This story has been updated with a statement provided by Envision Healthcare.
When Seabrook resident Donna Beckman got a surprise medical bill after a trip to her local emergency room last summer, she eventually learned it was because the doctor who treated her wasn’t part of her insurance network.
But Beckman’s story doesn’t just serve as a cautionary tale about how patients can be unexpectedly “balance billed” for out-of-network services at in-network medical facilities. It also illustrates how little the average patient knows about who’s involved in their medical care.
Until informed of the connection by an NHPR reporter, Beckman didn’t realize that a seemingly local physicians group that charged her for out-of-network care at Seabrook Emergency Room is actually connected to EmCare — a nationwide medical staffing company that has come under scrutiny for its billing practices. NHPR was able to uncover links between EmCare and the physicians group that billed Beckman because she provided her medical records for review as part of this story.
After visiting the Seabrook Emergency Room in August, Beckman got a bill from Portsmouth Regional Hospital, which operates the freestanding Seabrook ER. But she also received a separate bill of $1,648 from a group called Owascoag Emergency Physicians LLC.
The latter invoice charged her for the “emergency evaluation and management” she got during her hospital visit and billed her using the most expensive emergency room code, which is meant for the most intensive level of treatment.
Beckman’s records show that she received several lab tests and X-rays during her visit, but she says she only had about five minutes of actual face time with her emergency physician. The doctor reassured her that everything checked out fine and told her to follow up with her primary care doctor.
The invoice Owascoag Emergency Physicians sent to Beckman lists a return address in Philadelphia. But the company’s business filings with the New Hampshire Secretary of State tell a more complicated story.
The contact information listed on Owascoag Emergency Physicians’ business records is the exact address — on the 14th floor of an office building in Greenwood Village, Colo. — and phone number as EnVision Healthcare, EmCare’s parent company.
EmCare says it employs “nearly 16,000 clinicians providing patient care in more than 4,600 hospitals and other healthcare facilities nationwide,” and a map on its website shows that it operates at several locations in New Hampshire.
The company’s jobs board also shows it is hiring positions at several local facilities: Portsmouth Regional Hospital, Seabrook Emergency Room, Alice Peck Day Memorial Hospital in Lebanon and Parkland Medical Center in Derry. In Seabrook, specifically, it is recruiting emergency medicine physicians.
The invoice Beckman received for her ER visit also underscores Owascoag Emergency Physicians’ connections to EmCare: It says bills can be submitted online at “mymedicalpayments.com,” and that website tells people that they can direct additional questions to “email@example.com.”
EmCare did not respond to questions about its relationship with Portsmouth Regional Hospital or Seabrook Emergency Room until after this story was published. In a statement, the company said it's working "to move from out-of-network to in-network with as many insurers as possible."
"We agree that there is a problem with our current healthcare reimbursement system," Kim Warth, Envision's national director of communications, wrote in an email Monday night. "Patients are caught in the middle of a commercial dispute between payors seeking to reduce the medical costs incurred by their insureds and providers seeking fair compensation for medical services provided to those insureds. This challenge has only increased with the introduction of high-deductible health plans and narrow networks."
Portsmouth Regional Hospital did not respond to questions about its relationship with Owascoag Emergency Physicians, EmCare or other outside providers.
In an email, Portsmouth Regional Hospital spokeswoman Lynn Robbins wrote only that the institution “is sensitive to bills that patients may receive from affiliated or contracted physicians, and we encourage those physicians to participate in the same insurance networks as we do.”
EmCare’s reputation for leaving patients with large, unexpected medical charges has been well-documented, notably as the subject of an in-depth New York Times report last year: “The Company Behind Many Surprise Emergency Room Bills.”
The Times pointed to a 2017 Yale study that analyzed data on millions of emergency room visits and and found “notable changes in patient care and billing patterns after EmCare entered a hospital.”
The Yale study noted that EmCare is not the only company known to leave patients with out-of-network bills, but they found that “hospitals’ out-of-network billing rates increased by between 81 and 90 percentage points” after contracting with EmCare. Working with the company also “increases the amount facilities get paid via increases in imaging rates and the rates that patients are admitted from the ED to the hospital,” according to the study.
The Yale researchers also determined that “after EmCare enters a hospital, patients are 43 percent more likely to have physician services coded using the most high intensity, high paying codes.”
EmCare has disputed the findings as “fundamentally flawed and dated.” The company said the Yale paper included inaccurate and incomplete data, and that it "misled the public and our patients about many aspects of the healthcare services industry and, specifically, EmCare's operations."
But the Yale study and accompanying New York Times report spurred a Congressional inquiry into EmCare’s parent company and prompted a group of investors to file a lawsuit alleging they were kept in the dark about its billing practices.
In December, EmCare and another physicians group reached a $33 million settlement with the Department of Justice over claims that they got illegal payments for referring their emergency room patients to in-patient treatment at a chain of for-profit hospitals “when the patients should have been treated on an outpatient basis.” EmCare also agreed to enter into a “Corporate Integrity Agreement” with the federal government as part of the settlement.
Beckman, who is also a nurse, says she knows hospitals regularly outsource certain services to other companies to fill staffing gaps. And she initially assumed that the emergency room, which opened up about a month before she visited, had perhaps contracted with an outside doctors group for this purpose.
But she says at no point during her hospital visit was she told that her physician was out-of-network, or that some of her care might be provided by an EmCare affiliate. And this lack of transparency, above all, is what really troubles her.
“I'm not questioning the care, it's all about these billing practices,” Beckman says. “It's the choice. I didn't have a choice. I just thought that I was in trouble, I went to the emergency room. And again, you don't have a choice from that point on. You're going to be seen by the first available physician."