Another ER bill dispute

[ChristopherHoff]

What is the name of your state?I took my son to an ER in ohio on a saturday for an ear ache that had him in constant tears. i was there for 2 hours the first of which was spent waiting in a room to see a doctor. They fushed his ear with saline said he may have an ear infection but they where not sure and to watch it closely for a few days to a week. We left shorly there after.

I received two bills for my visit, one bill from the doctor for 146.00 which seemed very resonable. In fact since i am self employed they offer me a discount of 44.00 which brought my bill down to 102.00 even better .
The problem occured when i recieved my bill from the ER itself in the ammount of 830.75. It had two items on it, 66.25 in generic drugs and 764.50 for "Emergency Room". The generic drug chargs seems resonable however the ER charge seems way out of line. Keep in mind that this is not for any medication and the doctor billed separate, this charge is just for the ER. I inquired about the high charge and they stated that it was due to the them billing me on a ER severity level of 4. I dont know what that means as i dont know the severity scale however my belief is that they either elevated the severity level to high or they have the wrong information about the circumstances of my visit.

Please advise.

 

[somarco]

Sounds like you got off cheap.

ER's are staffed to handle everything from life threatening to a simple pain. Some ER's are like on TV, a constant bussle of traffic. Others sit idle for hours waiting on someone to come in.

Regardless, it costs money to have staff and equipment ready for use.

Many metro areas have doc in a box facilities that can treat someone like your son for a lot less.

Next time you might want to consider other options, such as calling your doc for a consult and asking for advice or even a prescription that can be picked up without an onsite exam.

Level 4 is a low level emergency.

I am not kidding with my clients when I tell them it costs $800+ just to get a cup of coffee at the ER. Good thing you didn't travel by ambulance. That could have added another $300+.

Now here comes the million dollar question . . . do you have health insurance?

 

[ChristopherHoff]

I guess i am just not used to paying such a large amount, I am self employed and have payed out of pocket before for ER services. My daughter had an ear infection some 3 years ago different ER, different state and my total bill came to just under 400 including all associated fee's. If you think this is normal i guess i can only take that advice into consideration. thanks for the advice on the doc in a box too

 

[ablessin]

Medical costs (unfortunately) are on the rise........ where I work the fee for the ER visits is quite high as well. That is why I think those Self-payers get the raw end of the deal. But, you should be able to work a payment plan out with the facility, contact the Patient Accounts office and ask to speak to the billing manager.

Always try to opt for urgent care clinics if you're PCP is not open. Next time, you could try Tylenol or Advil to help alleviate pain and call PCP first thing in the AM - or if your PCP has an after hours call doc, use that service as well.

All those options are far less costly than trips to the ER. Keep in mind that many people use the ER for non emergencies, and that could be why you had a 2 hour wait. Although sometimes 2 hours is nothing! I know it seems like an eternity when your kid is sick though! I was at the ER once from a car accident, and the lady in the bed next to mine was there for a cough. I was so mad. I think sometimes ER is taken advantage of. I am NOT saying that you did, if it was me, on a Sunday I may have done the same thing, especially if my kid had a feverm because it could have been more than just an ear infection! But yeah, check out urgent care clinic next time

 

[somarco]

I would beg to differ that self payer get a "raw" deal . . . thats not always the case. Medical providers prefer cash and the quicker the better.

If someone is covered by a third party payor, and all claims are coded properly and submitted on a timely basis, they usually get their money in a couple of weeks. (An exception is for those covered under taxpayer funded plans which can take months to pay).

The problem with self pay is they rarely pay up. If they do pay, they want to string it out over time.

Medical providers are not banks, nor are they benevolent institutions that can continue to provide services with no revenue.

Many times (but not always) a cash patient can get discounts approximating network discounts.

Of course, they have to ask . . .

Self pay is fine for small bills. But when claims go to $10k and up the provider gets stuck, those covered by third party pay get stuck (cost shifting) and dont forget about the patient who could not pay. They get turned over to collections, many times they are sued and have a lien place on their home or wages garnished and their credit is ruined.

 

[ablessin]

What I meant by the "raw" deal was that if I had no insurance and got a $500 visit bill, I'd have to pay the $500 - where if I had an HMO, the physician would get the contracted rate for being a "par" provider, and I would pay my customary copay and the rest would be a contractual adjustment.

yes. docs get paid faster when billing an insurance than the self pay population, because most of us don't have a "in case I get sick" stash tucked away..... so they would have to string the payments over a few months. If the self pay patient is not aware, they would not ask for a discount. Or they might be afraid to ask...... most providers are not going to offer up any deal.

 

[purple2]

Level 4 is a low level emergency.

I'm not following you on that point. Usually EDs assign E&M levels 1-5, 1 being the lowest. The 5 levels are based upon the 5 levels of CPTs 99281-99285.

The OP may very well have a point that level 4 was questionable for an earache. He should ask the hospital to investigate the coding to determine if it was accurate. Granted, hospitals are allowed to come up with their own internal points system to assign levels, but it's a bit hard to believe the service described would reach level 4 no matter what system they devised. Maybe there were additional services than those described.

 

[somarco]

I will defer to you on the CPT issue as I was not looking at it from that perspective. I dont handle claims on a regular basis and it could be that you are correct from a broader perspective.

A hospital I was affiliated with some time ago used a 1 - 5 staging for triage purposes. Level 1 was "life threatening" and 5 was "why did you bother coming in here".

 

[ablessin]

In NY, there are coding - SPECIFIC coding guidelines that have to be met in order to bill any level of service.

In order to bill a higher level, the doc must spend a documeted amount of time with the patient, and have moderate - high level of medical decision making.

The American Medical Association has set up billing guidlelines for this. I don't know if you google it if it will show the guidelines or not. You might have to be in compliance to actually see that - I don't know if that kind of info is open to John Q. Public or not.

Typically, anything over a level 3 the insurance carriers like to request to see the notes to ensure that the pysician is documenting how much time, etc he/she is spending with the patient to justify to the higher coding level of the service. At my office, we deal with this all of the time.

 

[purple2]

Ablessin,
What is in question here is the facility E/M level, not the physician's E/M. There are not specific coding guidelines for facility E/Ms.

Face to face time requirements don't apply to facility coding; they apply to physician professional billing. Facilities use the same CPTs but come up with their own internal guidelines to determine the level, per DHHS rules.

 

[ablessin]

Then the OP is going to have to ask for a meeting with the Facility compliance manager and ask them how they came up with the level of service billed.

Simple as that.