Patients entering the emergency departments of Calais Regional Hospital (CRH) and Down East Community Hospital (DECH) are usually in no position to query whether the attending physician and staff are part of their in‑network insurance. However, it matters if the patient's insurance is accepted as in‑network by the hospital but is considered out‑of‑network by the contracted care provider. The patient thinks they're covered, but it turns out they aren't for a sometimes significant portion of their care. Such occasions, called "surprise billing," have occurred often enough around the country to warrant federal and state legislation.
     The two Washington County hospitals recently collaborated to change their contracted service for emergency department and hospitalist providers from the Maine‑based company BlueWater to the Tennessee‑based Envision Physician Services in February 2020. They will have a three‑year contract and cite cost savings as the primary reason for the change.
     As reported in mid‑2019 by The New York Times, Envision Healthcare, owned by global investment firm Kohlberg Kravis Roberts since fall 2018, was one of the two largest backers funding opposition in 2019 to a proposed federal law to end out‑of‑network charges, or surprise billing. The proposed law had the support of Congress and President Donald Trump. There are State of Maine laws, on the books or to be considered in the upcoming legislative session, that attempt to protect patients from surprise billing and balance billing, but there are still ambiguities in some areas, says Maine Consumers for Affordable Health Care Policy Director Kathryn Ende.
     Envision spokesperson Aliese Polk says, "In an emergency, patients should not be forced to make financial decisions ahead of medical ones. For patients, seeking the most appropriate care is the priority, and we are committed to working with insurance companies to provide patients with access to care when they need it most." She did not provide a specific response about how Envision would ensure that surprise billing would not occur.
     DECH Director of Marketing and Communications Julie Hixon says that there is no reason to believe that patients will experience any difficulties with the transition. She adds, "Patients do not need to be concerned about any surprise out‑of‑network billing to Envision. They didn't receive any from BlueWater, and they won't from Envision. We can be certain of this because DECH does its own billing and coding."
    CRH Vice President of Community Relations DeeDee Travis, though, says, "Envision will be billing for the physician services for us." She adds, "The providers will be credentialed by the same payors that the facility is. Our intention is to try and avoid any billing issues."
     Of the decision to switch from BlueWater to Envision, Hixon explains, "We did not make this decision lightly and thoroughly vetted alternative vendors. All vendors offered comparable levels of service and expertise, but Envision Physician Services best met our needs while also offering a competitive price." She expects cost savings to be in the hundreds of thousands.
     "We have enjoyed our relationship with the current emergency department and hospitalist providers. They have been excellent to work with, and we appreciate the quality of service to our community," says Rod Boula, CEO of CRH. "It really came down to finding a better fit for the financial viability of the hospital while maintaining the high bar we set for quality of care." CRH has reduced the hospital's losses from $2.64 million in 2014 to $574,600 in 2018 and continues to work toward better financial health.
     Both hospitals expect to maintain current staffing levels when the changeover occurs. Hixon says that DECH and CRH "appreciate the quality services they [current providers] have provided to our community. Envision is open to the current emergency department providers joining their staff, and we are hopeful this will occur."

Protecting patients from surprise billing
     Out‑of‑network billing has been the subject of legislation at the federal and state level because of the devastating effect it can have on patients. It can happen when a person goes to a hospital emergency department that accepts their health insurance but receives care from a physician who is not part of the patient's insurance network.
      In 2017 the Maine Legislature enacted a law to protect Maine consumers from unexpected medical bills that fall in the in‑network out‑of‑network configuration. However, it specifically exempts emergency departments. Ende explains that while the law does exempt emergency care, there is a statute in Maine law meant to cover that particular gap. Maine law 4320‑C addresses coverage for non‑network emergency services. Ende says, "Where this gets a bit tricky is that the rule only addresses copayment amounts and coinsurance rates but does not address deductible amounts." She explains that balance billing is also important to consider when looking at costs consumers could be responsible for.
     Balance billing is when the provider bills the patient for the difference between the provider's charge and the allowed amount paid by insurance. Ende says, "Maine law 4303 prohibits balance billing for covered services rendered by participating providers. However, some large group self‑funded plans aren't regulated by state law. We hope any contract between a hospital and physician group would protect patients and ensure any health plan accepted by the hospital would also be accepted by the contracted physicians."
     However, Ende explains, "There is some ambiguity around balance billing." She notes that during the upcoming legislative session a bill will be discussed to "close the gap." She adds, "It certainly concerns us." Emergency care, she points out, is not something people can shop around for to find the right fit. The bill, LR 2881, An Act to Protect Consumers from Surprise Emergency Medical Bills, would amend the laws governing medical billing to protect consumers from unexpected medical bills in emergency situations. In summary, consumers would be held harmless when receiving emergency medical services from an out‑of network medical provider. If an issue arises with the difference in cost between what the insurer will pay for the out‑of‑network services and what the out‑of‑network provider charged for the service, an independent resolution process would be used to encourage providers and insurers to negotiate in good faith without the consumers being affected.