54 Archery Club Road New Ringgold, PA 17960

(570) 386-4574 info@straussinsurance.com

Emergency Room Visits and Out of Network Doctors


Imagine that you have some type of medical emergency. It could be chest pain or catching a foul ball in the eye. So long as it is serious enough to require a trip to the emergency room (ER). As a responsible policyholder, you go to a hospital that accepts your insurance plan. Once you arrive the professional staff and doctors take very good care of you. And, next thing you know, the hospital releases you from their care and you’re feeling much better.

A few weeks go by and then you get two explanations of benefits (EOB) from your insurance company.

  • The first one says that the hospital was paid in full. And that all you owe is your ER copay.
  • The second EOB states that the emergency room physicians were out-of-network. And that they may balance bill you for their services.

Naturally, you are confused. After all, you made sure to go to an in-network hospital. So, how is it that the doctors in that facility don’t take your insurance?

EXCUSE me Doctor, Who do you work for?

Often times emergency room doctors are not employees of the hospital. But rather, they work for independent medical groups. And these organizations negotiate their own contracts with insurance companies. Therefore, the hospital may accept your health policy but the doctors working there might not.

And ER doctors aren’t the only ones that do this. Anesthesiologists, ground/air ambulances and radiologists also regularly use similar billing tactics.

What to do if this happens to you

So we’ve explained why this happens. But what if you end up in the scenario described above? Below are a few pointers to help guide you through the process (and hopefully keep your sanity).

Check please!

Since the insurance company does not have a contract with the out-of-network providers, they will often mail a reimbursement check directly to you (the policyholder). We recommend that you deposit the check into your bank account. And then, make a payment with a personal check or credit card to the medical provider.

Others may recommend to simply endorse the check and send it back with the bill. However, once the check is signed, anyone can cash it. Therefore, it’s more secure to deposit the money and pay with personal funds.

The Art of the Deal

Just because your insurance company didn’t negotiate a lower rate with the ER doctor, doesn’t mean that you can’t! Give the provider’s office a call and ask if you can get a discount for paying in full. Or, if that’s not possible, perhaps you can work out a payment plan. Medical providers are more receptive to these offers than most people would think.

Also, call your insurance company and ask them for help. While they don’t have a contract with the out-of-network doctor, they do have a lot of influence with the hospital where they work. We have had several insurers “talk” ER physicians into accepting a substantially lower amount than what was originally billed.

In Conclusion

It’s unfortunate that our medical system allows this to happen. But, knowing the facts and how to respond will help you make the best of a bad scenario. And remember, a good insurance broker can help with this and many other similar situations. After all, we speak the “insurance” language. And many of us have good contacts with not only the insurance companies but with local medical providers as well.

So be sure that your health insurance broker is doing all that they can for you. And if not, please contact us anytime to see what a huge difference an independent, modern benefits broker can make for your company.


Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.