An urgent billing question: Couple surprised by emergency room coding after urgent care visit
A couple who took their baby to urgent care at St. Luke's hospital in Duluth on New Year's Day said they expected a $45 co-pay and were surprised to get a $308 bill instead.
What they learned, said Alyssa Campbell of Portland, Ore., was they had gotten urgent care but had been billed under an emergency room coding. "And that seems not right," she said.
In an era of extravagant medical bills, $300 isn't a lot. It's not a heavy burden for Alyssa and her husband, Kevin, both of whom have jobs, she said.
But it was unexpected, particularly considering that Alyssa Campbell is a social worker who helps clients with medical billing and that the couple had exercised due diligence to make sure — they thought — they would be faced with only the co-pay. It also opens a window to the complex world of medical billing and what people should do when a bill seems wrong.
In short: Question, question, question.
"Call the patient advocate," said John Strange, CEO of St. Luke's. "Call the billing people. Talk to them right away."
But the Campbells did all that, as well as contacting their insurer, without getting different results, Alyssa Campbell said.
And getting different results may take more persistence than most people are willing to invest.
Caitlin Donovan is spokeswoman for the Patient Advocate Foundation, a Virginia-based nonprofit that helps people with medical issues. On average, she said, their case managers make 23 phone calls on behalf of a single patient over a contested bill. In her own case, it took a year to resolve a billing dispute with a local hospital, Donovan said.
New Year's strep
The Campbells' billing issues began on Jan. 1 during an annual post-Christmas vacation in Duluth with extended family, Alyssa Campbell said. Most of the 18 adults in the clan had strep throat, and the couple's only child, 5-month-old Claire, had a cold. They knew it was unlikely a baby could develop strep, but they wanted to be sure.
They consulted the consumer website Yelp and found that the urgent care facility at St. Luke's came highly recommended, she said. She checked and found that St. Luke's was in-network with their insurer, Regence BlueCross BlueShield of Oregon.
They entered from the outside, under an entryway that's clearly marked "Emergency & Urgent Care." But Campbell said they only noticed the words "urgent care," and never considered their situation an emergency.
The service they received was efficient and friendly, Campbell said. Within minutes, they knew that Claire didn't have strep. The doctor advised them to keep an eye on her and sent them on their way.
"I was happy with everybody," she said.
Until the bill arrived, and the bottom line was $308, not $45. Certain it was a mistake, she called St. Luke's saying she wanted to file an appeal. The business office agreed to send her a line-item version of the bill. One item caught her eye. After the code 981, it read "PROF FEES EMER RM/URG CARE."
"I looked up the coding for that," she said. "The 981 code is for emergency room fee, and that's what my insurance told me is turning my whole visit into an ER visit in their coding."
Eileen Smith of the Minnesota Council of Health Plans, an industry trade group, confirmed that the 981 coding "is for emergency room professional fees."
The Campbells' insurer claimed they couldn't make an adjustment.
"They're saying we understand they're billing incorrectly, but there's nothing we can do," Campbell related. "They said their hands were tied. And St. Luke's said, 'Well, that's just how we bill.' "
At that point, she contacted the News Tribune, which — after checking with St. Luke's — suggested she contact the hospital's patient advocate.
But when she did so, Campbell said, she was referred back to the billing office, which sent her back to her insurer.
At that point, she said, she and Kevin "threw in the towel" and paid the $308 bill.
St. Luke's response
Eric Lohn, chief financial officer for St. Luke's, cited mitigating factors. The difference, he said, is that the Campbells went to the urgent care facility at the hospital instead of a free-standing clinic such as Denfeld or Miller Creek.
"We have different structures for a hospital-based urgent care and a free-standing clinic," Lohn said. "She didn't get charged for the emergency room even if it came across as that code."
Although the bill was higher than if the Campbells had taken Claire to a free-standing urgent care clinic, the emergency room charge probably would have been double what they paid, Lohn said. And because it was a holiday and the free-standing clinics were closed, they actually got the best deal possible.
Unlike in a free-standing clinic, a patient entering the hospital facility goes through a triage process in which she or he is directed to emergency or urgent care as deemed appropriate, Lohn said. This is explained in a form the patient (or, in this case, the patient's parents) sign when entering the facility.
There's no sign on the wall, however, explaining that the patient's bill may be higher than if they were treated in a free-standing urgent care facility, Lohn said. "It's so complex that we can't make a blanket statement saying your insurance company will treat this differently."
When asked about a different billing structure for urgent care in a hospital facility, the Patient Advocate Foundation's Donovan responded with a double negative. "It's not totally abnormal," she said. "There's all sorts of different reasons why something may be billed as an ER as opposed to urgent care. I wouldn't be surprised if some hospitals are just using those terms interchangeably."
Essentia Health doesn't offer urgent care at St. Mary's Medical Center, spokeswoman Maureen Talarico said. The closest urgent care facility to the hospital is in the Third Street Building downtown, but it's not billed as if it were a hospital setting, she said.
As for the patient advocate's role, St. Luke's Strange said it made sense to refer the patient to the experts in the billing department.
"The complexity and the number of different ways you can look at the billing is so incredible," he said. "It can be just mind-boggling."
Patient advocates have the expertise to help patients with questions about medical care, Strange said.
Alyssa Campbell said none of her questions were answered satisfactorily by anyone, in her view.
"The people on the phone are polite, but they're not very helpful," she said. "They're like, 'Well, that's how we bill.' It's just not a good answer."
For people on a tight budget, the difference could be significant, she said.
"For us, we're a younger family and we're working and it's not an issue," Campbell said. "But for a senior with a fixed income, it could really wreck the bank when you're expecting a $45 co-pay. It could knock you out."
On that point, there's no disagreement from St. Luke's.
"There are a lot of people that 300 bucks is a lot of money," Strange said. "And those are the ones you feel really awful about, when you know someone's struggling."
What to do about a questionable bill
Case managers at the Patient Advocate Foundation are available to anyone but primarily work with low-income patients, spokeswoman Caitlin Donovan said.
But there are steps patients can take on their own when a medical bill seems confusing, surprising or just plain wrong.
"The first thing to do is to question it," Donovan said. "Call up the hospital if you think it's wrong. And ask them to explain it to you, and always ask for an itemized bill."
Don't assume that the bill is accurate, she said. "There's studies that say at least half of hospital bills have errors."
Other tips from Donovan:
• Once you get an itemized bill, go online and use Google or another search engine to look at the billing codes. "(If) they're billing you for X, Y or Z and if you know you are in the hospital for B, then you ... might have a problem there," she said.
• Find a direct contact at the hospital. "My shortcut is try and get the direct phone number for someone in the billing department, because for some reason in every hospital I've ever interacted with you have to go through ... eight different prompts to get to somebody." Once you have your contact, try to keep working with that person.
• Negotiate. "Especially if you're uninsured, I would take a hospital bill as an opening offer," Donovan said. "If you are a good-faith actor and you're saying, 'I want to pay you; here's what I have,' or, 'Here's what I can afford per month to pay you,' they'll work with you, because they're not interested in being stuck with a completely unpaid bill."
Who to call
St. Luke's patient advocates — (218) 249-5400 or email PAdvocate@slhduluth.com
Essentia Health patient relations:
• East market (Northeastern Minnesota including Duluth, Northwestern Wisconsin including Superior) — (218) 786-3091
• Central market (including Brainerd) — (218) 828-7649
• West Market (including Fargo) — (701) 364-3217; (701) 364-4933
Patient Advocate Foundation — (800) 532-5274