Houston Chronicle by Jenny Deam Feb. 22, 2019
Sarah Hirsch was teaching a second-period art class at Manvel High School in November when she felt as if the room was spinning. It was unnerving enough that she went to the school nurse’s office to lie down and soon felt better. But when she stood, the dizziness came back.
The cause of Hirsch’s symptom was never determined, but the doctor who saw her the next day quickly discovered fluid in her ears, a common cause of dizziness that usually requires no immediate treatment. Yet, by the time she left the Montrose Emergency Center, a free-standing emergency room, Hirsch had accumulated more than $15,000 in charges that included two CAT scans, an electrocardiogram, two urine tests, blood work, and an IV of saline solution to prevent dehydration — even though she was told she was not dehydrated.
She now owes $13,794.49 because insurance covered less than 10 percent of the charges since it was out-of-network.
Hirsch’s staggering bill raises many familiar and troubling questions about medical care and costs, including the proliferation of excess tests and procedures, the uncertainty of insurance coverage and the responsibilities of providers to clearly disclose network affiliations and potential charges faced by patients. It also highlights a twist in the impenetrable maze of medical billing in the United States, one that patients rarely know about, much less how to fight back.
About one-fourth, or $3,500 of Hirsch’s nearly $14,000 bill was the facility fee, an overhead charge imposed by emergency rooms and hospitals for just walking in the door. Attached to the fee was a five-digit code, used in billing to describe the severity of the condition and scope of treatment. Those codes can spell the difference between paying a few hundred dollars or many thousands on top of bills for doctors and treatment.
Montrose Emergency Center, part of the SignatureCare chain of free-standing emergency rooms, rated Hirsch’s visit at the highest level of severity, typical of life-threatening conditions. She was never given a diagnosis or explanation for the extensive testing. She got a potassium tablet and some motion-sickness medicine and told to go home and rest.
“This is a total scam,†said Hirsch, who has challenged the charges and is awaiting a decision from her insurer. “If I felt like my life was threatened I would have gone to a hospital. I thought I was going to urgent care. I guess they figured we’ve got all of these toys, let’s use them.â€
Ending in ‘5’
Dr. R. Joe Ybarra, the legislative liaison for SignatureCare, said he did not find the tests ordered or coding unusual. In emergencies, he said, “we have to think of all possibilities.â€
In the coding used to determine facility fees, it’s the last number that matters. The higher the number, the higher the charges.
In Texas, the average facility price allowed by insurers for a low to moderately severe condition — a 99282 code — was $436 in 2016, according to Health Care Cost Institute, a research group that examined 1.4 million insured trips to Texas emergency rooms. It more than triples to an average of $1,411 if the visit was coded a 99285, the highest level. Texas has the highest average cost of level 5 facility fees in the nation.
These days, higher severity codes are appearing more frequently, according to internal insurance claims data and a review of dozens of patient bills by the Houston Chronicle. That, in turn, can lead to significantly higher prices billed to insurers, which ultimately, can get passed to unsuspecting patients.
An analysis of claims by UnitedHealthCare, the nation’s largest health insurer, found the use of the two highest facility fee codes rose 50 percent in the past decade, translating into a $1.5 billion increase in the country’s overall health care costs, said Tracey Lempner, a spokeswoman for the insurer.
Similarly, the Health Care Cost Institute, which gathers its data from insurers, found the amount spent for emergency room visits nearly doubled between 2009 and 2016. Prices rose across severity codes, but climbed fastest in the highest designations, said John Hargraves, a researcher at Health Care Cost Institute.
In Texas, the increase of high severity codes mostly came from free-standing emergency rooms, analysts said. The phenomenon of fully-equipped emergency rooms often tucked into retail centers got its start in Houston about a decade ago.
Between 2015 and 2017, Blue Cross and Blue Shield of Texas, the state’s largest insurer, had a 49.9 percent jump in the use of the two highest severity codes at free-standing emergency rooms, said Dr. Robert Morrow, president of the insurer’s Houston and Southeast Texas office.
The emergency medicine industry, however, says the statistics are misleading. They argue that any increase in higher severity codes is a result of people arriving sicker and in need high-level treatment, sometimes after delaying care because of high-deductible insurance plans.
Those with less serious ailments or injuries go elsewhere, such as urgent care clinics or their doctor’s offices, say free-standing industry officials.
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https://www.houstonchronicle.com/business/article/Cracking-the-Code-How-facility-procedure-codes-13635306.php
