Health Policy Journal Club

Health Policy Journal Club: Nobody Likes Surprises

Good news! There are fewer surprise bills now than a decade ago.

A surprise medical bill is one a patient receives from an out-of-network provider after seeking care at a facility considered "in-network" by their health insurance plan. In many cases, patients are unaware they are receiving care from an out-of-network physician, and they subsequently experience significant anxiety and challenge in paying these medical bills. Thus far, individual states have taken measures to protect patients from surprise billing. The topic continues to grow in relevance as insurers narrow provider networks to cut the cost of coverage, leaving more patients at risk for obtaining out-of-network services.

While previous studies used only survey data, these authors uniquely used medical claims data from the Truven Health MarketScan Commercial Claims and Encounter Database encompassing treatment episodes (2007-2014) for patients with employer-sponsored insurance. Encounters were considered likely to produce a surprise medical bill if the:

  1. Hospital was in-network and the ED provider or hospital-based provider was out-of-network.
  2. Hospital and the ED provider were both in-network, but an out-of-network provider not based in the hospital treated the patient.
  3. Ambulance transported the patient to an out-of-network hospital.
  4. Physician for an elective inpatient admission was in-network, but another out-of-network provider treated the patient.

In 2014, 20% of hospital admissions from the ED, 14% of outpatient visits to the ED, and 9% of elective inpatient admissions were considered likely to generate surprise medical bills. The respective rates from 2007 were 28%, 18%, and 14%. That’s right, there are fewer surprise bills now than a decade ago.

Geographic variation in the rate of potential surprise medical bills suggests that there is room for improvement with the opportunity for policy implementation in those states reporting a greater rate of surprise medical billing. Out-of-network emergency physician payment defined by the ‘greatest of three’ federal regulation allows insurers to use nontransparent methodology to transfer financial liability and surprise medical bills to patients while lowering reimbursement for emergency services, particularly worrisome for providers in states that ban balance billing. ACEP Past President Rebecca Parker, MD, FACEP, commented, "The EMTALA mandate gives the insurance industry the upper hand and can exploit the situation, because the doctors have to see all the patients, regardless of insurance status or ability to pay.”

Transparency in how insurance companies provide fair coverage for their beneficiaries and calculate payments to providers is greatly needed, as the present one-sided media perspective has misled the public by placing blame solely on physicians.

Additionally, the likelihood of a surprise medical bill increasing with the age and complexity of the patient’s diagnosis supports the need for further research regarding factors that promote or discourage surprise medical bills.

ARTICLE: Garmon C, Chartock B. One in Five Inpatient Emergency Departments Cases May Lead to Surprise BillsHealth Aff (Millwood). 2017;36(1):177-181.


A surprise medical bill is a bill from an out-of-network provider that was not expected by the patient or that came from an out-of-network provider not chosen by the patient. In 2014, 20% of hospital inpatient admissions that originated in the emergency department, 14% of outpatient visits to the ED, and 9% of elective inpatient admissions likely led to a surprise medical bill.

PMID: 27974361 

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems.

As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula.

This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.