It’s bad enough when a sprained ankle or a fever that just won’t let up results in a trip to the emergency room for you or your child. It’s even worse when, instead of receiving a bill for a co-pay of $75 or $100, you get hit with one for $1,000, $3,000, or even more.
Surprise medical bills for amounts much greater than patients are used to paying have become increasingly common nationwide after visits to the emergency room — including at Stony Brook Southampton Hospital.
That was the case with Melissa Sidor of Westhampton Beach, who serves on the board of the Health and Welfare Council of Long Island, a regional umbrella organization for health and human services providers. As a result, she said she considers herself an educated consumer when it comes to health care.
Ms. Sidor, who has a Blue Cross/Blue Shield insurance plan, had to make two trips to the emergency room last spring.
“First, I got such an exorbitant number of bills — bills from the hospital, and bills from all sorts of different doctors who saw me,” she said. “Then I got this bill from 24/7 Emergency Care for $2,313, on top of all the other bills.”
After numerous calls to her insurance company and 24/7 Emergency Care — which contracts with Stony Brook Southampton Hospital to provide the physicians who staff its emergency room — Ms. Sidor said she learned a harsh truth. “You go to an in-network hospital, and you think you are in network,” she said. “Apparently not.”
Ms. Sidor is not alone.
Assemblyman Fred W. Thiele Jr. said his office gets frequent calls from constituents who are surprised to learn that just because the hospital takes their insurance, it doesn’t mean the doctors staffing its emergency room do.
“An individual in an emergency room is at their most vulnerable,” he said. “They are not necessarily reading the warnings that the service may be out of network.”
“It’s one of the biggest complaints we get from our clients,” added Anthony Cardona of Cardona Associates, an insurance broker in Water Mill. “They tell us, ‘I went to the hospital. I have insurance, but they told me it wasn’t covered.’
“There’s a big lack of transparency in our system,” he continued. “When it comes to health insurance, when it comes to the real cost of care, nobody really knows what they’re in for, especially in emergency room cases.”
Officials at Stony Brook Southampton Hospital said they were sympathetic to the plight of their patients — and willing to work with those who cannot afford to pay their bills — but that the higher costs associated with emergency care is just one of the many problems facing the American health care system.
Dr. Darin Wiggins, the head of the hospital’s Emergency Department, in a written statement he provided during a recent interview, said the hospital has had its contract with 24/7 Emergency Care for 15 years. It’s a common practice for hospitals to farm out emergency room services, one that is shared by two-thirds of hospitals nationwide, he said.
Since 2008, health insurance deductibles have more than doubled on average, rising at 12 times the rate of inflation, he continued. As a result, plans that once required a modest co-pay or deductible are now requiring policyholders to pay a much higher amount.
“A lot of patients don’t understand the system,” Dr. Wiggins said. “That’s normal. They are patients, not billing companies. We spend a lot of time helping them understand their own insurance.”
“The day of people getting insurance from their employer that covers everything are long gone,” said Christopher Schultheis, the hospital’s chief financial officer. “Patients have more skin in the game.”
He said costs have risen most acutely “over the last five to seven years,” but that the trend began in earnest about 15 years ago, when Congress began trying to corral the high cost of Medicare and Medicaid by limiting increases in the reimbursements it paid health care providers for services covered under those programs.
Hospitals then began to band together to get higher reimbursement rates from private insurers to help close the gap. Insurance companies, in turn, passed their increased costs to their policyholders through increased premiums, higher deductibles, and reduced coverage. “They had to make up the rate increases they were paying” to hospitals somewhere, Mr. Schultheis said of insurance companies.
There’s been no change here at the hospital,” he said. “The difference is in how plans are being written and what is being offered to employers.”
Gerard Anderson, a professor of health policy and management at Johns Hopkins University in Baltimore, Maryland, said while insurance companies can be blamed for many of the ills facing the American health care system, they are not the only ones at fault when it comes to the rise in the amount of surprise billing.
Over time, he said, physicians have learned to play the profit game, too, seeing an opening to maximize revenue if the patient has no control over who provides the services they receive. While a patient typically chooses a primary care doctor or the surgeon who will perform a scheduled surgery, they have no choice of who cares for them when they are brought into the emergency room after a car accident or heart attack.
Other physicians who fall into the category of being outside the patient’s choice are anesthesiologists, radiologists and pathologists, he said.
“If no one chooses them, they can charge whatever they want,” he said. “So they tend to be out of network.”
There is another troubling development, he said: Hedge funds have begun to eye physician practices as a lucrative investment. “They are basically paying physicians a huge amount of money to be purchased,” he said. “Then the hedge fund gets to charge whatever it wants for the services.
“People are totally flabbergasted when they get their bills,” he continued. “They tell you the price a month or two months after you walk out of the hospital.”
But it’s not all doom and gloom. Dr. Wiggins said the hospital will provide help to those unable to pay their bills, and Mr. Schultheis said one of the benefits of Southampton’s merger with Stony Brook Medicine two years ago is that the Stony Brook financial assistance policy, which the hospital now works under, is more generous than the one formerly in place.
Assemblyman Thiele said patients can take advantage of a law New York State passed in 2015 that allows patients to fight surprise out-of-network bills through independent dispute resolution. In 2015, 149 people sought the arbitration provided for by the law — and that number had swelled to 1,148 by 2018. Patients have seen their bills reduced by more than $400 million over the lifespan of the law.
Although Congress doesn’t seem to be able to get much done these days, Prof. Anderson said he was optimistic both parties would set aside their usual partisan differences to tackle the issue, perhaps by setting limits on the rates that can be charged for specific procedures.
“It would be fun to blow it up and start all over again,” he said of the American health care system. “But that’s not going to happen. We are going to have to work with Band-Aids.”
In the meantime, everyone from brokers to doctors agree that it is imperative that consumers educate themselves about just what their health insurance plans cover — and don’t cover.
“The reality is we try to do our best educating our clients, but they don’t want to hear it,” said Mr. Cardona. “But with health insurance, you can’t use it and then figure it out afterward. By then, it’s too late.”