NORTH COUNTY -- A trip to the emergency room is always handled the same way: Treatment first, payment second.

But that approach can mean extra unexpected expense if a patient's health insurance company does not contract with the emergency room doctor who does the work.

Dr. Richard Burruss, head of the emergency room medical group at Tri-City Medical Center, explained Tuesday that, when a patient is treated in the emergency department, he or she ends up with two bills: one from the hospital and one from the doctor.

Tri-City is currently in a contract standoff with Blue Cross. The sides have returned to the negotiating table, but were unable to report a new agreement Wednesday. Since the contract expired Jan. 1, both Tri-City and Blue Cross have told the public that it can still receive emergency care in the hospital's emergency room. But no one has mentioned that ER doctors don't do Blue.

Burruss said that the hospital's ER doctors have never contracted with Blue Cross because the insurance provider would not offer adequate rates.

"The rates that they offer to pay are less than what it costs us to provide the care," Burruss said.

So while the hospital's portion of an emergency-room bill would still be fully covered by Blue Cross, the doctor's portion wouldn't, at least not completely.

Leslie Porras, a spokeswoman for Blue Cross, said that all Blue Cross insurance contracts include a "nonparticipation clause" that puts her company on the hook for a certain portion of care provided by doctors who do not have contracts.

"Blue Cross will pay a portion of the bill in those situations," Porras said.

But how much will Blue Cross pay, exactly?

Porras said it is impossible to make a blanket statement for all California Blue Cross members, because most have different plans.

"For any members that have a specific question, we advise that they call us at the number on the back of their insurance card," Porras said.

Tri-City emergency room doctors are not the only ones who do not have a contract with Blue Cross.

Dr. Jim LaBelle, director of the emergency medical group at Scripps Memorial Hospital, Encinitas, said Wednesday that his group also has no contract with Blue Cross.

Like Burruss, LaBelle said previous attempts to broker a contract fizzled over reimbursement rates.

"We met with Blue Cross several years ago, and, basically, they offered rates that were below Medicare," LaBelle said. "We simply can't afford to pay our doctors the sub-Medicare rates, so we don't have a contract."

In contrast, Andy Hoang said the emergency room doctors at Palomar Pomerado Health in Escondido and Poway do have a contract with the health insurance giant. Palomar Pomerado's ER director was unavailable for comment.

Sharp HealthCare, which operates a half-dozen hospitals in San Diego County, also has a mixed bag. For example: Sharp Grossmont emergency room doctors do not have a contract with Blue Cross, but their counterparts at Sharp Coronado do.

Doctors LaBelle and Burruss both said their medical staffs try to work with Blue Cross patients to make sure they get the insurer to pay as much of the bill as possible.

"We spend as much time as we can trying to educate them on what their insurance covers and what it doesn't," Burruss said.

Both doctors also noted that San Diego County in particular generally gets much lower reimbursement rates from insurance companies than do doctors in other counties. LaBelle said the medical industry still classifies San Diego County as "rural" and pays less than it does in supposedly more-urban areas such as Orange County.

"If we don't have the lowest reimbursement rates in the nation, I don't know who has lower," LaBelle said.

He added that patients will likely see more contract breakdowns such as the one at Tri-City as reimbursement rates continue to dwindle.

"In my opinion, the system is approaching a breaking point, and this Tri-City-Blue Cross problem is just one symptom of a larger problem," LaBelle said.

Contact staff writer Paul Sisson at (760) 901-4087 or psisson@nctimes.com. To comment, go to nctimes.com.