By Tara Bannow

The Bulletin

After taking a hard fall last August, Michael Cooper went to St. Charles Bend’s emergency room with what he was afraid was a dislocated hip.

Family Nurse Practitioner Allison LiaBraaten examined him, checked his X-rays, told him she didn’t see anything out of order and sent him home with pain medication.

Imagine his surprise, then, when about two months later he got a bill from Central Oregon Emergency Physicians for services rendered by a Dr. Frances McCabe, a person he had never seen before.

“I’m wondering, ‘What’s this for? This doctor never even saw me!’” said Cooper, who runs a music studio out of his home in Sisters.

His situation is far from unique. St. Charles Bend contracts with Central Oregon Emergency Physicians to treat patients in its emergency room.

That means patients can expect to receive at least two bills, just as they do for other hospital specialties, like anesthesiology and pathology, which operate under the same model: one from St. Charles and one from the provider.

Those who are aware of this can call ahead of time and make sure each person who will treat them accepts their insurance — although even if they don’t, the alternatives in Central Oregon may be limited.

In the emergency room, though, that’s generally not an option. Many patients, like Cooper, are learning that although St. Charles accepts their insurance, Central Oregon Emergency Physicians does not.

It’s a phenomenon that’s happening across the country, but is perhaps getting more attention recently as some struggle with narrow insurance networks and policies with higher deductibles.

A new law in New York will require that patients be given reasonable notice before an out-of-network doctor treats them. The changes also prevent out-of-network providers from “balance billing” for emergency care, or charging patients for whatever their insurance didn’t cover.

Most states, including Oregon, have laws that restrict balance billing for Medicare beneficiaries, but such protections are less common for the privately insured.

In Cooper’s case, McCabe reviewed and signed off on LiaBraaten’s work, a required practice. His insurer, Assurant Health, agreed to pay McCabe’s $563 bill at an in-network rate, as insurers will do for certain plans due to an Affordable Care Act provision that prevents them from charging patients more for out-of-network emergency providers. The doctors, however, still expect Cooper to pay the rest of the bill. He’s fighting the $49 charge on principle.

“You’re taking people who are at their most vulnerable condition, who are coming to the emergency room — some of them may not even be conscious — and they’re subjected to untold charges by a doctor who might not even look at them,” he said. “What was I to do? Say, ‘Let me know every single doctor who’s working in the ER right now who’s subcontracted and use my mobile device to see if they’re in my network?’”

The $879 bill from St. Charles came separately, and Cooper said he paid it with a check right away. He said he doesn’t usually quibble over ER bills.

Protecting bottom lines

Asked last week about the out-of-network charges patients receive for their emergency care, St. Charles administrators said their hands are tied.

Maryclair Jorgensen, St. Charles’ director of health plan administration and contracting, said because the emergency providers work as independent contractors and not employees, St. Charles doesn’t have the authority to tell them which insurance plans to accept.

“It’s kind of out of our purview, really, of saying ‘You have to accept this health plan,’” she said. “The health plan has to be negotiated, and we wouldn’t negotiate an independent contract.”

Doing so could potentially even get St. Charles into legal trouble, Jorgensen said.

“I cannot go and talk rates with them and represent them or be on the Blue Cross side, for instance,” she said. “That’s antitrust.”

But Dr. Mark Sampson, one of the directors of Central Oregon Emergency Physicians, said if St. Charles gave the word, his providers would follow it.

“Indeed the hospital could tell us that they wanted us to be in network with everyone that they are with, and obviously we would have to do that,” he said.

Jeff Miles, a Washington, D.C. attorney who has represented hospitals and health systems in antitrust cases for more than 35 years, said without knowing all of the circumstances in St. Charles’ case, he’s not aware of any antitrust provision that would prevent a hospital from making its contracted providers accept the same insurance plans as the hospital.

“The antitrust laws are a set of laws that promote and protect competition, and I don’t understand how it would restrict competition — result in higher consumer prices, for example — if the hospital conditioned the contract on the groups contracting with health plans the hospital contracted with,” he said. “In fact, it seems pro-consumer.”

That said, Miles said he’s never seen a hospital force the physicians to do so. He has, however, seen hospitals pressure physicians by arguing the importance of contracting with the same insurers. The reason hospitals don’t force the issue is twofold: To maintain positive relations with their doctors and to ensure the doctors don’t simply go elsewhere to provide care.

Asked why they don’t just accept all of the insurers St. Charles does so patients don’t end up with out-of-network charges, Sampson said some insurers reimburse far less for services than others, and that would hurt his company’s bottom line.

“What if insurance company A has an agreement with the hospital, but they agree to pay us 10 percent of what Blue Cross does? Would we agree to that? Probably not,” he said. “In that case, we wouldn’t be in concert with the hospital.”

The ACA protections don’t apply to plans created or purchased before March 2010, and they only apply to plans that cover emergency services. They also leave room for interpretation as to whether the visit was actually an emergency, which could dissolve the protections for some, said Cathy Schoen, senior vice president for Policy, Research, and Evaluation of The Commonwealth Fund, a nonpartisan group that researches health issues.

Sampson said his company accepts most of its patients’ major insurance carriers. Although he declined to provide a complete list, he said they do not accept LifeWise, Providence Health Plan, HealthNet, Aetna, Cigna and others.

In Pat Palmer’s mind, that’s unacceptable. Palmer, the CEO and founder of Medical Billing Advocates of America, said when a hospital draws up a contract with a provider, they can put whatever conditions they want in it. She thinks they should always require contracted workers to accept the same insurers the hospital does.

“They should not be signing if they don’t contract with the same insurance carriers that the hospital does,” she said. “That should be the rules.”

The good news

St. Charles’ emergency rooms in Redmond and Prineville operate under the same structure as in Bend, except the providers there work for a Tennessee-based operation called TeamHealth, one of the largest physician staffing companies in the U.S., with about 9,700 providers.

In an effort to provide better coordinated care to patients, St. Charles in June will hire 13 emergency providers in Redmond and Prineville, said Jeff Absalon, St. Charles’ chief physician officer. Many patients’ first contact with St. Charles is through the emergency room, and St. Charles employees can more easily refer them to the health system’s primary care providers and coordinate care from there, he said. Ultimately, the hope is they’ll get the preventive care they need and avoid costly ER bills, Absalon said.

This is good news for patients whose insurance companies consider TeamHealth an out-of-network provider. To be clear, patients will still get two bills, but they can rest assured that the providers will accept the same insurance carriers that St. Charles does, Jorgensen said.

The emergency providers at St. Charles Madras already are employees of the health system.

Contracting with providers to deliver care is a longstanding hospital practice across the country. St. Charles, for example, has contracted with Central Oregon Emergency Physicians, since 1974, Sampson said. All told, fewer than 20 percent — about 160 — of the providers who see patients at St. Charles hospitals are employees, Absalon said.

That said, St. Charles has over the past several years expanded the number of primary care physicians it employs, Jorgensen said. It’s in line with a recent national trend in this respect toward hiring providers rather than contracting with them, Schoen said,

For hospitals, having providers as employees allows them to oversee patients’ care both inside and outside of the hospital. This can help reduce readmissions, a metric that impacts federal government reimbursement for services, Schoen said.

It also gives hospitals more clout when it comes to bargaining with insurance carriers if they have the doctors on their team, she said.

For providers, becoming hospital employees allows them to gain efficiencies in their practices by linking to the hospital’s larger billing and IT systems, Schoen said.

An ethical issue

Cooper’s $49 bill from Central Oregon Emergency Physicians is dwarfed by that of Robert Goetz.

Goetz, a 55-year-old Bend resident who owns Alpine Accounting, threw his jacket over his head before heading out to a Christmas concert in December and heard that dreaded “pop” noise. It was his second dislocated shoulder in three days. Lucky for him, the first one happened when Bend Memorial Clinic’s Urgent Care unit was still open. This time though, he and his wife rushed to St. Charles Bend.

Two months later, the bill came from Central Oregon Emergency Physicians: $1,493. Like Cooper, Goetz was confused. He didn’t remember meeting anyone from Central Oregon Emergency Physicians, and no one told him he was going to see a provider who wasn’t covered under LifeWise, his health insurance carrier.

Not only does Goetz say he doesn’t recall signing any forms, he sat in the waiting room for 15 minutes. Staff there had plenty of time to warn him, but they didn’t.

“There is somebody that checks you in, they’re not just taking your blood pressure, they’re taking your insurance and they’re doing this and that and nowhere, no way do they advise you that someone that you may or may not see is not part of their network,” he said. “It’s a bait and switch almost.”

LifeWise sent Goetz a $386 check directly to pay its out-of-network portion of the bill, which would have cost $1,867 had Goetz not been insured.

Goetz, like Cooper, said he understands going to the ER will be expensive, and is making payments on the separate $2,300 bill from St. Charles.

Most people would have just paid the $49 remaining on the tab from Central Oregon Emergency Physicians, but Cooper said he’s fighting the bill to draw attention to an important issue. He believes St. Charles should require its emergency providers to accept in-network payments as payments in full for care.

“If they are a subcontracted doctor and not on staff at St. Charles, they can bill whatever they want and it’s unregulated and you’re stuck with the bill,” he said.

Many insurance companies do reimburse out-of-network emergency providers as in-network providers, but that doesn’t account for any charges beyond what the insurance company pays, which could be crushing, Palmer said.

After getting the run-around from Central Oregon Emergency Physicians, Cooper called St. Charles for an explanation. A representative explained that when he entered the ER, he signed a Conditions of Registration form that said he understood that care could be provided by physicians who are not employed by St. Charles.

St. Charles’ Conditions of Registration form — which all patients must sign — is a one-page document that contains five bullet points. Lumped in with sections on the risks of medical care and requirements to pay insurance deductibles, patients must agree to care “whether it is provided by St. Charles and its employees or by independent physicians and healthcare providers.”

Health care is the only industry in which customers sign agreements to pay without knowing what the price is, Schoen said.

“You would never buy a car where they said, ‘Here is the tentative price of the car but we’re not prepared to tell you what the tires cost, the steering wheel or the seats, but after you receive it, you might receive a bill for all of those,” she said. “We wouldn’t tolerate it.”

At this point, legislative action may be the best way to protect patients against unexpected bills, Schoen said. To that end, Cooper has launched a petition urging legislators to sponsor legislation to outlaw balance billing.

In the end, Schoen said, it’s an issue that will affect everyone by driving up the overall cost of health care.

“It’s in none of our interest to see a return to double-digit premium increases,” she said.

“We’ve been sacrificing wages to pay for health benefits for years. People haven’t seen their income go up. The sky can’t be the limit on what prices you’re being charged.”

A few weeks ago, Goetz got his second reminder bill from Central Oregon Emergency Physicians, which contained a warning that it could be sent to a collection agency if he doesn’t pay soon. He thinks that’s extreme, and doesn’t reflect well on St. Charles, the place he received his care.

“Essentially, St. Charles has a monopoly on emergency room visits,” he said, “and they should be dealing with the community better than with doctors like this.”

— Reporter: 541-383-0304,

Editor’s note: A clarification was published for this story April 16.

In the original story, a comment by Maryclair Jorgensen of St. Charles Health System may have been unclear. Referring to the potential antitrust issue, according to Jorgensen, St. Charles cannot get involved in contract negotiations between insurance companies and the providers the health system contracts with and who are not St. Charles employees.