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Why I can't afford to provide emergent care


Recouping money for emergency care you have already provided is a difficult task. See what one doctor did when he decided that he could no longer afford it.

Having an interest in the "medically necessary" part of plastic surgery translates to considering ED call. Although the concept of running around at all hours of the evening to repair people injured in accidents may seem romantic to the layperson, as you know, trying to obtain fair reimbursement for this work is more of a comedy or a tragedy.


I repaired her wounds in the ED while she was under local anesthesia, saving her a pile of money by not using the hospital operating room. She had an independent practice association insurance plan for which I was not a provider, but in California, where I practice, it doesn't make much of a difference anymore whether you are a provider for a plan. In 2006, Gov. Arnold Schwarzenegger outlawed balance billing by executive order. The California Supreme Court backed this position in 2009.

These days, emergency care essentially pays whatever the insurer wants it to pay-assuming the patient has insurance. If there isn't an insurer, then you usually get paid nothing. It is not as if you can go after the patient anymore. They just don't pay the bills.

About a week after the surgery, the patient reported to me at follow-up that she was suing her partner's homeowner's insurance for the incident and that her attorney wanted to speak with me. Later, the lawyer settled for a brief letter written about the event in lieu of more involved testimony. I dodged a bullet there.

The patient's face healed fairly well, considering she was a smoker. The wound matured, and her motor function recovered quite well. A few months after the surgery, her insurer paid less than one-third of the bill for her surgery. Later, the company denied coverage for her follow-up visits, citing the fact that I was not a provider with the plan. The patient ultimately paid these bills as a condition of obtaining the letter to help her legal case. On a percentage basis, I made less than half of what I billed for her care.


The summation of this experience for me is that, when it comes to providing emergency care, in most cases it is far more trouble than it is worth for physicians. The economic and political climates are such that a doctor cannot be assured of being paid anything for providing such care. Not only are we not paid additionally for working at ridiculous hours or on holidays, but in California, we can't even bill the patient when the insurer underpays or refuses to pay the claim. I followed this experience by resigning at any hospital that made ED call a condition of having operating room privileges.

Having the right of first refusal is the least we can ask for in an emergency. We are not permitted to inquire about insurance coverage when the hospitals call, and if a printed call schedule exists, we are obligated to serve the patient whether or not we ultimately will be paid for the care.

I will not permit my name to be added to such a call schedule, and when a hospital calls, I am selective about when I will participate and what kinds of cases I will see. The late-night emergency adventures of my past are going to stay in my past.

In the grand scheme, I liked doing trauma work. One of the last ED patients I repaired at a local hospital I subsequently dropped returned recently. Her surgical result is outstanding, and she is grateful. She also is among the very rare patients who paid her bill when her insurer refused to do so. If more people like her existed, the ED gambit wouldn't be such a bad bet for me and others like me.

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ohn Di Saia, MD practices in San Clemente, California. The Way I See It columns reflect the opinions of the authors and are independent of Medical Economics. Do you have an experience you would like to share with readers? Submit your writing for consideration to

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