She didn’t get treated at the ER. But she got a $5,751 bill anyway.

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On October 19, 2016, Jessica Pell fainted and hit her head on a nearby table, cutting her ear. She went to the emergency room at Hoboken University Medical Center, where she was given an ice pack. She received no other treatment. She never received any diagnosis. But a bill arrived in the mail for $5,751.

“It’s for the ice pack and the bandage,” Pell said of the fee. “That is the only tangible thing they could bill me for.”

Pell’s experience is not unique. Submissions to Vox’s ER database project found multiple examples of ERs charging patients hundreds or even thousands of dollars for walking through the door. Some never got past the waiting room. Some were triaged, but none received treatment from a doctor.

Pell left the ER when she discovered the plastic surgeon who would see her was out of network for her insurance. She decided to go to an in-network facility instead. She thought this was a smart way to avoid the costly fees that came with seeing a provider that wasn’t included in her health plan.

“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, which was sad but a choice I had to make.”

Pell’s health insurance plan paid the hospital $862, what it deemed a “reasonable and appropriate” fee for the services the hospital paid. That left Pell with a $4,989 bill that she received on February 28.

“There was no way for me to have avoided this bill, to have known what I would have been charged,” Pell says.

Hoboken University Medical Center, where Pell was seen, declined to comment on the bill. The hospital did, according to Pell, reverse the entire balance after Vox began inquiring about the fees.

“While we cannot comment on rates for emergency room services, we are reaching out directly to the patient to work on a settlement/resolution to her satisfaction,” said CarePoint Health spokesperson Jennifer Morrill.

High bills but no treatment

Pell’s story is not unique.

In the past six months, Vox has collected more than 1,000 emergency room bills submitted by readers in all 50 states and Washington, DC, as part of an investigation into emergency room billing practices.

The dominant storyline to emerge is what anyone who has visited an emergency room might expect: Treatment is expensive. And when health insurance plans don’t pay, patients are left with burdensome bills.

Our database revealed another side to emergency room billing. Patients can face steep bills even when they didn’t receive treatment.

Multiple patients submitted bills to our database for ER visits where they declined treatment because they learned it would be out of network, were frustrated with the wait time, or began to feel better.

They all ended up with significant medical bills, in the hundreds or thousands of dollars. These fees were often on top of additional fees from another health care provider where they ultimately did receive treatment.

Carolyn Wallace, for example, recently brought her 4-year-old daughter, Elizabeth, to an emergency room in Texas. The young girl ran into a coffee table and cut her forehead above her left eyebrow.

Wallace first went to an urgent care clinic, which directed her to the emergency room at Memorial Hermann Southeast Hospital in Houston. There, she and her daughter waited for about an hour. The only medical care Elizabeth received in that time, Wallace says, was a physician assistant taking her temperature.

Wallace ultimately decided to leave and seek treatment at a different urgent care clinic, where her daughter was seen quickly and received liquid stitches.

Then the bills for the emergency room started coming: about $300 from the hospital and an additional $669 from the physician assistant who took Elizabeth’s temperature.

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“I just felt that it was an exorbitant fee that was not at all in correlation to the service provided,” Wallace says. “It seemed really out of line with the situation. They didn’t give me new gauze or a bandage or replace the paper towel we brought from home. They didn’t give me anything to clean it with.”

The hospital reversed the $300 bill when Wallace protested. The larger doctor’s bill came from a third-party physician staffing company called Team Health, which Wallace is attempting to protest as well. A spokesperson for Team Health did not return Vox’s requests for comment.

These bills show the steep costs that emergency rooms can charge just for walking through their doors. The $300 fee that Wallace was charged is typically called a “facility fee,” the price of entering the facility regardless of what happens afterward.

Hospital executives often argue that these fees help them keep the lights on and doors open for whatever emergency might come through their doors, anything from a stubbed toe to a stroke patient.

But experts who study emergency billing question how these fees are set and charged, noting that they are seemingly arbitrary, varying widely from one hospital to another. A Vox analysis of these fees, published last year, shows that the prices rose 89 percent between 2009 and 2015 — rising twice as quickly as overall health care prices.

“It is having a dramatic effect on what people spend in a hospital setting,” says Niall Brennan, executive director of the Health Care Cost Institute, which provided the data for that analysis. “And as we know, that has a trickle-down effect on premiums and benefits.”

Facility fees typically are not made public, meaning patients only learn what their emergency room charges when they receive the bill. Patients who do not receive ER treatment often find that the facility fee is the only charge on their bill.

“Excessive and unrealistic”

I asked Ryan Stanton, an emergency room doctor in Kentucky, to help me review Pell’s bill — the $5,571 charge for the triage with an Ace bandage and an ice pack.

Generally, Stanton argues that physicians should get paid something for triaging patients because it’s a valuable service in its own right.

“I think there needs to be a fee because there is work done, there is responsibility taken by the provider,” he said.

He noted that in Kentucky, for example, the state Medicaid program typically pays a $50 fee for triaging its patients in the emergency room. I described to Stanton the bill that Pell received for her triage experience. He said that it seemed “excessive and unrealistic.”

“I don’t know why there would be a $5,000 charge for this,” he continued. “That certainly seems like a lot.”

Pell’s health insurance plan, Cigna, estimated that Medicare would pay $129.15 for the type of service she received — meaning that CarePoint was charging 4,453 percent of the price allowed by the government-run program.

Stanton said hospitals will often inflate their bills because they expect that insurance companies will not pay the entire charge. But tracking down the information about what a facility fee or triage will cost at your local hospital is incredibly difficult for patients, often impossible.

“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 says. “That’s a real shortfall for our patients.”

Insurance paid $862 for a triage visit — but the hospital says that isn’t enough

Pell’s insurance company, Cigna, contracted with a third party called Viant to determine a “reasonable and appropriate” fee for the visit. It landed on $862 as a fair price for the visit, and Cigna paid that to Hoboken University Medical Center in October 2016.

Viant warned Pell in a letter last fall that “some hospitals will not automatically reduce their bills, however, and may bill you for those amounts above the reasonable and appropriate amounts.”

Pell initially thought she was in the clear when a year went by and she heard nothing from Hoboken University Medical Center. But on December 31, 2017, she received a bill for $4,989 — the remaining amount beyond what her insurer had determined to be reasonable.

Pell wrote to CarePoint to appeal that bill in January, describing the content of her visit.

“I was triaged, waited and taken to have myself examined,” she wrote in the letter. “I specifically asked on multiple occasions, before anyone touched me, ‘are you out of network? If you are, I decline medical attention.’ I received an icepack and ace bandage and left to seek in-network medical assistance.”

But new copies of that same bill continued to come after that letter, including a bill dated January 29 that reiterated the amount she owes the hospital, and again on February 28.

After I began reporting this story, however, the hospital reached out to Pell and said it would zero out her bill, as well as refund the $100 copayment she made at the time of the visit.

Looking back, Pell isn’t able to see any way she could have actually avoided the surprise bill she was hoping to dodge by seeking in-network treatment.

“I wouldn’t have done anything differently. I would have done it exactly the same,” she says. “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.”

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