Austin Frackt at the Incidental Economist is pulling his hair out over the New York Times piece on out of network docs at in-network emergency rooms.
A number of people, especially ER docs, have taken exception to this….
The gist of their complaints seems to be that while 65% of hospitals are subcontracting to physician groups rather than employing them that’s not proof that they refuse to accept insurance. They further allege that they believe that the vast majority of those subcontracted groups are “in network”. Therefore, they claim that the likelihood of going to an in-network ED and encountering an out-of-network physician is very small….
I’m going to side mostly with the ER docs on this on the base point. Most ER docs are in-network for at least some insurance companies.
The big problem is information as emergency medicine providers are part of the PEAR provider category. Pathology, Emergency Medicine, Anesthesiology, and Radiology specialties are the PEAR specialties and they are a pain in the ass to deal with from an insurance company data managmeent perspective. The PEAR providers are “invisible” or “non-choice” providers. Patients don’t choose their pathologist, they don’t choose which doctor sees them at the ER, they don’t choose who puts them under or who reads their films. They don’t choose. On the other hand, patients choose their PCP, they choose their surgeon for elective surgery, they choose their cardiologist, they choose their hospital or urgent care clinic.
PAR specialists work behind the scenes and usually in support of chosen providers. Emergency Medicine is a little different in that they are front line providers, but once an individual is at the ER, it is the triage nurse and the air traffic controller who determines which doc sees which patient.
There are two ways to deal with the PEAR problem from a member perspective. The first is for major insurers to contract with the major PEAR provider groups at as many hospitals as possible. This is what Mayhew Insurance does where almost all ERs and other ancillary services at almost all the hospitals are either covered under the hospital contract or have a secondary contract. As you noticed, there are a couple of caveats and carve-outs. These exceptions are dealt with by the insurer paying usual and customary out of network rates to those providers and sticking the legal department on providers who then bill members for more. We can get away with this as our states of operation have reasonably consumer friendly regulators so if a doc bills $125,000 when usual and customary is $11,000, the doc is getting $11,000 or they are getting a long protracted engagement with the legal department which will reduce their net take-home to under $11,000. Other states allow for extortion under contracts of adhesion.
The second problem with PEARs is how to list them under a directory. The web directory is supposed to be a document that shows all providers that a member can choose to go to. PEARS aren’t chosen, so they fail the data requirements to be included in a directory. Adding PEARS is a simple technical tweak to most directory systems, but it is a misleading tweak in my mind as there is no guarantee that Dr. Smith who is in the directory will be at the ER when you go in with a sucking chest wound. Dr. Jones, who is not par, could be the ER doc. When I worked on the network side of the business, this was a debate we had every six to nine months as there is no good solution of showing or not showing PEAR participation.