Dr. 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 and in favor of the hospital’s bottom line.
Emergency visits are usually classified for billing on a scale from 1 to 5. Level 1 is minor and routine; level 5 requires complex care for 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 Health Care Cost Institute, which has studied ED coding.
Despite the lack of severity of Martand’s wound and the absence of medical care, his visit was classified as level 3, a moderate-severity problem.
Resolution: Incensed that he’d been charged so much, Dr. Bhatt made numerous attempts to get the hospital to reduce the charges. He also appealed to UnitedHealthcare to review the charges.
His efforts failed. In August, Dr. Bhatt received a letter from an SSM Health “patient advocate” informing him that the hospital would not adjust the bill and instructing him to contact patient billing to arrange for payment.
While Dr. Bhatt was trying to reach the patient advocate by phone, his bill was sent to Medicredit, a collection agency, which began sending him notices and calling him.
After KHN contacted SSM Health, Dr. Bhatt received a call from someone who worked on “patient financial experience” issues at the hospital.
The hospital agreed to forgive the $820 facility fee. Dr. Bhatt agreed to pay the remaining $38.92, the professional fee for the ED nurse’s work. Dr. Bhatt also received a notice from Medicredit that it would take no further action against him.
The takeaway: The Bhatts did what most parents would do when a pediatrician advises them to take their child to the hospital.
But EDs are among the most expensive places to get care in the U.S. health system.
If you have a relatively low-level issue, think twice before even registering at the front desk, the act that initiates the billing process. If your doctor doesn’t have same-day appointments or after-hours service, think about urgent care, which is often much cheaper if the center isn’t attached to a hospital.
And remember that if you go to a hospital ED with a relatively minor issue, chances are that you’ll have to wait, as the Bhatts did. Patients with more serious problems will be seen first.
Once you’re taken past the front desk, you will almost certainly be hit with a substantial facility fee even if you don’t receive care.
Appealing that fee to the hospital can occasionally be successful, but there are no guarantees. And, as Dr. Bhatt learned, don’t expect the health insurer to offer much help. Most insurers won’t challenge how a medical visit is coded except on extremely expensive medical claims that will cost them money.
In this case, Dr. Bhatt was on the hook for the whole fee because he had a high-deductible plan, so the insurer had little incentive to take up his cause.
For now, patients’ best hope, many advocates believe, is to publicize the high prices that hospitals charge for their services, inside and outside the ED.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.