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One source of unexpected charges are stand-alone emergency rooms, which are non-hospital facilities whose numbers have roughly doubled in the past decade. As they’ve bloomed across the country—like “Texas wildflowers in the springtime” as one health economist put it—so has patients’ bewilderment at their fees.

I recently spoke with Rod, who lives in Spring, Texas, a state where the number of freestanding ERs has exploded from 25 in 2011 to 145 today. One day in October, Rod’s wife Debbie began complaining of chest pains. Over the course of several hours, Rod grew increasingly worried because Debbie has a family history of heart attacks.

“You never know at first where they're coming from or what it is,” said Rod, who asked that I only use the couple’s first names. “She wanted to see if they would pass. Then we talked about it again, and we figured it would be best to take her to an ER to get checked.”

But first, Rod did what health-policy experts advise: He shopped around. He says he used an Aetna insurance app on his phone to try to compare the prices of emergency rooms nearby. A stand-alone ER called First Choice seemed like the best option.

Debbie, who has insurance through her job as a public-school teacher, presented her Aetna card to the intake workers at First Choice. The couple asked how much the total visit would cost.

Here’s what happened next, according to Rod: First Choice assured them that there would be no facility fee, a type of charge that hospitals sometimes tack onto bills to cover the cost of building operations and equipment. Rod asked for an estimate of all the other charges the couple would accrue. He says the workers told him it would depend on the types of tests the doctor ordered, and that they couldn’t know the total ahead of time.

“We quizzed those people for quite some time,” Rod says. The workers demurred, but the couple decided to check in regardless.

Debbie was seen, and the doctor said there was nothing to worry about. They went home.

A few weeks later, the first of several bills rolled in. “The very first charge when I open the bill is a facility charge for $2,258,” Rod said—the one First Choice said he wouldn’t incur. There were some blood tests, a $300 electrocardiogram, and so forth. The total was $4,605.

Rod called First Choice’s billing office. “No, we always charge a facility charge,” he recalls them saying. (A First Choice spokesperson would not comment on the facility fee mix-up, but did point out that the company mentions the fee on its website.)

How likely people were to complain about a surprise bill,

from a base of “all respondents” (Consumer Reports)

“Yeah, $500 is a big deal to me,” Rod said, referring to the post-deductible sum, rounded-up, that he owed First Choice. But he’s more upset that “the [intake workers] did not seem to know what they were doing when they were trying to find the information for us. I don't think they lied. I think they're a victim of working in a system that's so complex that even the people working in it don't understand it. The only way you find out is when you get your bill.”