Elliot Dear, Esquire — Out-of-Network Reimbursement Lawyer

A surgeon who takes emergency call does not pick the patient, and the patient does not pick the surgeon. When the hospital pages, the surgeon comes in and operates, whatever insurance the patient happens to carry. That is how an on-call specialist ends up out of network with a plan the specialist did not choose to deal with. Elliot Dear, Esquire, starts from that fact whenever an emergency claim lands on his desk.

The Call Schedule Decides

Hospitals keep specialists on a call schedule to cover the emergency department. A plastic and reconstructive surgeon or an oral and maxillofacial surgeon may be called in to repair an injury the emergency physician cannot close alone. Nobody checks network status before the case starts, and nobody should. The patient is treated first; the plan only enters the picture afterward, on paper.

Out of Network by Circumstance

For the surgeon, being out of network on an emergency case is not a decision made about that plan. There is simply no contract with it. So the plan sets its own allowed amount, with no negotiated rate behind it, and the payment that comes back can sit far below the billed charge. Elliot Dear treats that gap as a dispute to be argued, not an adjustment to be written off.

Where an Emergency Claim Is Heard

The plan decides the forum. An emergency claim under a fully insured New York plan is heard in New York State Independent Dispute Resolution, which the Department of Financial Services administers. A self-funded plan falls outside the state process. Elliot Dear reads the EOB to place the plan before any submission is built, because getting the forum right comes before any argument about the number.

Making the Night Visible

The record from an emergency case does real work. The operative note shows what the surgeon walked into at an hour nobody schedules: the injury, the complexity, the decisions made with no time to spare. Elliot Dear builds the submission from that note, the billed charges and the EOB, measures the allowed amount against the FAIR Health 80th percentile, and signs it under his New York bar number.

For Surgeons Who Take Call

A surgeon who covers the emergency department can send one emergency claim and its EOB for a free review. Elliot Dear, Esquire, reads it with the call night in mind, not only the line items.