Emergency Room Overcharges –Surprise!

Santa Clara, CAAlmost one-third of Americans with health insurance who wind up in an emergency room find out after the fact that their health plan doesn’t cover as much as they thought. Given that there are about 140 million ER visits each year, and “surprise” emergency room charges are so frequent that 59 percent of Americans have been contacted by a debt collector and 16 percent of Americans’ credit reports include medical debt due to overdue medical bills, it’s not such as surprise that this debt totals about $81 billion.

Exorbitant emergency room costs can be intentional or careless mistakes. Either way, they are far too common. In fact, they are more the norm. But why is medical care so outrageously expensive, whether or not you are insured? “Hospitals and doctors keep sending patients surprise bills because they make money by doing so,” said Charles Silver, co-author of “Overcharged: Why Americans Pay Too Much for Health Care.”  He says hospitals and doctors face little risk of losing customers-- It's not a place where you can really shop for health care, nor can you make a lot of decisions about where you want to go.

There are several reasons why patients get slammed with surprising emergency room fees.

Emergency Room Cost Discrepancies

A family was charged $18,000 for a nap and a bottle of baby formula after taking their 8-month-old son to ER when he hit his head. And a woman was charged $6,000 for an ice pack and a bandage when she ended up in the ER after she fainted and cut her ear during the fall. A man was charged $40,000 for a bat bite (not related to coronavirus!) but many people are getting charged facility fees for coronavirus testing.

Health policy journalist Sara Kliff investigated ER costs when someone sent her a bill a few years ago. Kliff wanted to know why a band-aid would cost $629. She discovered it’s not about the cost of the band-aid, or the $6,000 ice pack. Rather, it’s the facility fee: the cost of keeping the ER door open, the lights on and staff at the ready. But not all facility fees are equal, from a few hundred bucks to over 10K. And if you don’t inquire beforehand (who prepares for an ER visit?) when you get a bill in the mail, it could make your blood pressure soar.

Say you are given one ibuprofen pill in ER. You might get charged $60 but the hospital pharmacy charges $6 for a bottle. And that is over and above the facility fee. Kliff says pregnancy tests are money-makers: she has seen charges over $400. And the kit in the drugstore runs from $5 to $20 for multiple tests. Charges are justified by having to keep so much in stock, from bat rabies treatments to pregnancy test kits.

Health Care System stacked against Patient

Here is another incident: A university student gets hit by a city bus and ends up in a city hospital where he gets a CT Scan to check for brain injuries. He needs stitches and gets discharged with a 27K bill. He has insurance through his father. In this case the hospital’s patients are typically low income on Medicaid-- it is known as a ‘safety net’ treatment center so they don’t contract with private insurance companies. The student had no choice – he was unconscious and woke up in Zuckerberg San Francisco General Hospital.

Kliff actually called out one hospital on a patient’s charges. A woman fell and wound up in the same hospital. “She ends up with another bill over $20,000 that the hospital was pursuing from her until I started asking questions from it, and the hospital ultimately dropped the bill.” It takes a reporter to publicly shame and get charges dropped!

 Trauma Fees

Trauma centers charge for putting together a trauma team to meet you when you're coming in because first responders in the field, maybe the EMTs, have determined that you meet certain trauma criteria. San Francisco General charges up to 18K – without any services rendered-for trauma fees.

Co-Pay v. High Deductible Insurance

People with co-pays are usually charged less. “They… have to bear the costs of that emergency room visit up until the point they hit their deductible and the insurance kicks in, whereas the person who has a co-payment, they're just going to have to pay that flat fee and…probably not worry about paying more, but there's often surprise bills lurking in the corner that could affect both of those patients as well,” Kliff says during an NPR interview.

Surprise Billing

One common practice is out-of-network doctors working at in-network emergency rooms. For instance, if you have an emergency and have time to look up a hospital and find their ER is in network, you will choose to go there. But that emergency room has doctors on staff who aren't covered by your insurance plan. Kliff says research indicates that 1 in 5 emergency room visits involves a surprise bill like this: If you see an out-of-network doctor, you could be charged more if that doctor thinks their services are worth more than the price dictated by the insurance company.

Unless this has already happened to you, here's another surprise. Some insurance plans only cover true emergencies, and a true emergency is sometimes determined after the diagnosis is made. For example, a woman goes to ER with severe abdominal pain, thinking it’s appendicitis. But it’s an ovarian cyst that she received treatment for later, at another facility. Her insurance company, Anthem, sent her a letter saying, we're not going to cover that visit because it was not a true emergency. She appealed it. Her appeal was denied. Kliff made inquiries to Anthem and the charges went away.

Not everyone has access to Sarah Kliff, but everyone has access to legal help. An experienced emergency room overcharges attorney can review your case and determine whether you can get you a substantial discount, or have the charges dismissed.