Emergency Room Charges
As you sit in the Emergency Room (ER) at your local hospital, you should be focused on your health. But, it’s nearly inevitable to grow concerned about “what this ER visit is going to cost?” Emergency room charges always make us cringe because they always have a premium price tag. If you are blessed with a copay and low insurance your costs will be more controlled, but with todays high deductible insurance plans, some of the ER costs will be assigned to you to pay on top of your copay.
Key Takeaways
ER billing uses levels; patients should confirm that all ER charges (physician and hospital) reflect the same level
Expect additional charges on your hospital bill from ancillary service charging (lab, radiology etc.)
Separate bills will be sent by all physicians during your stay
Uninsured patients should speak to the billing representatives in the ER after discharge, do not leave without doing this
Emergency Room Billing Overview
When visiting an ER, you may receive several different bills. You will likely get a hospital bill, a physician bill, and possibly bills for other service providers. The Hospital bill will include all departments that have interacted with you during your time in the emergency room. Separately, physician providers or associated departments that you see in the emergency room will also send individual bills for their service. Emergency room care is charged based on a level system (see below for details), when reviewing your hospital and ER physician bill a simple but important trick is to make sure that all bills reflect the same patient level.
Emergency Room charges
ER charging is done by Levels, there are set levels and a corresponding set charge, regardless of time spent, based on the level you are assigned at the completion of your visit. There are 5 levels and each one has a set criterion for use. In today’s world of EHR (electronic health record) systems there are modules created just for ER that are used with an algorithm and configured based on the hospitals guidelines. Yes, that’s correct, each hospital gets to determine what the guidelines are for the ER level charge.
For you the patient to make it a little easier I will give you a few examples of each level.
Level 1 and 2 are typically for the runny nose, ear infection, minor cut on the finger that needs no stitches. The patient does not have an x ray, and often you will see a Physician Assistant or Nurse Practitioner as your provider. There could be a prescription given. These are minor visits that could be seen at an Urgent Care clinic if one was open or your physician office if you could get an appointment.
Level 3 visits are for patients who present with more severe symptoms. Perhaps stomach pain, flu, diarrhea and vomiting, a deeper cut that needs stitches, dehydration, etc. You could receive an IV solution with or without medication in it, receive stitches, and your time in the ER will be longer due to the regime of orders given. Perhaps labs and x ray and or respiratory therapy are also used. These patients typically go home once all orders are complete.
Levels 4 and 5 are for patients who are typically very sick and could, depending on the results of the tests run, end up staying in observation or be admitted to surgery or Inpatient status. These patients would have labs, EKG, x ray and or CT/MRI, respiratory therapy O2 or breathing treatments, prepped for surgery, and have possible multiple physician specialties consulting on their situation.
Critical Care is not an ER level it is a status that is charged separately for time providing stabilizing medical care of a patient who has one or more organ failures and where there is the possibility of death. This charge is over and above the level charge and you will see a critical care time charge for this service. Once the patient is stabilized the critical care time charge stops, most usually the patient is admitted to ICU or transferred out of the ER to a higher level of care.
Trauma Level of Care is used when the trauma team is called, this is a group of specialist physicians and specialist ancillary departments that will be needed to take care of this patient. The patient is either received by ambulance or Life Flight (helicopter) to the facility and is in critical condition. The ER is the receiving area and after assessments and stabilization the patient is then moved to surgery, ICU, CCU for the remaining care. These are patients in critical condition from car accidents, shootings, bombings etc. They receive 100% of all services within the facility.
Ancillary Services
Ancillary departments are lab, radiology, respiratory, PT/OT, EKG/Echo, supplies, pharmacy. You will see this as a separate charge for the items or services they provided. Every charge should have an order for the service. Without an order its not billable. All of the above services will be appear on your bill in date order received by the specific department.
Supplies
Supplies are classified as routine non billable and billable supplies. Routine means exactly as it sounds, anything used routinely on every patient are not billable. A billable supply is specific to the patient and to the specific needs based on orders received for services. For instance, we don’t bill for bedpans, basins, water pitcher etc. used in admission to an area. Everyone receives them regardless of their medical issues. However, if you receive an IV the tubing will be charged along with the bag of solution as its specific to the order received. For more information, see our article on reviewing supplies on medical bills.
Physician Billing
Physicians bill separately for their professional services provided during your hospital stay. You will receive a separate bill from ER physicians that you have seen. ER Physician bills also use a 5- level code and the level used is based on documentation for services ordered, patient status or seriousness of presenting problem, and additional care given to the patient based on time. Again, the hospital and the ER physician bill should be using the the same level in their bills. If they are not, I would recommend an audit to see why the difference.
You will receive a bill from any physician other than an ER doctor separately. If you see a cardiologist for a consult, or a GI doc, or orthopedic you will receive a bill from that physician separately for the consultation. If you see a specialist and then are whisked off to surgery you should only see the surgery charges as the consult is included in the surgery because the decision for surgery was made at that time.
One bill that always confuses patients are the Hospitalist bills. A Hospitalist is a physician that takes over your care when you are admitted to observation or inpatient status. You may still be in the ER as they could possibly have an observation unit in the ER or the inpatient area does not at that moment have a bed available and you remain in the ER until one is available. So if a physician comes into your ER room and says Hi and that they are going to be taking care of you, ask him/her are you my hospitalist? Then you will know for sure. This is important because you will receive an additional bill for the Hospitalists services.
What to do if you are uninsured
IF YOU DO NOT HAVE INSURANCE, make sure that you ask to speak to a financial counselor about your bill at the time of discharge. Don’t just walk out the door and think you can deal with this later. Most facilities have billing staff in the ER that can help you with financial aid and get the ball rolling. They can get you started on the application for Medicaid coverage, talk about payment plans, applying for charity care or other agencies your individual state has for help. What this does is put your account into a presumptive status, rather than cash pay, which is then sent to a select group of people who will follow up with you once you get home on financial help. This is important as cash pay means you pay upfront and then have to negotiate any errors, while presumptive status means that the hospital will help to qualify your account for aid (Medicaid, financial assistance, charity care, etc.) and you will have to pay after a determination is made.
If you were admitted from the ER to an inpatient status your ER bill is now part of the inpatient bill and is handled differently by your insurance, being paid based on a diagnostic grouping not by singular charges.
Wrap-up
Don’t leave the ER and go home without knowing what your responsibility is for the bill.
Wait until you receive all bills and your insurance EOB to compare the charges and to see what you are responsible for paying.
If you are unsure about the charges have your bill audited to make sure that all documentation (orders) are matching the charges you receive.
Keep the physician and the hospital bills with the EOB from the insurance company stapled together and keep them in a folder for healthcare expenses.
