Emergency Room Cost Overcharges and Hidden Fees

oth insured and uninsured emergency room patients claim they are charged too much because of emergency room overcharging practices. From surgery costs to administrative fees to equipment charges, ER’s routinely overcharge their patients for services.

Help is available, though. Attorneys have filed successful lawsuits against hospitals on behalf of patients (both insured and uninsured) who have been overcharged for ER treatment.

The $100 aspirin is not an anomaly. A Michigan woman was charged $1,059.06 for the privilege of sitting in an emergency room waiting area. She went home after waiting about an hour, having never seen a medical professional other than the woman who put a plastic band around her wrist. A mother rinsed her daughter’s eyes in an emergency room sink because the eye wash station was dirty. That cost $1,400. These situations are sometimes resolved in ways short of a lawsuit.

However, several years ago Swedish Health Services in Washington State settled a class action lawsuit brought by up to 50,000 uninsured patients who claimed that charges to uninsured patients were greater than those charged to other patients for the same treatment and were not authorized by its Condition of Admission forms.

If you were a patient and were billed an excessive amount for emergency room treatment, you too may have been a victim of emergency room overcharges and hidden fees.
  An emergency room bill for patients is often much greater than the emergency room cost or ER bill that is submitted to an insurance company for the same ER treatment. If you have an emergency room medical bill dispute—regardless of whether you paid all, a portion, or none of the bill—attorneys are currently investigating excessive emergency room fees and ER overcharges that both insured and uninsured patients have been billed for.

Insured patients with big deductibles face rising insurance premiums and out-of-pocket expenses for ER visits. In recent years, emergency room costs have risen exponentially as hospitals attempt to fund their operations by overcharging those who cannot pay, through their insurance plan, or otherwise.

Uninsured patients may be paying more for their ER expenses than insurance companies are charged for the same procedure. Some uninsured patients are forced into collections to pay for bills that are reportedly inflated.

Inappropriate ER Visit Both insured and uninsured patients may discover that they cannot be reimbursed for services rendered if their ailments turn out to be less serious than initially feared. For instance, Anthem, one of the country’s largest health insurance plans, denies coverage for emergency room visits that it deems “inappropriate” because they aren’t, in the insurer’s view, true emergencies. Such denials are made after patients visit the ER, sometimes based on the diagnosis after seeing a doctor, not on the symptoms that sent them to ER in the first place.

And some states have mirrored Anthem’s policy. For instance, Kentucky charges Medicaid enrollees $20 for their first “inappropriate” emergency room visit, $50 for their second, and $75 for their third.
 
As ER billing practices become increasingly complicated, patients rarely know in advance what they’ll have to pay. Since 2009 emergency room charges have jumped by as much as 85 percent, according to VOX.com.

Basically, there are two components to emergency room costs: the physician and the facility. Emergency room “facility fees” can start at $400. A doctor's fee will add anywhere from $200 to $1,000 to that total. X-Ray and lab fees add another $400 to that, and can bring a quick visit for a minor problem to $1,800.

Excessive Facilities Fees Facility fees cover the basic cost of keeping the lights on and the doors open whether the ER is busy or not, but the fees are calculated according to a complicated formula that also factors in the level of care provided. Same lights, same doors, but the facilities fee charged for treating a heart attack may be more than that for stitching up a knee. ER facility fees are coded on a scale of 1 to 5 to reflect the complexity of care delivered to the patient.

Facilities fees can add millions of dollars to a hospital’s coffers in the course of a year depending on how a treatment is coded. A Vox.com study (December 2017) reported that emergency rooms across the country increasingly used higher intensity codes.

Upcoding: Upcoding may be a major price-driver in the “facilities fee” portion of emergency room bills. Ninety percent of bills have coding errors, which can mean you have been overbilled or didn’t deserve bill in the first place. Upcoding is often exposed through Emergency Room Overcharging lawsuits. The Center for Public Integrity claims such practices have cost the Medicare program more than $11 billion in fraudulent fees. Doctors in emergency rooms determine which code to enter into insurance forms for the care they provide, and the more complex the care, the bigger the bill. As a result, what doctors get paid increasingly reflects more on their “coding” skills than clinical ability.

Upcoding is relatively easy to contest. Investigate that bill and get some legal help.

Room Overcharge: Room Overcharge: A physician admits a patient from ER to a regular room in hospital overnight, for example, but the patient is taken to a private room instead of a semi-private room. A patient should not be billed at a private room rate when a semi-private room is not available or not requested by the patient or physician.

Out-of-Network When a doctor in the ER accepts your health insurance plan, they’re in network. When you go to an emergency room that doesn’t take your plan, they’re out of network – and you can wind up with exorbitant overcharges.

A 2016 study by two researchers from the Yale School of Public Health and the Yale School of Management that looked at more than 2 million emergency department visits found that more than 1 in 5 patients who went to ERs within their health-insurance networks ended up being treated by an "out-of-network" doctor. Patients were exposed to additional charges not covered by their insurance plan, and the average out-of-network bill those patients faced, unless their insurance plan ultimately agreed to cover it, was more than $622, reported CNBC.

Depending on your insurance policy, you may be required to pay the difference between what the insurer reimburses and what the provider charges in out-of-network situations. And charges are often arbitrary: what might cost one patient $200 could cost another $2,000 or more.

ER bills for out-of-network care are 4.4 times higher than what Medicare allows for the same services. According to a nationwide study by the Johns Hopkins School of Medicine, and published in the Journal of the American Medical Association Internal Medicine, this costs patients more than $3 billion a year. ER physician charges totaled about $4 billion versus $898 million in Medicare allowable amounts. Overall, the study found that ERs are charging from 1.0–12.6 times ($100–$12,600) more than Medicare pays for services.

According to the New England Journal of Medicine, ER doctors can contract independently with insurance companies and the hospitals where they work may not contract with the same insurers. This scenario can result in a large physician bill that the insurer doesn't cover or only partially covers, leaving the patient to pay the balance.

Balanced Billing Say an ER doctor charges $250 for a service. Your insurance plan’s approved amount is $190. So you “save” $60. On your claims and explanation of benefits statements, these savings are listed as a discount. Doctors or hospitals not in your health insurer’s network don’t accept that approved amount. You’ll be responsible for paying the difference between the provider’s full charge and your plan’s approved amount.

Hospital ERs claim they need balanced billing to offset the cost of treating uninsured patients. However, some states have passed laws that bar out-of-network doctors from balance billing patients who receive care at an in-network facility.

Chargemaster Providers often give insurers big breaks on quoted rates. Uninsured patients and out-of-network patients initially get billed at so-called chargemaster rates -- a computerized database containing the full “retail” price for every service rendered in a hospital. But the price can be inflated up to 10 times the actual cost to the hospital, as reported by Steven Brill in TIME(2013), in “Bitter Pill.”

Overcharging Insured Patients A recent Kaiser Family Foundation survey found that among insured patients struggling to pay medical bills, charges from out-of-network providers were a contributing factor one-third of the time. And 7 in 10 individuals with unaffordable out-of-network medical bills found that the provider wasn't in their plan's network when they received care.

Overcharging Uninsured Patients Uninsured patients and those who don't qualify for Medicare, Medicaid or other state-provided coverage can see emergency costs anywhere from 2-4 times the rate of insured patients for the same ER treatment, which can translate to thousands of dollars. This practice is not only grossly unfair, it often impacts those least able to pay excessive ER charges. As a result of over-billing, uninsured patients end up leaving the ER with bills that are much higher than people with medical insurance who receive the same ER treatment.

Hospitals nationwide charge grossly inflated "retail prices" to their uninsured patients, whereas insured patients typically are charged rates 50-75 percent less. Uninsured patients are billed for ER care at double or triple the rates charged to the insurer of the patients sitting right next to them in the ER, for the same treatment.

For instance, an uninsured patient may be billed $15,000 for a single overnight stay, which includes diagnostics—scans, x-rays, etc.—any treatments, and drugs. But an insurance carrier will typically be charged $3,000-$5,000 for exactly the same stay and treatment. The same is true with minor injuries, such as a dog bite. In such a case, an uninsured patient might be charged $800 for a few shots and stitches, whereas the insured patient's carrier is charged $250.

While attorneys advise all ER patients to check their hospital admission agreement and inquire as to potential charges before signing on the dotted line, it is especially important for uninsured patients to know what their ER charges may be upfront. Unfortunately, in a true emergency, careful review of the admission agreement may not be feasible. As such, an uninsured ER patient may simply wind up at the mercy of high ER costs and only realize that his bill is excessive when it's too late.

Be Pro-Active Whenever possible, before you need emergency treatment, research which facility your insurance plan covers. Ask for financial counseling while you are at the emergency room. In addition, hospitals are increasingly posting their financial-assistance policies in the ER. Many hospitals have this service available, and it can be the key to learning your rights. Medicaid-eligible patients are able to apply for coverage up to 10 days retroactively. An advocate for consumers who are stuck with outrageous ER cost always advises clients to demand an itemized bill, rather than a summarized document. billadvocates.com reportedly saw $11 charged for a single tissue, and $50 charged for a pair of latex gloves.
  If you believe you have been overcharged, you should speak with an attorney who specializes in these cases. Some pending lawsuits are awaiting class certification.

Uninsured patients who received treatment at a hospital ER and did not receive a special discount on their billing, may be eligible to file a lawsuit against the hospital, regardless of whether they paid all, part or none of their hospital bill.
 

Emergency Room Overcharging Legal Help

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Last updated on Apr-13-22