Tue. Dec 7th, 2021

Caitlin Wells Salerno knew that some mammals – like the golden-capped chipmunks she studies in the Rocky Mountains – invest insanely many resources in their young. It did not prepare her for the resources that the nature conservation biologist owes after the birth of her second son.

Wells Salerno went into labor on the eve of her term, in the early weeks of coronavirus lockdowns in April 2020. She and her husband, Jon Salerno, were instructed to walk through the emergency room doors at Poudre Valley Hospital in Fort Collins, Colorado, because it was the only open entrance.

Despite the strange covid mood – the emptiness, the silence – everything went smoothly. Wells Salerno felt good enough to turn down the help of a nurse who offered to drive her to the maternity ward. She even took a selfie, smiling as she entered the delivery room.

“I was just excited that he was here and it was on his due date, so we didn’t have to have an induction,” she said. “I did great.”

Gus was born healthy 10 pounds after about nine hours of labor and the family took home the next morning.

Wells Salerno expected the bill for Gus’ birth to be larger than for her first child, Hank, which had cost the family only $ 30. She was a postdoc in California with first-class insurance when Hank was born, about four years earlier. They were prepared to pay more for Gus, but how much more?

Then came the bill.

Patients: Caitlin Wells Salerno, a conservation biologist at Colorado State University and a lead researcher at the Rocky Mountain Biological Laboratory. She is insured by Anthem Blue Cross Blue Shield through her job.

When Wells Salerno went into labor in April 2020, she and her husband Jon were asked to walk through the doors of a Fort Collins, Colorado, hospital to the emergency room because it was the only open entrance. Their medical bill later included a $ 2,755 fee for level 5 emergency services. (Rae Ellen Bichell / KHN)

Medical service: A routine vaginal birth of a full-term infant.

Total bill: $ 16,221.26. Anthem BCBS ‘negotiated price was $ 14,550. The insurance paid $ 10,940.91 and the family paid the remaining $ 3,609.09 to the hospital.

Service provider: Poudre Valley Hospital in Fort Collins, Colorado, run by UCHealth, a nonprofit health care system.

What gives: In a system that has evolved to bill for everything and anything, a quick exam to evaluate labor in a small triage space can generate significant costs.

The total bill was huge, but what really made Wells Salerno’s eyes jump was a line for the highest level of emergency services. It made no sense. Was it to check in at the emergency room that she had been instructed to? She remembers going through security there on the way to childbirth and childbirth, yet there was a $ 2,755 charge for “Level 5” emergency department services – as if she had received care there as a patient with a heart attack or fresh from a car wreck . It is the largest item on the bill apart from the actual delivery.

Dr. Renee Hsia, a professor of emergency medicine and health policy at the University of California-San Francisco and a general practitioner, said level 5 charges are thought to be reserved for serious cases – “a serious threat to life or very complicated, resource-intensive cases” – not for patients who can walk through a hospital on their own. Emergency room visits are coded from level 1 to level 5, where each higher level obtains more generous compensation, in theory corresponding to the work required.

But over the last 20 years, hospitals and doctors have learned that there is great profit in coding visits. After all, the insurance company is not in the exam room to know what happened. A study by the Center for Public Integrity showed that between 2001 and 2008, the number of level 4 and 5 visits for patients sent home from the emergency room almost doubled to almost 50% of the visits. In Colorado, the Center for Improving Value in Health Care looked at billing for emergency visits from 2009 to 2016 and found that the percentage of emergency visits coded as level 5 steadily grew from 23% to 34% for patients with commercial insurance.

After repeated calls questioning the line item on her bill, Wells Salerno eventually got an answering machine from the billing department, which she shared with KHN, explaining that “the emergency room fee is actually the small area for OB triage before they take you to the birth and delivery space. “

A customer service representative later explained that it was for services provided there when a nurse placed an IV for antibiotics and her doctor checked her dilation and confirmed that her water had broken down – even though none of it was performed in the Emergency Department . And these services, performed before each delivery, are traditionally not billed separately – and are routine, not emergencies.

Some hospitals provide that package of services through an “obstetric emergency department.” OB-EDs are authorized during the emergency department and typically see patients who are pregnant for everything from unexplained bleeding to full-term birth. They bill as an emergency room even if they are not physically located near the emergency room.

Healthcare firm TeamHealth – owned by investment firm Blackstone and known for marking ER bills to boost profits – essentially says an OB-ED can be as simple as a renamed obstetric triage area. In a white paper, the company said an OB-ED is an “entrepreneurial approach to strengthening the hospital economy” because, with “little or no structural investment”, it allows hospitals to “charge facility fees that are otherwise lost in the obstetric triage setting. “

OB Hospitalist Group, which is owned by a private equity fund, markets a tool to help OB-EDs calculate levels of emergency care. In a case study, the OB Hospitalist Group reported that hospitals “leave a lot of money on the table” by billing OB-ED visits as level 1 and 2 emergencies when they could be considered level 4 emergencies.

A facility in Arizona said its revenue increased $ 365,000 per year. quarter after turning their obstetric triage area into an OB-ED. Poudre Valley Hospital’s website does not list “OB-ED” as part of the facility’s offer, although UCHealth documents refer to OB-ED beds in other facilities.

KHN spoke with four other women who, after giving birth in the Poudre Valley in 2020 and 2021, received ER taxes on their bills after healthy births. They had no idea that they had received emergency aid. One wrote a warning note on Facebook to other mothers in the area after receiving a huge charge – for the 10 minutes she spent in the triage room while she was fully extended and in active labor.

In the case of Wells Salerno, UCHealth and her insurance company have an agreement that Anthem BCBS pays a lump sum for vaginal delivery instead of paying for line items individually. “Being seen there in OB-ED did not affect this bill at all,” said Dan Weaver, a spokesman for UCHealth.

But in the case of one of the other mothers, it did: the hospital received $ 1,500 from the insurance company for that charge, and the mother was on the hook for an additional $ 375 for co-insurance.

Ge Bai, a professor of accounting and health policy at Johns Hopkins University, said it is a “questionable” billing practice and one that could mean something to those who do not have the same kind of insurance as Wells Salerno, or have none at all. .

Dr. Mark Simon, chief physician at the OB Hospitalist Group, said OB-EDs can help women avoid being hospitalized prematurely in childbirth, ensuring timely, more appropriate care.

UCHealths Weaver said they can also help pregnant patients with actual emergencies such as premature birth, preeclampsia or vaginal bleeding to get prompt care from specialists who are available 24/7, often without having to be hospitalized. But in hospitals like the Poudre Valley, healthy women who have healthy births also receive routine “OB-ED” treatment without their knowledge.

Weaver said the only time anyone at birth would not go through OB-ED – and therefore the only time they would not receive the emergency fee – is if they have a scheduled induction or cesarean section or are admitted directly from a provider’s office.

Hsia, a UCSF researcher and emergency physician, is not convinced: “If they actually want to charge a special fee that you did not get directly admitted from your doctor, it’s completely ridiculous.”

Wells Salerno’s “OB-ED” examination was performed by her clinician, but the OB-ED charge still appeared at her expense.

Solution: After trying to establish that the charge was not a mistake, Wells Salerno eventually threw in the towel and paid the bill.

“I was at a very vulnerable time during the pregnancy and immediately after the birth,” she said. “I just felt like I had been exploited financially at a time when I could not gather the energy to fight back.”

The fact that two healthy brothers could come up with such different price tags is not surprising to Dr. Michelle Moniz. “There is no clinical reason why we have this level of variation,” said Moniz, assistant professor of obstetrics and gynecology at the University of Michigan and its Institute for Healthcare Policy and Innovation. Her research shows that people with private insurance pay anything from nothing to $ 10,000 for the birth.

“You do not get what you pay for,” said Wells Salerno, who maintains that both of her children – despite their price difference – are equally “amazing”.

Data from the Colorado Division of Insurance shows that the Poudre Valley typically received about $ 12,000 for similar births by 2020, about 43% more than the typical Colorado hospital. So the more than $ 14,000 Wells Salerno and her insurance company paid is very high.

Takeaway: Everything in our healthcare system that is labeled as an emergency room is likely to come with a large additional fee.

Expectant parents should be aware that OB-EDs are a relatively new feature in some hospitals. Ask if your hospital has those kinds of fees and how it will affect your bill. Ask both the hospital and your insurance company in advance how much the birth is expected to cost. In Colorado, the Center for Improving Value in Health Care offers a price comparison tool for common medical procedures, including vaginal delivery.

If you need a real emergency room meeting, look at your bill to see how it was coded, levels 1 to 5 – and protests if your visit was misrepresented. Ask, “Has this bill been encrypted?” You are the only one who knows how much time you spent with a doctor and how much care was given. Here is a chart that will help with the correct definition of each level.

Know that victory is possible. At least one mother won the match and had the emergency tax removed from her birth bill at Poudre Valley Hospital. It took hours on the phone with UCHealth, a lot of self-confidence and countless repetitions of the birth history – and how an emergency charge for a routine birth just did not give and does not make sense.

Bill of the Month is a crowdsourced survey conducted by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill that you want to share with us? Tell us about it!

Kaiser Health NewsThis article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, an impartial health policy research organization unrelated to Kaiser Permanente.


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