ER Charges: Underserved and Over-Charged thanks to Upcoding

Los Angeles, CAWhen a nine-year old accidentally had gasoline splashed in her eyes, her mother immediately drove her to the closest hospital emergency room. They were directed to the eyewash station but it was so dirty they couldn’t use it, so Brianna’s mom rinsed her daughter’s eyes at a regular sink. Turns out, they would have been better off using the gas station’s eyewash, which was free. The ER sink cost $1,400: the hospital charged $600 and the ER doctor fee was $800 (for walking into the room, saying Brianna needed an eyewash station and walking out). Upcoding has become common practice, resulting in emergency room overcharges and increased health costs for everyone.

Levels of Care

Brianna’s care was billed as “Level 3” which means a health problem--such as fractures or signs of infection--is significant but not life threatening. Most hospitals are based on a five level triage system, with five being the most severe. Dr Kathleen Handal explains that there are commonly three levels of ERs:

• Level 1: Highest level ER, indicating the ability to give definitive, rapid care for all critical emergency situations; usually associated with a teaching hospital. Resources within the hospital (diagnostic and intensive care units) can continue to care for these patients. Level 1 trauma centers have an in-house trauma surgeon and on-call specialists available, as well as an open operating room.

• Level 2: The ER can care for most emergencies. All specialties are on-call and available within 60 minutes; usually no residents on staff. Emergency medicine (EM) doctor cares for patient until back-up specialist responds to the request for assistance. In-hospital resources are limited.

• Level 3: Treatment by EM doctors. Not all specialties available to come to ER to help. Patient will be stabilized and transported to an appropriate care facility. Trauma patients will be transferred to another hospital that is equipped to handle the trauma.

(If a hospital has a Level 3 trauma designation it can charge thousands of dollars more for trauma expertise. One hospital that is owned by the largest for-profit hospital chain in the United States, the Hospital Corporation of America, charges nearly $10,000 on top of regular medical treatment for trauma care. According to the Las Vegas Review Journal, money was the impetus for Centennial Hills –the hospital Brianna visited, to seek a level 3 trauma center.)

What is UpCoding?

“Upcoding” occurs when a healthcare provider, such as an ER doctor, submits codes on medical bills to patients for more serious (and more expensive) diagnoses or procedures than the provider actually diagnosed or performed. Just about any service or medical procedure can be up-coded, from billing a simple x-ray as more complex to having a nurse treat you but billing treatment by a doctor to using a sink as an eyewash station. Upcoding is illegal--it is fraud--but hospital ERs and healthcare providers are continually caught doing it. And it winds up costing everyone, including insured and uninsured patients. Insured patients wind up paying more because health insurance companies overpay, and their monetary loss is balanced by increasing the cost of healthcare premiums.

Upcoding Fraud– Complaints to LawyersandSettlements

Jose from Anaheim: “I went to ER one night and paid $1,500 for a CAT Scan so they could tell me I had a hernia, which I already knew and told them as much. They charged me another $900 for drugs and I agreed to make monthly payments, but I wasn’t able to pay it right away. About six months later I was mailed a bill for $14,000. WTF, how can they do that? Now my credit is ruined.”

Charlie from Virginia: “I was bitten by a bat, phoned my doctor’s office and was told to go to ER. I never saw a doctor. I was given Human Rabies Immune Globulin, a rabies shot, a Benadryl shot and a bill for $44,151.44. I was charged $33,168.04 for the immune globulin by itself. Then I did some research and the CDC estimates that it costs between $3,000 and $7,000.”

Jason from Alabama: “I went to the ER and was diagnosed with bronchitis after having blood tests and an x-ray. I was there for only two hours and was billed $3,710.30. As if that isn’t bad enough, it was adjusted (I have no idea why, it didn’t say) from $6,746.00. It was just bronchitis! And my insurance didn’t go into effect until a few months later. How on earth can they do this?”

Betty from Nashville: “I went to the closest ER for a stomach problem. (Our insurer never told us where or where not to go.) They ran some heart tests and other tests, even though I was complaining about a stomach ache. I am also a runner and very healthy. What a surprise to get a bill for $4,000 after they already got $2,000 from our insurance company! This is outrageous. We have been emotionally and financially drained: my husband is a retiree and we both work part time. What can we do?”

What You Can Do – Be Proactive

Whenever possible, don’t go to ER. Call your doctor first or call your insurer’s nurse triage hot line. Go over your bill, read the small print. If you think the charge looks wrong, call the hospital’s billing department. Mistakes can and do happen. You can negotiate a bill, even when you have insurance. The majority of hospitals will discount private paying patients’ bills. But act sooner than later as unpaid ER bills are forwarded to collection agencies. If that happens, you should consider legal advice.