Dhaval Bhatt had been warned about hospital emergency rooms.
“People always told me to avoid the ER in America if you aren't really dying,” said Bhatt, an immigrant from India who had a Ph.D. in pharmacology within the U.S. and it is now a study scientist at Washington University in St. Louis.
But when Bhatt's 2-year-old son burned his hand on the kitchen stove on a Wednesday morning in April, the household's pediatrician directed them the next day to the local children's hospital.
Bhatt was traveling. So, his wife, Mansi Bhatt, took their son towards the hospital and was sent to the emergency room. A nurse took the toddler's vitals and checked out the wound. She said a surgeon would inspect it more closely.
When the surgeon didn't appear after more than an hour or so, Bhatt's wife took her son home. A healthcare facility told her to create a follow-up appointment having a doctor, which ended up being unnecessary because the burn healed quickly.
Then the balance came.
The Patient: Martand Bhatt, a toddler covered by a UnitedHealthcare insurance plan supplied by the employer of his father, Dhaval Bhatt.
Medical Service: An urgent situation room visit for any burn sustained when Martand touched an electric stove.
Total Bill: $1,012. UnitedHealthcare's negotiated rate was $858.92, which the Bhatts were responsible for because their plan were built with a $3,000 deductible.
Service Provider: SSM Health Cardinal Glennon Children's Hospital, certainly one of 23 hospitals owned by SSM Health, a Catholic, nonprofit health system with more than $8 billion in annual revenue.
What Gives: Many patients don't understand that they can accrue huge bills nearly as soon as they walk through the doors of an ER.
Unlike a cafe or restaurant or perhaps a mechanic who won't charge if a person gets tired of awaiting a table or perhaps an inspection of the rattling engine, hospital emergency rooms almost invariably charge patients every time they check in.
And once they register, patients is going to be billed – normally a lot – whether treatment was rendered or not.
Martand Bhatt received very little medical service. A nurse practitioner looked over the toddler, listened to his heart and stomach, and looked in the nose, mouth and ears, according to provider notes made by a healthcare facility and shared with KHN by Bhatt.
The nurse didn't change the dressing around the wound or order any testing.
“My objection for this is that there wasn't any care provided,” Bhatt wrote to Bill of the Month.
“My wife did not drive for Forty-five minutes to get at an ER and wait for an additional 1 1/2 hours for someone to tell me our child's vitals – weight, height, temperature and blood pressure level – were OK,” Bhatt continued. “We already knew that. – It is absolutely ridiculous and unethical.”
When the Bhatts left the er, Martand was “alert, active and well-appearing,” according to the notes.
The nurse's assessment of Martand cost $192, that was discounted by UnitedHealthcare to some negotiated rate of $38.92. The bulk of the Bhatts' bill – $820 – was something called a facility fee.
Hospital officials defend these fees as essential to keep your er open 24 hours a day as a community asset.
SSM Health spokesperson Stephanie Zoller Mueller declined to discuss the details of Martand's medical problem even though the Bhatts gave their permission for that hospital to do this.
In an email, Zoller Mueller said the costs were “appropriate” based on the “acuity of condition, discharge instructions, vital sign monitoring, traumatic wound care (and) numerous assessments.”
She added: “A patient doesn't have to receive additional treatment – procedure, labs, x-rays, etc. – to validate an ED [emergency department] level charge.”
But some patient advocates say these facility fees are applied much too widely and really should be limited to patients who actually receive medical care.
“It's simply not right for someone to be charged if they are not given treatment,” said Adam Fox, deputy director from the Colorado Consumer Health Initiative. “Patients aren't availing themselves of a facility when they do not get care.”
At the very least, hospitals could communicate more clearly to patients about the fees they might be charged for coming to an urgent situation room, said Maureen Hensley-Quinn, senior program director in the National Academy for State Health Policy.
“People should know that when they walk in to receive care, there is this fee that they will be assessed,” Hensley-Quinn said.
Hospitals could also post at the entrance towards the ER standard fees for different levels of emergency care.
Bhatt's fee still could have been lower if the hospital had classified his son's injury as minor. But, again, the hospital billing process worked against the family – as well as in favor of the hospital's bottom line.
Emergency visits are often classified for billing on the scale from 1 to 5. Level 1 is minor and routine; Level 5 requires complex take care of life-threatening conditions. And hospitals are increasingly using the highest-severity codes to classify emergency visits, research shows.
“There are financial incentives for billing at a higher severity,” said Aditi Sen, who directs policy and research at the nonprofit Healthcare Cost Institute, which has studied er coding.
Despite the lack of harshness of Martand's wound and also the lack of medical care, his visit was considered Level 3, an average severity problem.
Resolution: Incensed that he'd been charged so much, Bhatt made numerous attempts to obtain the hospital to reduce the costs. He also attracted UnitedHealthcare to examine the charges.
His efforts failed. In August, Bhatt received instructions from an SSM Health “patient advocate” informing him that the hospital wouldn't adjust the bill and instructing him to contact patient billing to arrange for payment.
While Bhatt was trying to reach the patient advocate by phone, his bill was delivered to Medicredit, a collection agency, which began sending him notices and calling him.
After KHN contacted SSM Health, Bhatt received a phone call from somebody that worked on “patient financial experience” issues at the hospital.
The hospital decided to forgive the $820 facility fee. Bhatt decided to spend the money for remaining $38.92, the professional fee for the ER nurse's work. Bhatt also received a notice from Medicredit it would take no further action against him.
The Takeaway: The Bhatts did what most parents would do whenever a pediatrician advises these to take their child towards the hospital.
But emergency rooms are some of the priciest places to obtain care in the U.S. health system.
If you have a relatively low-level issue, think twice before even registering in front desk, the act that initiates the billing process. In case your doctor does not have same-day appointments or after-hours service, consider urgent care, which is often less expensive if the center isn't mounted on a hospital.
And keep in mind that should you go to a hospital emergency room having a relatively minor issue, most likely you'll have to wait, as the Bhatts did. Patients with increased serious problems will be seen first.
Once you're taken past the front desk, you'll almost certainly be struck with a substantial facility fee even if you don't receive care.
Appealing that fee towards the hospital will often be successful, but there are no guarantees. And, as Bhatt learned, pricier the insurer to offer much help. Most insurers won't challenge how a medical visit is coded except on expensive medical claims which will cost them money.
In this case, Bhatt was responsible for the entire fee while he were built with a high-deductible plan, therefore the insurer had little incentive to consider his cause.
For now, patients' best hope, many advocates believe, is to publicize the high prices that hospitals charge for his or her services, outside and inside the er.
Bill of the Month is really a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Have you got an interesting medical bill you need to share with us? Tell us about it!
Noam N. Levey:
nlevey@kff.org,
@NoamLevey
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