s office
to provide you with accurate information.

There are many different networks offered by the same health insurer. If you call a provider and
ask, “do you accept Florida Blue?” The answer will almost always be “yes.”** (Florida Blue is the
largest health insurer in Florida)** However, Florida Blue has multiple plans with multiple
networks. Although the doctor or hospital you want to go to might be in-network with the Florida
Blue – Blue Options plan, they may not be in network with your Florida Blue – Blue Select Silver
Plan. A lot of times the physician does not even know which networks they participate in!

In order to verify your provider’s network status, you will need:

• The provider you wish to see’s name, service address, and contact number.

• The NPI (National Provider Identifier) – Contact your provider to request their billing NPI.
Ask if the provider bills the NPI as an individual or as a group. (Organizational healthcare
providers such as hospitals, physician groups, facilities, etc. would submit a claim under
a group NPI).

Once you have the information above, follow this triple-check system to help you avoid
going out-of-network unnecessarily. (Stay tuned for an upcoming blog post regarding
Surprise Medical Bills):

1. Check your health insurance web portal. Every web portal is different based on the
health insurance carrier. Typically, you can search by provider/facility name, specialty,
geographical location, NPI, hospital affiliation and more. If the provider does not
populate in the search results, they are most likely to not be within your plan’s network. If
you are unsure, refer to #2,below.

***NOTE: It is highly recommended that you register for access to your health insurance
web portal, if you haven’t already done so. Most health insurance web portals provide
access to your benefit details, claims submitted by your providers, amounts applied to
deductibles and out-of-pocket maximums, and other valuable resources. TIP-If you
are changing insurance companies, verify how long after separating from the company
you will have access to your information on the internet. Some companies only allow
thirty (30) days—other two (2) years.

2. Call your health insurance company directly at the number on the back of your card.
Give the customer service representative as much information regarding the prospective
provider as possible (name, address, specialty, NPI, etc.).  Ask what the name of your
health insurance network is if you are unsure (see #3).

IMPORTANT: Always ask the customer service representative for a reference number at
the end of the call. Document the representative’s name, date, time,and details of the
call. This information can be extremely helpful if you experience any problems in the
future. For example, your claim could be processed out-of-network when you were
advised the provider was in-network.

3. Verify the network status information you received from your health insurance company
with the provider’s office. Ask for the insurance verification representative at the
provider’s office. Provide them with your Health Insurance Network information and the
details of your call with your health insurance company’s representative. Ask them to
confirm their network status.

4. A provider’s network status may change, sometimes without notice to you. Contracts
between insurers and providers are generally renewed annually (often near the beginning
of the calendar year). Check your established provider’s network status annually to avoid
any surprises.

If you receive conflicting information from either the health insurance company or the
provider’s office, ask to speak with a supervisor to help you clarify the discrepancy. Always
remember to document the name, date, details, and if available, a reference number for
every interaction you have with your health insurance company and providers.

It all boils down to taking a little extra time to verify and confirm your provider’s network
status with your health insurance plan. Ultimately, it is your responsibility to know your
provider’s network status, even in an emergency. Out-of-network, out of luck. Stay in-network, save a buck!

If you are unsure if your medical bills may have been processed out-of-network vs. in-network, or otherwise have trouble with medical billing and health insurance matters, contact one of our Board-Certified Patient Advocates at Human Health Advocates. We can help!