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Perhaps it seems that ER physicians work on a "commission" basis because of the relatively short time they spend with their patients. These physicians are usually not on the payroll of the hospital, they are members of a "pool" of a private medical group who often rotate among several hospitals on a contract basis. As such, they are not reimbursed on a "per-patient" basis. They are paid by the number of hours they are staffed in that hospitals' ER. (This also explains why you often receive a separate bill from this ER group, in addition to one sent by the sponsoring hospital.)

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