ER charge

[TWR]

My wife went to a free standing private ER called First Choice in Houston, TX with no hospital affiliation for a bad migraine. I was charged for a level 5 visit which was billed at $3043.00. MY BCBS disallowed $1992.00. They paid $1411. My portion is $1100. That includes pulse ox?? $56, Toradol 15mg $100, Zofran 1mg $52, and acharge called IM/SQ which I am guessing is sticking a needle in the butt for $87 !!! Physician E/M was $404 face to face less than 15 minutes. I will call the main office and question these charges starting with a level 5 charge. She was not in cardiac arrest or having an MI. Also when do you do CT's of head, with every cc of "headache" and history of them. I vented and feel better, Thanks

[EMEDPA]

recently took one of my kids for a slam dunk sore throat/step to a local urgent care when the pediatrician's office was closed.

800 bucks for strep test and shot of pcn..

[TWR]

At a retail clinic it would have been about $75 plus the PCN

[Acebecker]

strep gets a level 2 new patient or level 3 established patient charge of $106 plus about $25 for a rapid strep (if I even do one). the ABx is $4 at WalMart - we generally don't do injections if there is a good alternative for several reasons. I can't phathom how someone could charge you $800 for that. the person charging $75 for that visit isn't being thorough enough IMO, but that would get us off topic.

 

to the OP: I would investigate that charge very thoroughly. sounds like it isn't legit to me. 15 minutes f-t-f and level 5 ER charge? really? someone screwed up.

 

Andrew

[True Anomaly]

Those free-standing ER's have to justify their costs somehow, including sponsoring concerts and other local events (which I've heard radio advertisements for First Choice sponsoring such things before), as well as their PR "ambulance" they take to public events.

 

The idea of any kind of ER sponsoring a concert just makes me apoplectic.

[jwells78]

Wow, 3K huh? AND they only gave her 1mg of Zofran?! Something doesn't add up here... HA with IM Meds and a head CT? Not sure that's coded as a 5... but hey- I don't code for billing, so what do I know...

[Avalon]

NPR just ran an interesting story on such inflated charges at free standing ED's on Friday morning's "All Things Considered." If I am not mistaken, the story was taped in Texas. Listen to the podcast and see if anything there is helpful in terms of questioning these considerable charges for a rather routine presentation.

[TWR]

[h=1]Patients Can Pay A High Price For ER Convenience[/h] by Carrie Feibel

 

 

August 13, 2013 3:00 AM

fromKUHF

 

 

 

[h=3]Listen to the Story[/h]Morning Edition

7 min 49 sec

 

 

 

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In case of emergency, go to the strip mall or the hospital?

 

 

iStockphoto.com

Medical entrepreneurs are remaking the emergency room experience. They're pulling the emergency room out of the hospital and planting it in the strip mall.

It's called a "free-standing ER," and some 400 of them have opened across the country in the past four years.

The trend is hot around Houston, where there are already 41 free-standing ERs and 10 more in the works.

"I think these emergency medical centers are springing up like Texas wildflowers in the springtime," says Vivian Ho, a health economist at Rice University in Houston. "It's really amazing."

Some of the new facilities are owned by hospitals, but the majority are owned by for-profit companies. Ho says they may offer excellent care, but they're also chasing profits.

"They are usually set up in places where there are high-income patients who are well-insured and who want to see someone quickly," says Ho. They're not being built in poor neighborhoods, rural communities or areas with lots of uninsured people.

Patients like Lisa Boncler love how accessible they are. She came to the Texas Emergency Center in the affluent Houston suburb of Atascocita to get stitches on her scalp after she gashed her head on a gate handle.

"This is not the first time I've been in here," says Boncler, who has a choice of six different ERs, two based at hospitals and four free-standing, like Texas Emergency Center. "It's always fast [and] I don't feel like I'm picking up 1,000 germs."

The waiting room, furnished with brown leather armchairs and a coffee station worthy of a spa, is empty because patients are usually seen right away.

But Texas Emergency Center is a real emergency room. It's licensed by the state and staffed around the clock by a doctor and a nurse.

"We're a service to the community. We give them back the most valuable thing: time," says Terri Hardy, who is chief of clinical operations for Texas Emergency Center. "They come here and we see them immediately. We perform the same labs, the same X-rays, the same CAT scans, the same ultrasounds. ... It's convenience."

Free-standing ERs can make a lot of money because they charge ER prices. A visit that might have cost $200 at an urgent-care center can cost four or five times as much at an ER.

Bills are just like at the hospital ER — you pay for the treatment, the doctor's fee and something called a facility fee. That fee is for all the overhead, including expensive equipment like the CAT scanner and the lab.

Patients are sometimes shocked when they get the bill.

Steve Henderson, 41, lives in Spring, a suburb north of Houston. He woke up one morning in March with back spasms so bad he could barely walk. He dragged himself to his car and drove to what he thought was an urgent-care facility.

The sign did say emergency, but it just didn't look like an ER.

"My idea of an emergency room is attached to a hospital with crash carts and cardiac arrest and car wreck victims and all that stuff," he says. He says the place he went looked like "your friendly neighborhood doc-in-a-box" in a shopping center with a doughnut shop across the street.

Henderson got a shot in his back, a prescription and, later, a bill for $1,200 — $900 of that for the facility fee.

"I knew there'd be some kind of fee for this place. But $900 for just walking in the door is outrageous," says Henderson, who is insured but hadn't met his deductible. He was on the hook for the whole fee.

Similar consumer complaints can be found online and on file at the Better Business Bureau.

Insurance companies are also pushing back. By law, they must cover emergency room visits, even if the ER isn't in their network.

"For these free-standing ERs, we've seen our dollars and visits just about double over the past year," says Shara McClure, a vice president for Blue Cross Blue Shield of Texas. "While ER is a choice, it's a high-cost choice and it's one that can cost five to seven times more than a typical office visit."

But standalone-ER executives emphasize they treat real emergencies all the time.

"The problem with urgent care is if you're having something serious, you go there [and] they either call 911 or they send you to the emergency department," says Brian Orsak, co-founder of St. Michael's Emergency Rooms, which has three locations in Houston. "We're equipped basically to handle anything."

But that level of care has a price to the entire health care system, says economist Ho, at a time when the government — and insurers — are trying to control those costs

Some states have tougher regulations for free-standing ERs, like requiring them to be part of a hospital system.

And some insurance companies have sued over the facility fees or persuaded the ERs to sign contracts and accept lower payments.

For now, it's up to the medical consumer to figure out where to go for the right level of care at the right price.

[68W2PA]

Heh...

 

Reminds me of when my son was born. While in the hospital, they asked me if I wanted to give my son his first bath. I said sure! I bathed him in a small basin with a heat lamp over him. Took me maybe 5-6 minutes at the most. A couple months later, I got a bill for $800 for the privilege of bathing my son.

[mdebord]

For now, it's up to the medical consumer to figure out where to go for the right level of care at the right price.

 

And herein lies a large part of the problem. People go to the ER when they should have gone to their PCP and vice versa, often causing added expense to themselves and delaying much-needed care. We've had two uninsured teenage girls recently who were very sick (one septic from ruptured appy and one possible meningitis) whose parents didn't take them to the ER because they didn't want to pay. Instead, they got billed twice - once as new outpatients and then whatever ER/imaging/surgery charged anyway. I try to educate these people when I see them, but it's usually after the fact. I think there needs to be some broader education. Health class in high school might be a good option; unfortunately, what I remember of it was a joke.

[True Anomaly]

That article that TWR posted is fascinating. If you read between the lines, the future of these stand-alone places is already written: current law makes insurance companies pay for ER visits, so the insurance companies' next step is to help state legislators craft statutes that separate these stand-alone ER's from more traditional ER's, thereby allowing them to get out of paying for ridiculously over-priced places. In this time of true penny-pinching and holding hospitals accountable for only paying for inpatient services and visits that are truly necessary (read- meet InterQual criteria, for those who know what that means), once insurance companies get out of having to pay for stand-alone places, people aren't gonna want to go there and pay the entire bill. So I think the market will correct itself and these places will likely go away as quickly as they pop up.

 

Just my thoughts.

[jen0508]

My wife went to a free standing private ER called First Choice in Houston, TX with no hospital affiliation for a bad migraine. I was charged for a level 5 visit which was billed at $3043.00. MY BCBS disallowed $1992.00. They paid $1411. My portion is $1100. That includes pulse ox?? $56, Toradol 15mg $100, Zofran 1mg $52, and acharge called IM/SQ which I am guessing is sticking a needle in the butt for $87 !!! Physician E/M was $404 face to face less than 15 minutes. I will call the main office and question these charges starting with a level 5 charge. She was not in cardiac arrest or having an MI. Also when do you do CT's of head, with every cc of "headache" and history of them. I vented and feel better, Thanks

 

 

15mg toradol IM? 1mg zofran IM? those are tiny doses. i give my migrainers 60 IM, unless they are elderly. i cant believe they charged that much

[medic25]

Those free-standing ER's have to justify their costs somehow, including sponsoring concerts and other local events (which I've heard radio advertisements for First Choice sponsoring such things before), as well as their PR "ambulance" they take to public events.

 

I hope people remember that you can't lump all free-standing ER's together as profit mills and glorified urgent cares. There are many that are fully functional ED's; the only thing they lack is the hospital upstairs to admit the patient. Our free-standing ED is staffed by the same docs and PA's who staff the more traditional ED at our parent hospital, and we see the full spectrum of EM patients (barring a few EMS exceptions for trauma, STEMI, etc.). I can't speak for the costs in this particular case, but a good free-standing ED will still have the costs associated with preparing a traditional ED; it's not cheap to have a full lab, DI department (x-ray, CT, ultrasound), plus a fully staffed ED with the same physicians, PA's, RN's, techs, registration staff, etc. necessary to run a department. I definitely agree that there are some ridiculous charges in the US health care system, but the same can be said for every part of the hospital.

[roman6163]

Same question as Jen0508. Only 1mg of Zofran??? That doesn't make sense. I usually give 4 or 8mg at a time. No way that could have improved your nausea.

[TWR]

update on my wife's bill. Spoke to BC/BS customer service. She was very helpful and called First Choice ER for me. Apparently, First Choice automatically raises the Facility charge to a Level 5 when a CT is performed. They don't however tell you that. I then called and spoke to customer service at First Choice in Dallas. The lady was pleasant and explained everything. I assured her that I was not looking to get out of paying but wanted the level 5 lowered as the facility charge is what the insurance company pays from and I have to pay 20% of the balance. I did name drop that I worked in family medicine for 28 years and told her some of the charges were ridiculous ie: $87 to administer an IM injection. She said she would have some committee review the bill and get back to me in 2-3 days. PS: they don't take off the $100 you pay in the ER.

[TWR]

Final decision from First Choice ER. After review of the billing they would not lower the level 5 fee but will allow a 30% discount if paid in full or $125/ month at the original charge. Although I am not completely satisfied, $795.94 was better than $1137.05. My take away lesson here is firstly to thank everyone who responded to my "rant". Secondly do NOT accept what is placed before you as the gospel according to St. John. Tom

[bobuddy]

TWR - I am not sure how much you want to fight this - but I would be interested to see the documentation for the visit that made it a level 5. I dont accept that doing a CT scan should automatically bring the visit to a level 5 - especially with them giving such tiny doses of zofran and toradol. One thing our clinic managers harp all the time at us - they dont care what level you think it should be - the documentation is the most important part. If there is no documentation to prove the complexity of the visit or the amount of time spent - no level 5 or level 4 or whatever can be charged.

 

Just a thought.

[EMEDPA]

I have to do my own coding now at 2 of my jobs.

my rule of thumb is this:

if admission, document to level 5 and charge level 5

if workup with labs/consults/etc and d/c home, document to level 4 and charge level 4

if only 1 test and minimal decision making(ankle sprain for example), document to level 3 and charge level 3.

nothing in the er should be level 2 except for a dressing change, suture removal , or minor procedure which then also has a procedure code(say a finger lac).

[bobuddy]

I have to do my own coding now at 2 of my jobs.

my rule of thumb is this:

if admission, document to level 5 and charge level 5

if workup with labs/consults/etc and d/c home, document to level 4 and charge level 4

if only 1 test and minimal decision making(ankle sprain for example), document to level 3 and charge level 3.

nothing in the er should be level 2 except for a dressing change, suture removal , or minor procedure which then also has a procedure code(say a finger lac).

 

Agree with above. I now have to do my own coding and we are audited every three months. We have an hour long meeting with the billers/coders and we go over 20 different patient visits for each of the providers. At our meeting last week, they also brought up with the new rules/regulations you have to document the COMPLEXITY of the case - because so many providers were just listing numerous diagnoses (hypertension, hyperlipidemia, hypothyroid, diabetes, etc) regardless that they were stable and you were not changing anything - to up code.

 

So, if you really want to fight the charge that was submitted to the insurance, I would ask to see the documentation that they did to make this a level 5. I am suspect based on your original post - that they could come up with the correct documentation.

[EMEDPA]

I think listing other dx if relevant is appropriate.

for example on an admitted pt I might list the following:

1. Acute Pyelonephritis

2. Type 2 DM, poor control

[TWR]

Final decision from First Choice ER. After review of the billing they would not lower the level 5 fee but will allow a 30% discount if paid in full or $125/ month at the original charge. Although I am not completely satisfied, $795.94 was better than $1137.05. My take away lesson here is firstly to thank everyone who responded to my “rant”. Secondly do NOT accept what is placed before you as the gospel according to St. John. Tom

[CAdamsPAC]

It's all about the Benjamins, accept that and everything else will be clear....

[LIPPER]

My wife went to a free standing private ER called First Choice in Houston, TX with no hospital affiliation for a bad migraine. I was charged for a level 5 visit which was billed at $3043.00. MY BCBS disallowed $1992.00. They paid $1411. My portion is $1100. That includes pulse ox?? $56, Toradol 15mg $100, Zofran 1mg $52, and acharge called IM/SQ which I am guessing is sticking a needle in the butt for $87 !!! Physician E/M was $404 face to face less than 15 minutes. I will call the main office and question these charges starting with a level 5 charge. She was not in cardiac arrest or having an MI. Also when do you do CT's of head, with every cc of "headache" and history of them. I vented and feel better, Thanks

If it were done in an ER with inflated costs then I suppose some would chalk it up to supporting the system of those who are uninsured......That it occurred in a for-profit arena just accentuates the mark-up. Either way the insured still pays for it. My insurance got zapped for $10K for a chest abd/pel CT, $10K in labs for 3 days etc....The whole ER/Hospitalization billing system is flawed, relative to need; What was I gonna say? No don't do the test. Add overbilling on top of that-->oh what a feeling, now I need a colonoscopy.

[medic25]

If it were done in an ER with inflated costs then I suppose some would chalk it up to supporting the system of those who are uninsured......That it occurred in a for-profit arena just accentuates the mark-up.

 

If the free-standing ER is advertising as an emergency department and accepting Medicare, then they are just as bound by EMTALA as a traditional ED; when uninsured patients show up, they are still your responsibility.

[LIPPER]

Final decision from First Choice ER. After review of the billing they would not lower the level 5 fee but will allow a 30% discount if paid in full or $125/ month at the original charge. Although I am not completely satisfied, $795.94 was better than $1137.05. My take away lesson here is firstly to thank everyone who responded to my "rant". Secondly do NOT accept what is placed before you as the gospel according to St. John. Tom

if there is concern of overbilling then have a friend who does coding to take a look at the encounter. If it's not an accurate charge then threaten to turn them in, or just go ahead and do it. Pay your bill first. and make sure you have copies of everything first so it can't be changed after the fact...I bet that might make them give you the visit for free. I doubt their corporate would want the attention of a chart audit. But hey, I'm passive-aggressive like that ;)