Aug. 29--CUMBERLAND -- When Diane Broadwater opened up an envelope containing a bill from her trip to the emergency room, she was shocked to find she owed more than $700, despite having CareFirst Blue Cross Blue Shield insurance.
"I was floored. flabbergasted ... What bothered me the most was I was never informed," said Broadwater. Broadwater was treated at the Western Maryland Regional Medical Center's emergency room. She was sent to the emergency room Outpatient Observation Unit, which provides care for patients not treated immediately and released, but not admitted to the hospital.
The medical professionals working in the observation unit don't have a contract with CareFirst Blue Cross Blue Shield and their services are out of network, the reason for Broadwater's big bill. Broadwater said no one ever told her that the observation services wouldn't be covered.
The issues in this case do not affect the regular emergency room, but only the observation unit, said Western Maryland Health System spokeswoman Kathy Rogers.
It's all part of complicated billing procedures and insurance contracts. Just because your hospital is a participating provider with an insurance company, it doesn't mean that all the physicians or other medical professionals at the hospital are participating.
The situation could have a big impact locally, since many county and other employees are covered by CareFirst BCBS. It's important to note that because a health care provider is not in the network at CareFirst, they may be in network for other BCBS plans. In addition, Allegany Imaging, which provides some radiological services at the hospital, is also currently out of the CareFirst network, said Rogers.
Allegany Imaging has temporarily discontinued its contract with CareFirst while it negotiates a contract, Rogers said. WMHS hopes the situation will be resolved soon, Rogers said.
WMHS contracts with Medical Emergency Professionals (MEP), a Germantown-based company, to staff the emergency room with physicians, nurse practitioners and physician's assistants. A separate company owned by MEP staffs the observation unit, said Dr. Angelo Falcone, the CEO of MEP.
"When the visit to the Outpatient Observation Unit is not deemed a medical emergency, the commercial insurance carriers make payment to the patient directly. The patient pays MEP after receiving payment from their insurance carrier and will be billed for the portion of the charge not covered by insurance," Rogers said.
The insurance company sent Broadwater a check for $216.66, which she has forwarded to MEP.
Things may improve in the future, but that won't help those being billed for services now.
MEP is negotiating with the main insurers in the area on a contract, but such negotiations tend to move at a slow pace, taking as long as six to nine months, said Falcone.
"We don't want patients to be disadvantaged, that's the last thing we want," Falcone said. Falcone encouraged patients with billing issues to call MEP directly "so we can work it out," he said. The number patients with an MEP billing issue should call is 301-944-0033, Falcone said.
Broadwater though, plans to fight her bill, not accept a payment plan.
"We have a right to be informed," she said. She believes WMHS needs to be more concerned about keeping patients informed and making sure providers accept patient insurance plans.
"You've got everybody in a bind," she said. And county employees and retirees, who have given up so much in pay and benefits over the years, are now faced with this, she said.
"We realize that this has been problematic for some of our patients, and the health system regrets the inconvenience," Rogers said.
Another thing that upsets Broadwater is that the bill amount from MEP keeps changing. Now, it's over $800, and she has no idea why. She'd like an itemized bill.
And federal law governs many billing procedures.
"We do try to remind patients that all physician services provided at the hospital must be billed separately by the physician in accordance with federal law. This includes the fees for hospital-based physicians, including the emergency department providers, anesthesiologists, pathologists, radiologists, and the hospital medicine team," Rogers said.
Broadwater was careful to point out she did not have any issues with the quality of the care she received in the emergency room.
Falcone said many of the changes in emergency medicine are being driven by health care changes, including a drive by government to cut what are considered unnecessary hospital admissions, especially those that last 24 hours or less.
That's a major purpose behind having an observation facility, he said. The observation unit opened about a year ago, Falcone said. Because it's considered an outpatient service, patients typically are responsible for about 20 percent of the bill, Falcone said. At WMHS, about 12 patients a day go into observation, Falcone said. That's about 20 percent of emergency room patients who under previous systems might have been admitted to the hospital.
MEP has 12 full time employees at WMHS and began their work there in January 2009. MEP's website may be found at www.emergencydocs.com/.
Contact Matthew Bieniek at email@example.com.
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