State of emergency: Murky billing policies add to ER uncertainty Colorado's patchwork of regulations and contracts make emergency room costs difficult to determine.

Pat Ferrier | The Coloradoan

Show Caption Hide Caption Cost of care: Urgent care vs. emergency department The same treatment can cost significantly more depending on the setting in which it's delivered.

Timnath resident Jim Mullin didn't stop to think about his finances when his 9-year-old daughter, Masyn, doubled over with stomach pain.

Worried her appendix might burst, Mullin rushed Masyn to Banner Fort Collins Medical Center's emergency room on Harmony Road, just a few minutes from their home.

Doctors ran a couple tests, ruled out appendicitis and sent Masyn and her dad home. Mullin said his daughter was well cared for during the visit, and doctors reassured her there was nothing seriously wrong.

Weeks later, Mullin's feelings about the visit changed when he received a bill for nearly $2,000: $214.90 for lab tests and $1,585.70 for the emergency room's facility fee.

He waited for his insurance company — Anthem Blue Cross Blue Shield — to pay its share, only to be told the visit would not be covered.

Banner Fort Collins wasn't contracted with his insurance plan, meaning Mullin would be required to pay for the more expensive "out-of-network" visit. And since he hadn't hit his $2,000 deductible, Mullin was stuck paying the entire bill.

Masyn's temporary stomach pain turned into a lingering headache for her dad.

Mullin's is a cautionary tale about the tangle of regulations and contracts that govern emergency rooms in Colorado, where a patient's view of how much an ER visit will cost, or if insurance will cover the bill, is often obscured.

Had Mullin driven a few blocks west to UCHealth's standalone emergency room, his insurer would have covered the trip as "in network."

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And while Banner's Fort Collins emergency room isn't covered by Anthem Blue Cross Blue Shield, its ER facilities in Greeley and Loveland are considered in network.

Making the wrong choice can mean the difference between paying hundreds of dollars for a trip to the emergency room — or paying thousands.

That's why Mullin and local lawmakers are on a campaign to alert consumers of existing differences and make emergency room billing more transparent.

Mullin wants to know why Banner's accepted insurance plans weren't posted somewhere in the ER during his daughter's visit, or why nobody told him the visit would cost him more than anticipated.

Health care providers say it's generally understood that a trip to the ER will be more costly than receiving care at another facility, but a federal law and a complex insurance landscape prevent them from sharing cost information with patients.

That's no consolation to Mullin.

"There's a consumer uproar when people are overcharged $4 at McDonald's," Mullin said. "I'm talking $1,500."

Facility fees complicate costs

Part of what drives up emergency room costs across the United States are so-called facilities fees added to patient's bills. These fees cover costs emergency rooms incur to provide nurses, staffing, technology, housekeeping, security and other essential services around the clock.

Costs for doctors, drugs, tests and treatments are billed atop a fee that is commonly tied to the level of care a patient requires.

That's the model used by Banner's Northern Colorado emergency rooms.

"Charges are dependent on what actions are taken to diagnose and treat the patient," spokeswoman Sara Quale said. "It is clear that care in an emergency setting will cost more than care in a physician's office or urgent care center."

The facility fee charged for Mullin's daughter's visit to Banner Fort Collins Medical Center's ER was $1,585. The fee for the lowest tier of care at Banner begins around $350.

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The facility fee at Poudre Valley hospital's ER is tied to one of five emergency levels and ranges from $270 to about $2,300, for uninsured patients.

But that fee can be two to three times more for insured patients, a survey of nearly a dozen emergency room bills from the hospital shows. Facility fees ranged from $750 for a relatively simple visit such as stitch removal or a concussion exam to $4,645 for more critical care.

"The more complex patient who spends a long time there and requires more resources would be on the higher end," UCHealth spokesman Dan Weaver said. "Those who don't have a very serious condition would be on the lower end."

Complicating things, each insurance plan likely has a different contracted rate with each provider. That's why Weaver said it is important for patients to research and understand their plan details including their deductible, copay and coinsurance amounts.

That was less of an issue in the past for residents of Fort Collins, which was was home to only one emergency room two years ago. Patients' insurers either covered a trip to the Poudre Valley Hospital ER or they didn't.

But as competition for health care dollars increased and the city's population grew, so did patient's options.

In addition to Banner's emergency department, UCHealth built a $12.3 million freestanding emergency room on Harmony Road last year to complement its expanded ER at PVH. Kaiser Permanente opened offices here and contracted with Banner for hospital and emergency services.

An out-of-state group of doctors plans to open Fort Collins Emergency Center on College Avenue south of Harmony Road. It will not be affiliated with either Banner or UCHealth.

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Fort Collins Emergency Center representative Dr. Henry Higgins previously told the Coloradoan the center at 4858 S. College Ave. would accept most private insurance plans, but not Medicare or Medicaid. The Centers for Medicare and Medicaid Services doesn't recognize physician-owned emergency facilities and won't reimburse the cost of treatment.

Higgins did not return phone calls seeking comment for this story.

Today, Fort Collins patients have four emergency departments with different rates and different insurance contracts from which to choose. That's good news for people seeking immediate care, but potentially bad news for when they try to figure out their bill.

After several "arduous" months of calling Banner and Blue Cross, Mullin said he found few sympathetic ears and finally paid the full bill when Banner threatened to send him to collections.

Solutions hard to reach

Efforts to reform emergency room billing practices in Colorado have fallen flat in the last two legislative sessions.

The latest effort from Sen. John Kefalas, D-Fort Collins, would have created a new license for freestanding emergency departments. It failed in the early days of this year's legislative session.

Beginning in 2019, freestanding emergency departments would have been required to open only in underserved areas, meet cost transparency requirements and provide patients with lists of which insurers considered them in network.

"The problem we are trying to solve is people are often confused when they go into one of these facilities," Kefalas said. "When we hear that people are getting zinged for a common ailment because they went to an emergency room rather than urgent care because that's what's open and they get a $1,000 facility charge, that's what we are trying to solve."

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Kefalas' bill wouldn't have helped Mullin, since Banner's emergency department is attached to a hospital. But it would help those seeking treatment at freestanding emergency departments, the ranks of which have increased precipitously in the last four years.

Kefalas said he hasn't given up on introducing a similar bill next year.

It's an issue the Colorado Health Institute is watching closely.

"The concern is that patients visit these facilities for conditions that don't require a full-service emergency department to treat, and then they or their insurance company get charged a high facility fee," said Joe Hanel, spokesman with CHI.

"Colorado is a national hotbed for these facilities and national studies have shown Colorado's regulations of freestanding emergency rooms are lighter than most other states."

There are 49 freestanding emergency departments licensed by the state of Colorado as "community clinics with emergency care" because the state does not have a licensing category for the relatively new ER model, said Randy Kuykendall, director of the Health Facilities Division of the Colorado Department of Public Health and Environment.

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Freestanding emergency departments started showing up in Colorado about four years ago, Kuykendall said. Most are small — with 10 or fewer beds — not attached to a hospital and provide a "fairly sophisticated level of emergency intervention and care."

They also tend to be built in more affluent suburban areas close to urgent care centers, for which they can be confused. That confusion can end in a patient receiving an unexpectedly large bill, according to an analysis by the Center for Improving Value in Health Care.

Regulations dull transparency

Administrators say their hands are tied when it comes to disclosing what insurance plans are in and out of network.

Federal law prohibits them from discussing insurance or a patient's financial status. It's called the Emergency Medical Treatment & Labor Act, or EMTALA, which was designed to ensure a person's inability to pay did not prevent them from seeking medical treatment.

"Once a patient enters the emergency department with a health concern, we are not permitted to ask them about insurance coverage if that will delay treatment in any way," a Banner spokesman said.

Mullin said EMTALA makes it impossible for a patient to know what financial challenges might come after an ER visit.

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"Luckily, we are in a financial position that we will be OK." He's raising a stink, he said, "for the folks who can't afford it."

Had he known Banner was not covered by his insurance plan, he would have taken his daughter to the nearby UCHealth emergency department when she was stable.

Citing privacy laws, Banner officials declined to discuss Mullin's situation, but said Anthem Blue Cross Blue Shield has contracts with McKee Medical Center in Loveland and North Colorado Medical Center in Greeley, but not Banner Fort Collins.

"This is a fairly unique situation," Quale said.

That's why it's important for consumers to know exactly who and what their insurance plans cover before they experience an emergency, Weaver said.

Mullin said the first thing on his mind was to "get his child to the nearest ER, not figuring out" whether his insurance plan would cover the visit.

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Mullin is convinced hospital emergency rooms hide behind EMTALA because treating patients who are out-of-network generally brings in more money.

"They are inherently incentivized — and conveniently protected by EMTALA — to accept and treat as many non-contracted folks as possible."

Know in case of emergency

Nobody expects an emergency. Emergency personnel say it is crucial for patients to understand their insurance coverage and provider network before an emergency happens. Ask your insurance provider:

What hospitals and doctors are in my provider network? Where can I find a list?

What benefits exist when I receive care out-of-state, or outside my network of providers? What if it is emergency care?

What co-payments should I expect when I receive care?