Balanced Billing: Surprise Bills In Emergency Rooms That Could Cost You Thousands

BOSTON (CBS) -- A trip to the emergency room with a serious health problem is scary. Now imagine having to stop and get detailed information about every doctor or specialist who treats you. It sounds insane, but it might be the only way to avoid getting stuck with a hefty bill.

That's what happened to Zach Proman of Needham when he went to the emergency room with a fever of 105 degrees. "I felt pretty delirious, honestly, I don't remember much," he said.

After a battery of tests, Zach was given medication to bring the fever down and spent five hours in the hospital so doctors could monitor him. He was then released.

"I wasn't expecting any surprises until I got the doctor's bill," he said. All of Zach's tests and treatments were covered but his insurance company refused to pay a $593 dollar fee from the emergency room doctor. Why? Even though Newton-Wellesley Hospital was in his insurance network, the doctor wasn't.

"I went into the emergency room only aware that I felt really horrible, not really thinking about whether or not I needed to ask a doctor before they put their hands on me if they are covered by my medical insurance," he said.

It's called balance billing and it's a growing problem. A report by the Massachusetts Health Policy commission cited a study that analyzed thousands of claims and found 22 percent of emergency hospital visits nationwide involve an out-of-network physician. In some cases, the bills can be thousands of dollars.

Senator James Welch (D-Hampden) believes this is not something that Zach or anyone in an emergency situation should be worried about. "We are talking about people in their most vulnerable situations," he said.

That's why Welch is sponsoring a bill to set a standard rate for out-of-network care to avoid these surprise bills. "We in Massachusetts need to get a hold of and really make it clear that the patient should not be responsible for this balanced billing," Welch explained.

After months of negotiating, Zach was finally able to convince his insurance company to cover the cost, but he worries about other people who don't think they can fight back and just pay the bill. "It seems like there is a root problem here and it's getting passed around and no one really wants to fix it."

A Newton-Wellesley spokesperson told us this does happen, but Zach's experience is not typical.

Patients should also be aware that these surprise bills are not limited to emergency rooms, they can also happen with providers you don't actually see like radiologists who read X-rays or a pathologist who tests a biopsy.