In the shock following an medical emergency, our first instinct is to get ourselves or our loved ones to the best treatment possible–immediately. It’s this need that causes countless families to rush to emergency rooms each year, all seeking the best possible care for their loved ones.
Yet for many Americans, the real shock arrives days later in the form of a bill from the emergency room, which can incur costs of thousands of dollars. According to a 2016 Kaiser Family Foundation/New York Times survey of uninsured and insured people who struggled to pay medical bills, emergency room bills made up the greatest amount of medical debt.
The sometimes baffling nature of emergency room billing fees was illustrated in the case of Malcolm Bird. Bird’s wife was clipping the fingernails of his 1-year-old daughter, Colette, when she accidentally cut Colette’s pinky finger. The cut started bleeding, and Bird and his wife wanted a doctor’s opinion. In an interview with Vox journalist Sarah Kliff, Malcolm recounted how the family went to the emergency room, waited for 20 minutes, and were then seen by a nurse and a doctor. The doctor reassured the family that Colette was okay and that the bleeding was due to the many capillaries at the end of the finger. Then, Malcolm told Vox, “he literally runs the finger under the tap, dries it, puts a Band-Aid on it, and says that’s it.”
A Band-Aid later, Colette was perfectly fine–so Bird was shocked when a week later, he received a $629 hospital bill from the hospital. His insurance had reduced the price to $440.30, which Bird had to pay as per his deductible.
“My first thought was, how could this possibly cost $629?” Bird told Vox. Yet when he contacted the hospital to get the price reduced, the hospital administration remained firm.
Part of this is due to the inherent cost of using emergency services. In an interview with Kliff, chief executive of Western Connecticut Health Network John Murphy explained the concept of the “facility fee”, which is essentially the baseline price required to use an emergency room. Since it requires significant energy and resources to keep a fully staffed emergency room running around the clock, everyone who sets foot in an emergency room has to pay a baseline price to help maintain the services. In Bird’s case, the Band-Aid itself only cost $7–the remainder of the price was due to the hidden facility fee.
Renee Hsia is a professor at University of California, San Francisco who studies emergency room bills. “Facility fees are very arbitrary,” Hsia told Kliff. “There doesn’t seem to be any rhyme or reason to it.”
One proposed solution to what can seem like injust facility fees has been a tiered model, in which patients with less severe illnesses–like a cut finger–are billed less than those with more life-threatening, expensive conditions. However, this model can lead to its own issues: a 2012 investigation by the Center for Public Integrity found that from 2001 to 2008, many hospitals were increasing their Medicare billing for emergency room care. Medicare fees are based on a system of assigned codes, where more resource-intensive treatments are charged at a higher price tier. However, the Center found that “use of the top two most expensive codes for emergency room care nationwide doubled…from 25 percent to 45 percent of all claims.” Many of these supposedly “top-tier” claims were actually for relatively minor injuries.
This practice of assigning higher-priced Medicare codes to minor complaints is known as “upcoding”. Leatrice Ford is a Louisville, Ky. – based consultant who advises emergency rooms on their billing. “Hospitals are reluctant to give up on their overpayments,” Ford said in an interview with the Center for Public Concern, because Medicare is not checking. She said she had never heard of any hospital being audited for their distribution of E & M codes.
Until a dramatic change in our healthcare system is made, the issues of facility fees and upcoding will continue to affect thousands of Americans looking for emergency care. In this case of Collette Bird, the family was lucky: following Kliff’s inquiry, the hospital reversed his bill. However, the vast majority of people seeking healthcare may not be as fortunate. For them, a trip to the emergency room may do more harm than good.