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December 20, 2018

For 15 months, this reporter targeted 'outlandish' ED bills. Hospitals may not like what she found.

Daily Briefing

    Read Advisory Board's take: With sky-high ED bills, what do hospitals need to tackle moving forward?

    For more than a year, Vox reporter Sarah Kliff has read 1,182 ED bills as part of a project to examine ED prices, and she offers five key takeaways on what she's learned about ED billing in the United States.


    In October 2017, Vox put out a call for readers to submit their ED bills with the goal of building a database to shed light on ED prices throughout the country.

    Since the project launched, Kliff has read 1,182 bills. She's seen ED bills from all 50 states and the District of Columbia, and from patients of all ages.

    Here's what she's learned.

    1. Items available in the drugstore get marked up—by a lot

    While patients rightly assume hospitals rely on advanced devices and medications, depending on the injury, hospitals may use the same products patients could buy without a prescription at a drugstore. And in these cases, hospitals sometimes mark up the prices—significantly, Kliff found.

    In one instance, a woman went to the ED because she was worried her cornea had been scratched by fake eyelashes.

    The hospital gave the woman some eyedrops and sent her home. She later received a bill charging her $238 for those eyedrops. According to GoodRX, a vial of those eyedrops—a generic drug called ofloxaxin—costs between $15 and $50 at most retail pharmacies.

    The database includes several cases when hospitals marked up pregnancy tests, with one hospital charging $465 for one test. For that amount, "you could buy 84 First Response tests on Amazon," Kliff writes.

    Another bill shows a mark-up on antibiotic ointment bacitracin, known by its brand name as Neosporin. One hospital in Tennessee charged a patient $1 for bacitracin, while one in Seattle charged a patient $76 for the same ointment.

    2. At an in-network hospital, you still might get treated by an out-of-network doctor

    When patients wind up in the ED, even if they're at an in-network facility, patients could be treated by a doctor who's out of network—and then get billed the higher price. That happened to Scott Kohan, who woke up in an ED in Texas with a broken jaw following a violent attack the night before. The hospital was in-network, but the doctor that treated him wasn't, and Kohan ended up with a $7,924 bill from the surgeon.

    When doctors and the hospital disagree on their offered rates, "patients often end up stuck in the middle," Kliff writes. This isn't a pervasive problem, but rather research shows these scenarios happen in a small number of hospitals.  

    3.  Declining treatment won't always spare you from a big bill

    Patients get billed even if they don't see a doctor or receive treatment, Kliff writes. One patient, Jessica Pell, went to an ED in New Jersey after she fell and cut her ear. She didn't receive a diagnosis, only an ice pack, and a bill for $5,751, Kliff writes.

    Pell isn't alone, Kliff writes, noting that over the past year she encountered several patients with similar charges. The charge is for what's called a "facility fee," Kliff writes. "This is the fee that [EDs] charge for walking in the door and seeking care, something akin to a cover charge at a bar."

    Hospitals say that facility fees "help them keep the lights on and doors open for whatever emergency might come in, anything from a stubbed toe to a stroke patient," Kliff writes. However, experts who study emergency billing argue that these fees appear to be arbitrary and vary widely from hospital to hospital.

    An analysis of facility fees by Vox found that the prices of these fees increased by 89% from 2009 to 2015, twice as fast as overall health care prices. Niall Brennan, the executive director of the Health Care Cost Institute, said, "It is having a dramatic effect on what people spend in a hospital setting. And as we know, that has a trickle-down effect on premiums and benefits."

    4. It's difficult for patients to advocate for themselves in an ED

    Kliff writes that, when it comes to fighting high ED bills, "[p]atients are usually at the mercy of the hospital."

    There have been some cases of patients lowering their bills, Kliff writes. Some have negotiated them down by applying for financial aid, requesting a prompt pay discount, or discovering an error on their bill. Some have even argued their ED bills were coded incorrectly, and that the hospital had instead "used a billing code that should be reserved for really intense, complex visits when their visit was actually pretty simple," Kliff writes.

    But the process of negotiating ED bills down is far from simple, Kliff writes. One patient, Erin Floyd, said she successfully negotiated down two of her daughters' ED bills, one by 90% and one by 45%, saving her a total of $4,369. But to do so, Floyd said she "spent at least three hours on the phone." She added, "I was scanning, faxing, emailing, all while I was at work." Floyd added that the process was "incredibly stressful and long."

    But other patients did not see financial relief until journalists began reporting on the charges. According to Kliff, $45,107 worth of medical bills have been reversed as a result of Vox's ED project.

    Ultimately though, the hospitals hold all the power, Kliff writes. "The hospital has the trump card: It can send the bill to a collection agency, a move that could devastate a patient's credit. In those situations, there isn't anything a patient can do to stop them."

    5. Congress wants to do something

    As surprise ED bills have gotten more attention, many senators—both Republican and Democrat—want to address it, Kliff writes.

    Currently, there are two proposals in Congress aimed at addressing this problem.

    It's unclear whether either of these bills will become law, but the issue itself "seems to be gaining momentum" Kliff writes (Kliff, Vox, 12/18).

    Advisory Board's take

    Robin Brand, Senior Director, Revenue Cycle Advancement Center

    Although many hospitals and health systems are trying hard to eliminate "surprise" medical bills (and thus increase the likelihood that patients will actually pay), their efforts have generally focused on scheduled procedures and hospital stays. The ED financial experience, up until now, has been neglected.

    That's in part because the ED is an inherently tricky setting. Care happens fast, there's no way to predict what may happen, and traditional tactics to promote price transparency—such as online tools or point-of-service collections—either aren’t practical or are ill-advised.

    But increasingly, sky-high ED bills are garnering a lot of attention both from the media and Capitol Hill. Among the questions that hospitals and health systems will need to tackle moving forward:

    • How do we ensure we are sending bills that are correct, timely, and accurate in terms of charges?
    • How can we proactively let patients know whether the ED and/or the doctor is within network for them?
    • Are there opportunities to more proactively triage to lower cost care settings?
    • Can we begin the process of financial counseling and payment post-care but prior to the patient leaving so as to eliminate surprises and proactively provide patients with answers to their questions?

    Recently, my team in the Revenue Cycle Advancement Center surveyed more than 1,000 patients who had recently undergone surgery to learn about their financial experience. Although we targeted non-emergency patients, their responses still shed light on the aspects of the financial experience that matters most to patients. If you're a Revenue Cycle Advancement Center member, download our research note from Q4 2018 to learn more.

    If you're not a Revenue Cycle member but want to prepare for the future of price transparency, download our other related research reports to learn:

    What patients want along their financial journey

    Follow the patient financial journey, from pre-care through billing and collections. Learn a patient's questions and fears that arise at each step, and what tools and support your revenue cycle program must proactively provide.

    Download Now

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