When I moved to Washington, D.C., I was flush with a sense that I could make a difference in the world, both big and small. I could save the country through carefully-crafted policy solutions, and I could save the planet by commuting to work everyday on my bike. Before my job began, I decided to bike the route to work to check it out. Seven hours later I was checking out of the hospital with a cast over one arm and a sling over the other.
While this wasn’t the most spectacular entry into a career as a lifelong health policy wonk, it happens to be a great example of health care and billing in America. In my case, I was insured, and my insurance policy covered most of my costs. I wish I could tell you the particulars of what those were, but I can’t. I no longer have the original bill (understandable, it’s been over seven years), and despite spending the better part of a week trying to get them to send it to me, the hospital has been unable to furnish me with a copy either (unacceptable).
(It was a herculean effort just to be told it was impossible. I tried calling over twenty times. The first fifteen times I called, I was automatically directed by the answering service to a mailbox where I couldn’t leave a message because it was full. When I finally did get the billing office by calling the main line and demanding to be connected to a person, the people in the office told me they where aware of the problem with the answering machine but couldn’t do anything about it. Also, I spent over 2 hours on hold. I’m a bit shocked at their incompetence, which bodes poorly for their management of billing. I’m glad I don’t owe them anything. (Instead, a sample bill can be found here.)
But let’s take a look worst case scenario, and bureaucratic incompetence isn’t the worst case scenario, unfortunately. What would my accident have cost me if I didn’t have insurance? (I have starred every action where a new person can bill me).
After I hit the pothole that sent me flying through the air, I thought I was fine. But I was having some trouble walking and the people that saw the accident insisted on calling an ambulance.* The kindly EMT cut off my shirt and took me to the nearest hospital, where I was admitted to the ER* While in the ER the doctors* noticed I had hit my head, which was bleeding. Luckily I was wearing a helmet which is why I am alive (and this story is hundreds of thousands of dollars cheaper). They ordered X-Rays and an MRI* of my head to make sure I hadn’t suffered any brain trauma.
The total for everything, for the uninsured biker, would be about $2,000 for the hospital visit and an additional $1,700 or so for the ambulance ride. The price for the same exact care can vary from hospital to hospital, but $2,000 is not an extraordinary figure for a broken arm requiring a cast. This gets even more confusing, however, because not all this money is being billed by the same place. Over the course of the next month you may get a bill from the 1.) ambulance company that picked you up, 2.) the hospital that admitted you, 3.) the doctor you saw in the emergency room, if they are not employed by the hospital, and 4.) a company that read your X-Rays and MRI.
While in the hospital you can be billed for every single thing that enters, exits, or goes near your body. Every person that sees you, reviews your charts, or hears your name can bill you. Anything that goes on your body or comes off your body. Basically any time anything happens when you are in a hospital you can be billed for it. I was even billed for watching the TV in my room.
This can add up, and quick. When you get your bill, it is a confusing mess of indecipherable line items with high prices attached to them. To sort out what’s what and to provide some amount of clarity, you would need to request an itemized bill. Getting treatment from the ER may be easy, but understanding the costs is a lot more confusing.
While it is true that the ER can’t turn you away from care (a law called EMTALA guarantees this), that doesn’t mean they can’t charge you whatever they think is appropriate. Once you enter the ER, you have basically just entered into a contract to purchase services, while under duress, without knowing what you are buying and for how much. Not the best negotiating position. At the most basic level, there are two sides of the health care contract—just like any contract—the seller (health care providers) and buyer (called the payor in health care). There are three main variations on health care
a) In a truly socialized health care system, the health care providers, like doctors and nurses, are employed by the government and provide services to people as employees of the state. Like in England, the National Health Service, employees and pays doctors to provide care.
b) In a single-payor model, like Canada, the health care providers are independent but all the payment comes from a single government run insurance that all citizens are part of.
c) In a multi-payor model, like in America, there are numerous payors, from private insurance, to out of pocket uninsured individual, and government insurance. Private insurance can be purchased by individuals and provided to individuals by employers and unions. So back to the broken arm. Without insurance or some publicly funded type of coverage, breaking your arm can be very expensive in a multi-payor system. Part of the reason is that unlike other purchasers, who know they will need care so can negotiate payments ahead of time, you are out of luck. It’s like you’re on a sinking ship and a rescue boat comes along, but wants to charge you. Had you worked out an arrangement with a rescue boat company ahead of time you’d be all set. But now, you’re on a sinking ship and your options are drowning or taking whatever deal the rescue boat captain offers.
There is some hope, however. The rescue boat company doesn’t really benefit from charging you an amount you have no way of paying. Bankruptcy and lawsuits don’t help their bottom line. Therefore, you do have some room to negotiate the bill after the fact. One way is to try to find what they charge for Medicaid patients or private insurance patients, and get that reduced rate. You can call and ask about this rate and they should be forthcoming, however, you may want to do some research online beforehand in case they are reluctant to help you.
There are some resources, like Fair Health, which can also help you determine what a reasonable rate might be. To do this, get an itemized bill. It should list what you were charged and why, and should have the CPT codes for what you where billed for. CPT codes are the codes they use for billing purposes (such as ER visit, mild) and can be used to determine customary rates. Fair Health has some resources explaining this further as well as aCPT cost lookup. There are also several non-profits that can help you reduce medical debt, and a few useful guides. This from Massachusetts is a good resource, or this from California.
Even if you have insurance, you may not be out of the woods. There are two pitfalls for the insured. One is cost sharing. This can include deductibles and co-pays and other mechanisms that, even if you have health coverage, require you to pay money out of pocket for care. The other is out-of-network services (which may-or-may not get counted toward your deductible depending on your contract). These are basically services provided by health care providers that don’t have pre-existing contracts with your insurer. Rescue boats that haven’t worked out a deal ahead of time, who again, can charge you what they like. Your insurance company, because they don’t have contracts, may cover part of this, but not all. (The types of cost sharing and out of network issues, but for now just know, even the insured still pay for care, even after covering monthly premiums.
So before you start shaking your one good fist at the sky, here’s some final advice in the event you get in an accident. Do not take an ambulance if you don’t need to. Ambulances are notoriously bad billers, and while they provide an important service they do not provide that service for free. There may be a time when you need an ambulance, and during those times, do not hesitate when your life depends on it. But there are many times when a car ride (or taxi) will do.
If you can go to an urgent care clinic instead of a hospital you should. Again, they are much cheaper and don’t charge you so much just for walking in the door. When you are in the hospital, remember that you still have control, so speak up. If they are going to charge you for everything make sure you know what you’re getting. You have the right to refuse any care and say no. It can be scary and they can be pushy but keep your head. It is not likely that the physicians and nurses know how much everything is going to be billed for (their is a separate department for that) but they should know when something is billable—meaning when they do something they can charge for.
Finally, if you can’t get insurance at least you can shop ahead of time. If you live in an area with multiple hospitals, research them ahead of time and determine which you think is the best place to go in case of an emergency because of the level or care and rates they charge. One good indication is the use of hospatilists. A hospatilist is a physician that is employed by the hospital. This tends to be cheaper because you are getting billed by one place, as opposed to two, when you receive care in the hospital. There are a number of other factors to take into consideration. You can even try calling different billing offices and finding out what average ER costs are. Knowing ahead of time which hospital provides the best and most affordable service can be as life saving as the care you will receive inside it. This way when something happens you don’t have to make a decision while your femur is poking out of your skin.
Stone Goldman (not his real name) is a health policy analyst who has worked in various high level government positions in the health care field. Got health care questions? He’s got health care answers. Leave them in the comments or send them Stone c/o firstname.lastname@example.org.