Surprise medical bills spell big trouble for consumers, especially those who find themselves in an emergency room. Such surprises have surfaced as a major patient problem, but because of entrenched health care interests, a solution is not likely any time soon.

Here’s what happens. Patients arrive at the emergency room of a hospital that is in their insurer’s provider network. However, the physician who treats them is out of network.

Because ER docs are usually assured a steady stream of patients, many believe they don’t need to accept potentially lower fees from insurers in exchange for any new patients they might attract by belonging to a network. That’s not the case for other specialists who may rely on insurer networks for more business.

Whatever the reason, emergency room patients may be stuck with huge bills their insurance company may not cover, or it will pay less than if patients had used in-network doctors.

If you think this is unfair, it is.

A study by Yale researchers of more than 2 million emergency room visits across the country was just published in the New England Journal of Medicine. It found that out-of-network doctors treated 22 percent of the patients who visited emergency departments; the departments themselves were part of their insurers’ networks.

The average bill patients incurred was $623. The highest bill was more than $19,000. To put that number in perspective, this year the Federal Reserve reported that 46 percent of Americans were unable to pay a $400 expense without running up credit card debt or selling assets.

Not surprisingly, researchers found out-of-network ER doctors ended up getting paid a lot more than those who were part of a network. “The fact this type of price gouging has become routine operating procedure in so many emergency departments is shameful and appalling,” says Chuck Bell, programs director for Consumers Union.

A recent study in Texas by the Center for Public Policy Priorities shows how prevalent out-of-network ER doctors are. Using a 2013 report from the Texas Department of Insurance, the Center found that 45 percent of in-network hospitals in the state used by United Healthcare had no in-network ER doctors. Fifty-six percent of Humana’s hospitals had none. “Consumers would be astonished to see how poor the odds are of getting an in-network doctor in the emergency room.” Bell added.

The odds of getting redress are also low. Too many consumers don’t contest their bills. Only about 25 percent of those getting surprise bills do, Bell told me. Of those who do protest to their insurer, only half get their bill forgiven or reduced.

Surprise bills are a variation of what’s called balance billing, the gap between what insurance, including Medicare, pays and what a doctor charges. It’s been around for decades, but in the late 1980s, the outcry from Medicare beneficiaries became so loud that Congress did something about it.

For doctors who accept Medicare’s payment in full, there is no balance billing — called “excess charges” in Medicare speak. Doctors, including ER physicians who don’t accept that payment, can sock beneficiaries with excess charges. But Medicare limits what they can charge.

Beneficiaries can protect themselves from these excess charges should they use a doctor who doesn’t accept Medicare’s fee schedule by buying Medigap policies Plan F and Plan G. For those with Medicare Advantage plans, there’s no protection until the beneficiary reaches the plan’s out-of-pocket spending limit. After that, the doctor can’t balance bills separately.

There’s no similar help for those not on Medicare.

Many consumers are unaware that an out-of-network doctor is treating them.

The standard advice — to ask if your doctor is in the network — is silly when it comes to care in the ER. What patient having a heart attack is going to look up and say, “Hey doc, are you with Aetna?”

A few states — New York, California, Illinois, Connecticut and Florida — hold patients harmless if they find themselves with a surprise bill or require outside arbitration to decide a case. But Bell says it will take an act of Congress to solve this problem. Public outrage will have to get much louder if that’s to happen.

Because chances are high you’ll find yourself with such a bill, think twice before you choose to go to the ER for a problem that can wait until you see your regular doctor.

Although Obamacare was supposed to cut down on emergency room use, that hasn’t happened. People are still going to ERs for less serious conditions, many being enticed by hospitals themselves that advertise their ER wait times on billboards.

Our health care system is all about making money. And balance billing, its causes and consequences, is another sorry example.

Trudy Lieberman, a journalist for more than 40 years, is a contributing editor to the Columbia Journalism Review, where she blogs about health care and retirement at cjr.org. She can be reached at trudy.lieberman@gmail.com. This column was distributed by The Rural Health News Service.

The question, “Where is God,” is one that has been asked throughout the ages, usually when it involves some sort of tragedy.

The follow-up question often asked is more philosophical than the existential one I just mentioned: “If God is all loving and good, why is there evil in this world?”

These are questions that have entered my mind from time to time throughout this year.

The questions began in January as I thought my wife Michelle had cancer. She missed two months of work and the diagnosis that she had bone cancer seemed to be true.

However, in March she was back to normal and back to work, having no trace of cancer. My worries were over, or so I thought.

A few months later, I celebrated with Michelle and my daughter Faith by going to Disney World. This was something Michelle always wanted to do with Faith.

Then a month later to the day, I received an unexpected phone call from my mother-in-law telling me that my wife of 23 years had died. After Michelle pulled over to the side of the road, she became unconscious, with my 7-year-old daughter Faith in the back seat.

When Faith saw her mom unconscious, she climbed up to the front seat to try to wake her up, but to no avail.

I was left with the question of why. Not just why did Michelle die, but why did Faith have to have the last memory of her mom be that she died while sitting on her mom’s lap?

I had no answers. But what would happen just a few months later created even more questions.

It had been about five months after this tragic day when I was having lunch with friends at Harrison Country Club in Columbus before we were supposed to play a round of golf. Midway through the meal, I received a phone call from my youngest brother.

He began the conversation by stating, “I don’t know how to tell you this.” These were the same words that my mother-in-law used when she told me Michelle had died. A lump in my throat emerged immediately, as I braced myself for what was surely to follow.

With my eyes closed, I awaited the news I knew I didn’t want to hear. He told me that my brother Shannon had been killed by a drunk driver earlier that day. I didn’t even know how to process what I just heard.

Again, a senseless tragedy that didn’t have to happen.

I found out that the person Shannon would later take home after work had quit his job and he was working late for this young man. Shannon’s charitable nature motivated him to give the young man a ride to his home after he finished his shift.

Unfortunately, his normal route home was in the opposite direction. Had he gone his normal route, Shannon never would have been hit by that car.

It has been a few weeks since that fatal day as I struggle through the grieving and healing process. In thinking about how I should react, I felt that there were three ways I could respond to these tragedies.

First, there was the religious way. When I say religious way, I am not referring to religious practice in general. To the contrary, I am referring to the substitute Christian response that depersonalizes God and chooses to suppress the experience. After all, religious people have it all together and never struggle.

Second, I could have chosen the secular way. This way is rooted in the therapeutic. One simply talks his or her way through their emotions and processes them accordingly. No touch from God needed.

Instead, I chose what I will call the Christian way. Christianity teaches that God is personal and interacts with his people. He comforts and consoles them and touches them in their times of need.

Much of this interaction comes by way of interacting with God’s written word, the Bible.

It has been my experience that when tragedies like this happen, unbelief is waiting to destroy your faith in God.

To counter this, I have spent a lot of time standing on God’s promises and meditating on his character and nature that is revealed in Scripture. I have found that when I choose to stand on his word, in faith, the Holy Spirit does a work in my heart that is redemptive and strengthens me at the very core of my being.

Despite these tragedies, to quote a line from an old hymn, “all is well in my soul.”

Columbus’ Tim Orr is an adjunct faculty member in religious studies at IUPUC and author of the recently published book “We Named Her Faith: How We Became a Gospel-Centered Family.” He can be reached at tmorr@iupui.edu.