He went to an in-network emergency room. He still ended up with a $7,924 bill.

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On January 28, 34-year-old Scott Kohan woke up in an emergency room in downtown Austin, Texas, with his jaw broken in two places, the result of a violent attack the night before. Witnesses called 911, which dispatched an ambulance that brought him to the hospital while he was unconscious.

“The thing I remember most was my lips were caked in blood and super dry,” Kohan says. “My head was throbbing, so I touched the top of my head, and I could feel staples there.”

Kohan called for a nurse, who explained that he would need jaw surgery that night. In the meantime, he tried to check whether the hospital — Dell Seton Medical Center — was in his insurance network.

“I was on my iPhone lying there with a broken jaw, and I go on the Humana website and see the hospital listed,” Kohan says. “So I figured, okay, I should be good.”

Except he wasn’t: While the emergency room where Kohan was seen was in his insurance network, the oral surgeon who worked in that ER was not. That’s how Kohan ended up with a $7,924 bill from the oral surgeon that his health plan declined.

“In hindsight, I don’t know what I could have done differently,” Kohan says. “I couldn’t go home. I had a broken jaw in two places. I tried to check if the hospital was in network.”

“Surprise” medical bills are common in emergency rooms

Kohan’s experience is not unique.

In the past six months, Vox has collected more than 1,300 emergency room bills submitted by readers in all 50 states and Washington, DC, as part of an investigation into emergency room billing practices.

The dominant storyline to emerge is what anyone who has visited an emergency room might expect: Treatment is expensive. Fees have risen sharply in the past decade. And when health insurance plans don’t pay, patients are left with burdensome bills.

Vox’s database shows that patients are especially vulnerable to these surprise bills when out-of-network doctors work at in-network hospitals.

“It does happen quite a lot in the emergency room,” says Christopher Garmon, an assistant professor at the University of Missouri Kansas City.

Garmon published a study last year that found as many as one in five emergency room visits led to a surprise bill from an out-of-network provider involved in the care.

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“When somebody is out of network and the patient knows that, they can avoid those providers,” Garmon says. “Here, it’s very hard for patients to know this is going to happen.”

Garmon found that surprise bills are the most common in emergency room visits where the patient is ultimately admitted to the hospital for further treatment. Twenty percent of those patients end up with an out-of-network bill, often from specialists such as anesthesiologists and pathologists.

For patients who stay in the emergency room — who have a shorter visit that doesn’t lead to a hospital admission — the risks are still high. An estimated 14 percent of those patients end up with an out-of-network bill for care delivered during their visit.

“Even with a PhD in surprise billing, you couldn’t make sure to avoid a surprise bill”

When doctors and hospitals join a given health insurance plan’s network, they agree to specific rates for their services, everything from a routine physical to a complex surgery.

Doctors typically end up out of network when they can’t come to that agreement — when they think the insurance plan is offering rates that are too low but the insurer argues that the doctor’s prices are simply too high.

Unless states have laws regulating out-of-network billing — and most don’t — patients often end up stuck in the middle of these contract disputes.

These surprise bills appear to be especially common in Texas, where Kohan lives. Garmon’s research, for example, finds that as many as 34 percent of emergency room visits lead to out-of-network bills in Texas — way above the national average of 20 percent.

Separate data from the Center for Public Policy Priorities, an Austin-based think tank, finds that a staggering number of Texas emergency rooms have zero in-network emergency physicians — meaning that patients are guaranteed to see a doctor who does not accept their health insurance.

The number varies among health insurance plans. CPPP estimates, for example, that 18 percent of Texas hospitals have zero in-network emergency room physicians for Blue Cross patients. The number rises to 63 percent of hospitals for Humana, the health plan that Kohan uses.

“Even if you were a good consumer and checked all the ERs around you, that network could still change each month,” says Stacey Pogue, author of the CPPP report. “Even with a PhD in surprise billing, you couldn’t make sure to avoid a surprise bill.”

“That’s the doctor’s choice”

Kohan realized something was amiss with his medical bill about one week after his surgery.

“A week later, I was obsessively checking the Humana website,” he says. “I saw that everything came up in network except a bill for surgery that it was says was rejected.”

Kohan called his insurance plan, which assured him that nothing was wrong — that the doctor had likely coded the visit wrong and would just need to resubmit the claim.

Kohan’s doctor did resubmit the claim, and increased the price of the surgery by about $2,300, billing records show.

Humana once again denied the claim. And on April 18, the doctor’s office began billing Kohan directly, requesting that he pay $7,924.13. Kohan was in the middle of appealing Humana’s decision to deny his claim when he submitted this bill to Vox’s billing database.

“I went to a hospital where I am covered, and did everything I reasonably could do to confirm that I was going to be covered before having surgery,” Kohan wrote in his appeal. “Unfortunately it didn’t work out the way. Please, help me finally move past this unexpected disaster and begin to continue.”

I reached out to the doctor who saw Kohan, an oral surgeon named Derrick Flint.

His office manager, Perla Canizales, told me that Dr. Flint does not participate in any medical insurance networks. I asked why.

“We just are not; we just don’t take any medical plans,” she said. “That’s the doctor’s choice.”

Flint himself did not respond to my request for an interview. But the day after Canizales and I spoke, Kohan said she called him — and let him know that the entire $7,924.13 charge was being dropped.

I also reached out to Dell Seton hospital to ask why it contracts with an oral surgeon who does not accept any medical insurance.

The hospital declined an interview but provided a statement noting that this is a common practice across the country.

“We are grateful to our highly-skilled doctors, nurses and the entire team of providers who successfully care for patients experiencing medical emergencies,” the hospital statement says. “Like many hospitals across the country, we also contract with private independent doctors who provide critical areas of specialty care in our facilities and manage their own insurance contracts.”

States are trying to fight back. It isn’t easy.

Texas has had a law on its books since 2009 meant to allow consumers to fight cases like Kohan’s.

The 2009 law allows patients to contact the state when they receive surprise medical bills above $500. The state’s department of insurance will then initiate a dispute resolution process between the hospital and the provider.

The problem with that law, Pogue argues, is that it requires patients to contact the state — and patients often aren’t aware of the option. Kohan, for example, didn’t know he had these rights until I told him.

Pogue’s research suggests this is really common: Only 3,824 Texas patients have used the law to resolve their surprise bills since 2009. CPPP estimates that this is a tiny fraction of the 250,000 surprise medical bills sent out in the same time frame.

“Our system is placing the burden on consumers,” Pogue says.

Other states, such as California and Connecticut, have more comprehensive laws that require insurers and doctors to settle their out-of-network billing disputes directly, without ever trying to collect the fees from the patient.

But even those laws have limited reach; they only cover patients who have smaller health insurance plans that are regulated within the state. This leaves out big insurance plans that large companies often buy, which have members across the country.

“We need a federal solution,” says Garmon, the researcher. “Right now it’s a patchwork, where some states have protections and others don’t. And there are no protections if you’re in a self-insured, large-employer plan, and there needs to be a solution for those people.”

Garmon favors an approach that he describes as “baseball-style arbitration,” where each side comes up with a price it feels is fair and then they work toward the middle. “They’d be forced to come to the table, and that would take the patient out of the middle,” he says.