July 3, 2018

She declined ED treatment—and got a $5,751 bill anyway

Daily Briefing

    When Jessica Pell sought care at an ED after fainting and hitting her head on a table, she declined care from an out-of-network physician because she couldn't "afford any surprise bills." She left with an ice pack and a bandage—then got a $5,751 bill, Sarah Kliff writes for Vox.

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    Background

    Pell's story is part of a year-long project Vox launched in 2017 to examine how EDs charge patients for medical care. For the project, Vox is reviewing readers' submissions of ED bills from the last five years to develop an ED billing database. So far, Vox has collected more than 1,000 ED bills submitted by patients in all 50 states and Washington, D.C.

    In the latest installment, Kliff writes about how patients who proactively decline care from out-of-network providers can nonetheless get saddled with surprise medical bills.

    Many of those surprise medical bills, Kliff writes, result from a charge commonly called an "emergency facility fee"—a base fee most hospitals charge for any ED service. Hospitals have said facility fees are necessary to cover ED overhead, but some experts but say the fees appear to be arbitrary and vary widely. A previous Vox analysis found the fees generally are not publicly shared.

    Pell's story

    Pell said on Oct. 19, 2016 she presented at the ED at Hoboken University Medical Center after fainting and hitting her head. She sustained a cut on her ear from the fall. Pell said she was triaged and given an ice pack and an Ace bandage, but when she learned the plastic surgeon who would see her was out of her insurance network, she declined further treatment.

    "I decided to decline treatment because I can't really afford any surprise bills right now," she said. "The bill I'd probably incur would not be worth saving my ear," she said, "which was sad but a choice I had to make." Instead, Pell sought treatment at an in-network facility.

    Even so, Pell received a bill for $5,751 for her initial ED visit.

    Pell's insurer, Cigna, worked with a third party company, Viant, to determine a "reasonable and appropriate" fee for Pell's visit. According to Kliff, Cigna estimated that Medicare would have paid $129.15 for the type of service that Pell received, which meant that the provider was charging more than 4,000% of the Medicare price.

    Ryan Stanton—an ED physician in Kentucky—said he agreed that patients should pay a triaging fee, but that the ED's price seemed "excessive and unrealistic."

    According to Stanton, determining exactly what a facility fee or triage will cost isn't easy. "If you call and ask, they are not going to tell you. Right now there are not a lot of great tools and there aren't great databases," Stanton said. "That's a real shortfall for our patients."

    The insurer ultimately agreed to pay $862 for the services provided and warned Pell in a letter that "some hospitals will not automatically reduce their bills, however, and may bill you for those amounts above the reasonable and appropriate amounts."

    After over a year of silence, Pell received a $4,989 bill, which she contested.

    In response to a request from Vox, a spokesperson for the hospital declined to comment on the case but said it was reaching out to the patient to reach an agreement. Pell said the hospital ultimately reversed its charges and refunded her the $100 copayment she paid at her visit.

    But after reflection, Pell said she's not sure how she could have avoided this bill. "I wouldn't have done anything differently. I would have done it exactly the same," she said. "I followed my instincts, and they were all correct. There is no way for me to have known. There was no way to avoid this" (Kliff, Vox, 5/1).

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