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Mar 5, 2013 12:08 PMPublication: The East Hampton Press

Separate Emergency Room Billing May Be Bitter Pill To Swallow

Mar 8, 2013 7:16 AM

As she was power-walking through East Hampton with her girlfriends during an East End visit last spring, Marcie Krempel’s jaunt was cut short in the worst way when she was tripped up by a sandy roadside ditch.

Instinctively, she threw her hands forward to protect her face—and broke both arms in the fall.

At Southampton Hospital’s emergency room, she was assured that her Blue Cross Blue Shield of Florida, or Florida Blue, insurance was accepted there. She was treated, and a long—and still ongoing—recovery followed.

Despite the hospital’s assurances, however, she was shocked to receive hefty bills from doctors who treated her at the hospital—including a $10,400 out-of-network bill from an orthopedic surgeon who treated her briefly in the hospital, and another $500 out-of-network bill from an emergency room physician.

As it turns out, Ms. Krempel’s situation is not unique.

The majority of the approximately 220 doctors who treat patients at Southampton Hospital—and most similarly sized hospitals nationwide—are not hospital employees but independent contractors, according to Dr. Fred Weinbaum, Southampton’s chief medical officer and chief operating officer. As such, they negotiate contracts with insurance providers on their own and bill separately from the hospital, regardless of whether the hospital accepts a patient’s insurance.

And, Dr. Weinbaum said, it is the patient’s responsibility to be aware of this.

Most medical specialists, such as orthopedic surgeons, anesthesiologists and obstetricians/gynecologists, for example, fall into this group. They appear in the staff directory on the hospital’s website alongside hospital-employed doctors, with no distinction indicated. The hospital uses them to ensure that the services of a particular professional is available 24 hours per day, seven days per week, and the independence is favorable for doctors. But patients—already reeling from trauma—often feel left in a bind.

“Talk about a bait-and-switch,” Ms. Krempel said. “I didn’t see any signs saying the orthopedic surgeon and the other doctors were a different corporation. There were no balloons saying that they were out of network.”

Ms. Krempel was shocked by the high bills and said that any reasonable person, given assurances that their insurance was accepted, would expect to be covered for all services. “What if I was unconscious? 
I’m supposed to wake up and ask every doctor who sees me if they’re covered by my insurance?”

She said she is now fighting with her insurance company over the “egregious” bills from the doctors.

Ms. Krempel’s insurance company so far has offered up $1,131.84 toward the orthopedic surgeon’s $10,400 bill, but says she is responsible for any charges above that. Citing her medical records, Ms. Krempel said the surgeon saw her for only about 20 minutes. For the emergency room physician, the out-of-network amount allowed was $288.80 out of about $500 billed, the difference of which she says she is expected to pay out of pocket.

Ms. Krempel’s orthopedic surgeon, Dr. Mark Creighton, declined to comment on the billing practice.

Mark Wright, a spokesman for her insurance company, said her case was still under review. He would not comment on the practice in general.

Ms. Krempel, for her part, is still in therapy and is just regaining the use of her dominant right hand.

To date, it is unclear if the doctors will settle with her insurance company. The orthopedic surgeon said he is free to charge whatever amount he chooses, Ms. Krempel said, while the emergency room physician’s office was initially willing to work with her on the bill—pending her appeal through her insurance company—but, without warning, hired a collections agency to come after the fee.

“It doesn’t seem fair to the patient. Mental health is just as important as physical health, and it’s very upsetting to a patient who’s recovering to receive a bill that’s huge,” said Kevin Luss, a health insurance broker and financial planner at The Luss Group in Southampton. “I don’t see a bad guy here. There just needs to be communication, because I think people are probably paying for things they don’t need.”

Ultimately, he said, many claims get covered by the patient’s insurance. Part of the problem, though, is that the insurance companies do not necessarily receive the bills—the patients do. “What this requires is that patients, unfortunately, need to become their own best advocates,” he said.

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"I don't see a bad guy here"?? Typical insurance industry double talk! There is a very clear bad guy(s) - the hospital, the doctor and the robber baron insurance industry as a whole! Why was this not disclosed up front? We need universal coverage - medicare for all. "No bad guy"?! HAH!
By witch hazel (224), tatooine on Mar 8, 13 9:26 AM
1 member liked this comment
Universal coverage in and of itself does not have any impact on outrageous fees. That has to be legislated separately - either mandating fixed fees for services based on geographic location, or eliminating network exclusions for emergency treatments. $10K for orthopeadic work on broken arms seems high but maybe she had special injuries or complications. Ironically that doctor probably charges 30-40% less for the same work if she was in "his" insurance network.

Mandating universal coverage ...more
By Funbeer (273), Southampton on Mar 8, 13 1:15 PM
I found this out the hard way over ten years ago. I required treatment via the emergency room at 1 am. The "on call doctor" took two hours to arrive. Only when I got the bill did I realize he was "out of network". I spoke with a gentleman in the finance dept. to dispute the bill and told him that I should have been told that the doctor was "out of network". The hospital had my insurance info. They knew my plan. I was told, "I was lucky to have been treated". My response was, in the two plus hours ...more
By auntof9 (159), Southampton on Mar 8, 13 2:48 PM
Caveat emptur, indeed.
Mar 8, 13 8:55 PM appended by Mr. Z
"emptor". Oops, my bad...
By Mr. Z (11847), North Sea on Mar 8, 13 8:55 PM
same happened to me at Mather Hospital- I went to ER was told they accept my insurance- have a copay of $100 but was billed by the ER doc for $500 and was told he was not in network and that none of the ER docs are- go figure
By esmsharks (2), manorville on Mar 8, 13 9:38 PM
Insurance companies suck everyone should be able to but into Medicare. Anyone who tells you different is selling insurance.
By lo-cal (78), southampton on Mar 8, 13 10:15 PM
What a shameful situation. Thanks for writing this article. I will think twice next time I have to use Southampton Hospital. I would expect that if the hospital accepts someone's insurance, those that are privileged to work there should live up to that commitment. I guess I'm wrong. The shame here is that the patient, who can afford and pays for medical insurance, is stuck to negotiate a minefield between their insurance and the medical provider. I would also consider suing the doctors and hospital ...more
Mar 10, 13 5:07 PM appended by V.Tomanoku
Oops,my apologies to the Hospital and doctors. I retract my comment about malpractice. Its inappropriate. Its really the lunacy of the situation that is mindbogling.
By V.Tomanoku (790), southampton on Mar 10, 13 5:07 PM
This kind of thing happened to me. It is a disgrace that the physicians who have privileges at the hospital can do this to the patients who have no choice in an emergency. I was charged over $600 by a physicians who never came back to check on me. Eventually, I had to be sent to Stonybrook where the care and the coverage was good.
The hospital should only aalow physicians who are in their network to work. No outsiders robbing the unsuspecting public. Shame on Chaloner and the board
of ...more
By localcitizen (110), Southampton on Mar 11, 13 4:15 PM
Daughter had a head in jury scare about two years ago. We finished paying off the fees that weren't covered a few months ago. She had no more than a superficial exam by an ER doctor, who asked her to track an object he moved with her eyes, had a conversation with her to see what happened. She sat on an exam table, crumpled up the paper. The charges for his exam and the ER visit were over $700. Other daughter broke a glass while working at a restaurant--thank goodness for worker's comp...however, ...more
By M. O'Connor (147), Southampton on Mar 14, 13 12:24 PM
isn't Obamacare working?
By Jaws (245), Amity Island on Mar 15, 13 2:23 AM
The greed of the doctor is the major culprit here. I had a friend with a similar situation. He went in and had a soft cast put on. The doctor billed him 9500!!!. Insurance company reimbursed him 3500 which is 90% UCR. Medicare (which he accepts) would have paid him 1800. He is still suing my friend for the balance. Hospitals should close the door on doctors with this type of integrity.
By razza5350 (1911), East Hampton on Mar 15, 13 7:05 AM
Most are now accepting 30% cash. Heck thats cheaper than buying insurance. Hear is one thing we can thank the illegals for. Seriously.
By double-D (96), southampton on Mar 17, 13 8:03 PM