Tom Schrette and Alan Cash

Tom Schrette and Alan Cash

J.L. Sousa

Dear Readers: Our March 9 contrasted emergency room care with urgent care centers. We received a very informative rebuttal from Dr. Andrew Fenton, medical director, Napa Valley Emergency Medical Group.

Dr. Fenton’s full letter was in the letters to the editor in the Register on March 20. We have included just the final summary paragraph and the ensuing emails between us.

Dr. Fenton: The urgent care can be a helpful resource for people with minor medical issues where they can receive care promptly. But this is no substitute for emergency care delivered by highly trained specialists that is available 24/7/365.

When people with SCAN, or any other health insurance including Kaiser, have symptoms of an emergency they should go immediately to the closest ER or call 911. The doctors and nurses of the ER are prepared to help, and we have personally seen too many tragic stories of people who waited too long.

Tom: I am so appreciative of his feedback. We had discussed the issue of MDs who specialize in certain areas and are not contracted with any insurance carriers.

Dr. Fenton: (Tom) mentioned that many insurers have changed to an EPO (Exclusive Provider Organization) product with zero out-of-network coverage (true).

He also mentioned that the ER docs are not contracted with any carrier. That is mostly true but we do have a contract with the Veterans Home, Napa State Hospital, Meritage WHA, and with QVMC to treat all of their employees with Anthem Blue Cross and to accept whatever payment is made (and to never balance bill employees the remainder after the underpayment).

Overall, the percentage of patients we see with Cigna, Aetna, HealthNet and United is very small.

Frankly, Anthem Blue Cross is a problem-payer statewide and the California chapter of the American College of Emergency Physicians is trying to work with the DMHC representing multiple emergency physicians groups about how to get Anthem Blue Cross to “play nice.”

Tom and Alan also state, “people go to an emergency room … and then face a huge bill because it ‘doesn’t qualify’, as an emergency.”

State and federal laws prohibit insurers, including those with a SCAN plan, from denying emergency medical coverage as long as the ER visit is warranted from the perspective of a “prudent layperson.”

Even proposed changes to federal healthcare laws do not change this standard and the guarantee of coverage for emergency care.

Tom: Again, I want to thank Dr. Fenton for this input.

California Assembly Bill 72 may put an end to this discussion. It states that if a consumer does not have an in-network provider option, the insurer is required to pay the provider as in-network.

To clarify, the ER doctors’ charge is generally the smaller side of the emergency room bill; the larger side is the hospital charge, generally $1,000 for walking in the door.

Submit questions or reach the Health Insurance Guys at Schrette Insurance, 1556 First St., Suite 105, Napa, 94559; 255-9511; schrette@gmail.com; or alancash@gmail.com.

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