Jeffrey Craig Hopper is a probate attorney and Little League coach in Austin, Texas, so he knows all about following the rules. Still, accidents happen. Last June on the Little League field, an errant baseball smashed into his face.

His wife, Jennifer, remembers rushing to the field.

"His eye was swollen shut enough that we weren't sure if he could see," she says.

Even in that moment of panic, Jennifer Hopper realized that there are rules when it comes to using health insurance that can hugely influence the size of the medical bill. Care providers who are "in network," she knew, cost much less, so she made absolutely sure to drive Jeffrey to the emergency room of a hospital in Austin that is part of their insurance network.

That sounds straightforward, but, as the couple soon learned, it doesn't always work out that way — some patients still get slapped with big bills, even when they try to play by the rules.

In the end, Jeffrey was OK — the ball broke some facial bones around his eye, but they healed and his vision was fine. Jennifer, however, was surprised by what happened next. After she'd already settled with the hospital, paying the copayments for the ER, the ER doctor sent the couple a separate bill for more than $700.

"It felt kind of random," she says. "How do I know who's going to charge me, and who's not going to?"

Like many patients, Hopper assumed that if she went to a hospital that the insurance company had designated as being within her network, the doctors who work there would also, of course, be in the network.

But that's not necessarily true. Emergency room doctors, radiologists and anesthesiologists often don't work for the hospital. They work for themselves, often in large practice groups, and it's up to them to sign their own deals with insurance companies.

Many of them don't. In those situations, the doctors can bill the patient for whatever the insurance company wouldn't cover — because the coverage took place within the approved hospital network, but outside the approved network of physicians.

"I couldn't let that go — it just felt wrong," Hopper says, "because there was no way out. There was obviously no way we could have avoided the situation, given our emergency."

The Center for Public Policy Priorities recently analyzed ER billing by the three biggest insurers in Texas — Humana, Blue Cross and United Healthcare.

The report found that in more than half of Humana's Texas hospitals, none of the ER doctors who see patients there were within Humana's network.

The same was true at just under half the Texas hospitals that take United Healthcare insurance, and at about a fifth of those that take Blue Cross.

Stacey Pogue, a health policy analyst and the report's author, says that sort of arrangement is unfair to patients.

"No other consumer services are sold to us this way," she says. "It would be like going into a restaurant, and ordering a meal and then getting a bill from the waiter, and from the restaurant separately, and the cook separately and the busboy separately. And some of them will negotiate with you on the price, and some of them will accept coupons, and the others don't."

Texas insurers have said they would like emergency room doctors to join their networks, but can't force them to.

The ER doctors counter that insurance companies often don't pay them enough, even if they do join the network.

The economics of ERs are complex, explains Dr. Bruce Moskow, president of the Texas College of Emergency Physicians.

"In an emergency department we see everyone, and we're not even legally allowed to ask if they're going to pay their bill," Moskow says. "Large numbers of people pay nothing."

There is a mediation process in Texas for some of these out-of-network bills, but it's only for certain types of insurance, and for certain situations.

Some other states have tried to tackle the problem. In California, ER doctors aren't allowed to send a separate bill to HMO patients. In New York, a newly passed law requires out-of-network doctors and insurers to hash out payment on their own, and leave patients out of it.

Texas legislators have held hearings on this issue recently, but the discussions haven't yet led to any new regulations.

Jennifer Hopper says she spent weeks appealing her bill, going back and forth between the doctors and the insurance carrier. Eventually she filed a complaint with state regulators. After that, she says, the bill simply disappeared.

Pogue says the typical advice — for patients to "do their homework" ahead of time and know who's in their network and who isn't — isn't always possible, especially in the middle of an emergency.

"If you're wheeled into the emergency room door, you can't ask the emergency room physician who runs up to stabilize you, 'Are you in network or out of network?' That physician needs to be concentrating at that point on giving you lifesaving care, not rattling off the list of insurance companies that he or she contracts with," she says.

Jennifer Hopper tried to do her homework by figuring out where to go for a possible future ER visit. Online, she searched her health plan to find ER doctors who were actually in her insurance plan's network. But she found fewer than five at the hospitals her plan uses in Austin. She doubts the odds of getting those doctors the next time she or a family member needs care.

"So the reality," she says, "is that all the transparency in the world doesn't change the fact that — knowing everything — I could not be sure I would get a different outcome."

This story is part of a reporting partnership that includes Houston Public Media, NPR andKaiser Health News.

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