Two Yale economists are calling for states to end a practice that allows some doctors to surprise patients with large medical bills after visits to a hospital emergency room.

The bills appear when people show up for treatment at a hospital that's in the patient's insurance network but the hospital has hired doctors who are independent contractors who choose not to be part of that network.

The result: unexpected bills that average $622, according to a new analysis in the New England Journal of Medicine by Zack Cooper and Fiona Scott Morton.

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They found one person who was billed an extra $19,603 after going to an emergency room where the extra costs were added in and not covered by insurance.

Even a $622 bill is daunting when nearly half of Americans can't cover a $400 expense without borrowing money or selling assets, according to data from the Federal Reserve.

Patients "are not thinking of the bill when they need to get care and they get walloped later with a bill from a physician they didn't know, couldn't choose and couldn't avoid," Cooper told Reuters Health in a telephone interview.

"It's roughly analogous to going out to dinner, having a decent meal, paying the bill, and eight weeks later getting a $10,000 bill from the guy who served the bread. And they threaten to send us to collection if we don't pay," he said.

"It isn't just emergency care," Cooper said. "This happens for a whole lot of other things - anesthesiologists, assistant surgeons, radiologists and laboratories. This is a vagary of how we pay for health care. But the emergency room example is particularly egregious."

In response, the American College of Emergency Physicians (ACEP) released a statement in which its president, Dr. Rebecca Parker, complained that "the study does not discuss that insurance companies are misleading patients by selling so-called 'affordable' policies that cover very little until large deductibles are met - then blaming physicians for charges.”

Dr. Parker also challenged the $19,603 bill and noted that Cooper and Morton didn't identify the insurance company supplying the data.

The two economists suggest that "the best solution would be for states to require hospitals to sell a bundled ED (emergency department) care package that includes both facility and professional fees."

Dr. Jim Augustine, an ACEP expert on out-of-network issues, said billing used to be a package deal until the federal government demanded separate billing in the 1970s and 1980s. What has changed, he told Reuters Health by phone, is that the insurance companies have decreased what they will pay for and set up narrow networks of providers.

"Insurance companies would like to have bundled reimbursement setups because it's advantageous for their contracting," he said. "It's not advantageous for the people who provide care for them."

Cooper and Morton said if physician costs were bundled with the cost of each emergency room visit, hospitals would determine what physicians would be paid and that agreement would be part of the emergency room package. There would be no surprise bills for consumers and it would preserve marketplace competition because if a doctor doesn't like what a hospital is willing to pay for treating patients, the doctor could work at a different hospital. Hospitals would compete by offering the best rates to attract good doctors.

Under such a system, they said, "Most crucially, patients would always be protected."

In their study, Cooper and Morton found that 22 percent of visits involved patients going to an in-network hospital emergency room staffed by out-of-network doctors.

The odds of that happening varied regionally. It was seen in 89 percent of visits in McAllen, Texas, but virtually no visits in Boulder, Colorado.

"The fact that we see places where this just doesn't happen really tells us that this doesn't really need to happen," said Cooper, an assistant professor of health and economics at Yale. "There's a lot of things that are broken in healthcare that we can't fix or (are) really challenging. This is one that's really big, that harms a lot of people, and that's really easy to solve."