Urgent Care Costs?

[jenn_jenn]

One of my biggest frustrations is medical billing. Health care costs are so high and I have no way of validating that what I'm being charged is correct.

I recently made a trip to urgent care. I went to an in-network urgent care and they have my entire medical history on file. My doctor's office is literally one floor up from the urgent care; it's part of the same hospital.

I spent not even a total of 5 minutes combined with the nurse and doctor because it was a fairly easy issue to resolve: I received an IV for pain management of a reoccurring and diagnosed problem....and then got a bill for $625.

The IV itself was $300 and the rest was just the visit fee. Whaaat?

I knew the trip would be expensive but honestly, had I known it would be $625 expensive, I would have lived another sleepless night of pain and waited for my doctor to see me on Monday.

Does anyone have tips for validating medical billing? And in the future, what is one supposed to do in this kind of situation? Is there a way to receive off hours care without this kind of cost?

[disneysteve]

I recently made a trip to urgent care. I went to an in-network urgent care

I spent not even a total of 5 minutes combined with the nurse and doctor

I received an IV

The IV itself was $300 and the rest was just the visit fee.

I knew the trip would be expensive but honestly, had I known it would be $625 expensive, I would have lived another sleepless night of pain and waited for my doctor to see me on Monday.

Does anyone have tips for validating medical billing?

Let me start by saying that I am an urgent care physician and I've been in practice for 25 years.

You raise a few different points and questions. Let me start with the last one. How to you verify medical bills? You should always request an itemized bill. Generally a hospital or medical facility will just send a summary bill which doesn't break down all of the individual charges but you need that to know if the bill is correct. It is quite common for bills to contain errors. You may be billed for a product or service you didn't actually receive. You may be double-billed for something because two different people entered charges for the same thing. Review the itemized bill line by line and make sure it is correct. If you aren't sure what a charge is for, call and ask.

As for your urgent care visit, I have to say I find it pretty impossible to believe that the tech and provider spent "not even a total of 5 minutes combined" with you especially considering that you received IV therapy during your visit. I know that in our facility, the tech is with you for at least 5 minutes just doing your intake, getting your height and weight, taking your vital signs, doing a med review, checking allergies, and recording the history of why you are there. Then the provider goes in, reviews your history and gets more information from you before doing the physical exam. We don't do IV therapy in our center but we then order any tests or treatment that we are doing (x-ray, medication, culture, etc.). The tech goes back in to perform that stuff. Then the provider comes back again to go over the results with you, discuss the treatment plan, and discharge you. I don't see how they could possibly have registered you, gotten you all set to see the provider, been seen by the provider, had an IV put in and received the medication, and been done all in under 5 minutes. A really efficient visit with no tests or medications being administered might be 15-20 minutes minimum.

As for what was charged, the bill might have been for $625 but what was your actual responsibility? You likely have a copay for $50-100 for that visit, right? Your insurance will pay the rest and likely at a reduced contracted rate.

What could you do instead? As you said, you could have waited until the next day to see your doctor. Or you could have asked upfront how much it would be if you paid cash instead of using your insurance. Our site charges $170 for the visit and then additional charges depending on what is done. It sounds like this place charges $325 for the visit which sounds awfully high but I don't know the details.

[msomnipotent]

Does reviewing the itemized bill even matter anymore if she is in network? They look at the coding and not the charges. If she asked up front how much this would cost, they would probably tell her to ask her insurance company. Then her insurance company would ask for the diagnosis and billing codes, and then she may or may not be able to get them from the billing department. It was so frustrating for me the last time I tried that I gave up and never asked again. I would rather be surprised.

If your network has multiple locations, sometimes you can find an office that has late hours and get an appt there on the same day. You can avoid urgent care that way. Although our urgent care doesn't cost us any more than a normal visit as it is the same network. I only have to pay a larger copay if I go to the ER. I'm sure something like a Minute Clinic wouldn't be able to do an IV, but they are cheaper than an ER visit for me.

[jenn_jenn]

Let me start by saying that I am an urgent care physician and I've been in practice for 25 years.

You raise a few different points and questions. Let me start with the last one. How to you verify medical bills? You should always request an itemized bill. Generally a hospital or medical facility will just send a summary bill which doesn't break down all of the individual charges but you need that to know if the bill is correct. It is quite common for bills to contain errors. You may be billed for a product or service you didn't actually receive. You may be double-billed for something because two different people entered charges for the same thing. Review the itemized bill line by line and make sure it is correct. If you aren't sure what a charge is for, call and ask.

As for your urgent care visit, I have to say I find it pretty impossible to believe that the tech and provider spent "not even a total of 5 minutes combined" with you especially considering that you received IV therapy during your visit. I know that in our facility, the tech is with you for at least 5 minutes just doing your intake, getting your height and weight, taking your vital signs, doing a med review, checking allergies, and recording the history of why you are there. Then the provider goes in, reviews your history and gets more information from you before doing the physical exam. We don't do IV therapy in our center but we then order any tests or treatment that we are doing (x-ray, medication, culture, etc.). The tech goes back in to perform that stuff. Then the provider comes back again to go over the results with you, discuss the treatment plan, and discharge you. I don't see how they could possibly have registered you, gotten you all set to see the provider, been seen by the provider, had an IV put in and received the medication, and been done all in under 5 minutes. A really efficient visit with no tests or medications being administered might be 15-20 minutes minimum.

As for what was charged, the bill might have been for $625 but what was your actual responsibility? You likely have a copay for $50-100 for that visit, right? Your insurance will pay the rest and likely at a reduced contracted rate.

What could you do instead? As you said, you could have waited until the next day to see your doctor. Or you could have asked upfront how much it would be if you paid cash instead of using your insurance. Our site charges $170 for the visit and then additional charges depending on what is done. It sounds like this place charges $325 for the visit which sounds awfully high but I don't know the details.

I was hoping you'd chime in given your expertise. So firstly, thank you.

The doctor and nurse were with me for a very brief time. The nurse took my blood pressure when I first walked in, while simultaneously reviewing my medical file. Like I said, I'm a patient at the hospital so everything was already in their computer system. I have a documented history of chronic migraines and this was a particularly bad one (hence the visit).

They didn't take my height and weight, that was all info I filled out on a form prior to seeing anyone. Allergies were also something filled out on the form as well. The nurse checked my blood pressure, verified I was still taking my medications, and reviewed my current symptoms. I'd estimate that all in all it took a few minutes.

The Dr. came in to tell me they were giving me an IV and then the nurse tech administered. There was no physical exam or anything of the sort. The IV took time of course but they weren't with me during that period. So maybe 5 minutes was exaggerating a little - but truthfully not by much at all.
I've been to this urgent care a couple times in the past for migraines and this experience was definitely different.

To answer your question, my responsibility was $625. The total bill was around $750. The reason my portion was so high was because I haven't met my annual deductible yet. I had different insurance for my previous visits, I thought coverage was similar and wrongly assumed pricing would be roughly the same.

I did request an itemized bill which is why I knew the IV was around $300 and the rest was the visit fee which was classified as an L4. From my Google searches, I learned visits can range between 1 to 5, depending on resources used during the visit. It was really the visit fee that bothered me the most given the lack of time spent with anyone. The Dr. wasn't even able to answer my one question and told me to call my neurologist in the morning this wasn't his area of expertise. Don't get me wrong I was very grateful for their care but it didn't seem like a particularly resource heavy visit given that the IV administration and IV medication itself were billed separately.

I'm requesting the documentation of why my visit was classified as an L4, so far no one I've spoken with in their medical billing department has been able to answer this question. Which is what is so frustrating about medical billing - the lack of transparency. Even after two phone calls, no one has been able to tell me why my visit was classified as it was.

Am I just totally out of whack for thinking an urgent care visit with an IV of Toradol seems abnormally high at $625?

[jenn_jenn]

Does reviewing the itemized bill even matter anymore if she is in network? They look at the coding and not the charges. If she asked up front how much this would cost, they would probably tell her to ask her insurance company. Then her insurance company would ask for the diagnosis and billing codes, and then she may or may not be able to get them from the billing department. It was so frustrating for me the last time I tried that I gave up and never asked again. I would rather be surprised.

If your network has multiple locations, sometimes you can find an office that has late hours and get an appt there on the same day. You can avoid urgent care that way. Although our urgent care doesn't cost us any more than a normal visit as it is the same network. I only have to pay a larger copay if I go to the ER. I'm sure something like a Minute Clinic wouldn't be able to do an IV, but they are cheaper than an ER visit for me.

Yes, I've tried to get quotes before and it's worked out just as well as you'd described. And even when I managed to receive a quoted price, it's usually wrong by a decent amount.

Minute Clinics are a likely an option - that's a really good idea. Wish I had thought of that before. Of course, it wouldn't have worked in this specific scenario but that's because I was trying to hold off until seeing my doctor on Monday and ended up caving Sunday in the middle of the night. I'd have been better to go to a Minute Clinic over the weekend day. They even have their pricing online - amazing! Thank you for the suggestion.

[msomnipotent]

I'm requesting the documentation of why my visit was classified as an L4, so far no one I've spoken with in their medical billing department has been able to answer this question. Which is what is so frustrating about medical billing - the lack of transparency. Even after two phone calls, no one has been able to tell me why my visit was classified as it was.

Am I just totally out of whack for thinking an urgent care visit with an IV of Toradol seems abnormally high at $625?

I think you would be farther ahead by talking to the medical records department. Depending on how big the practice is, the person you talk to on the phone about your bill is not the person that put the charges or codes on the bill, or even billed your insurance.

[disneysteve]

There was no physical exam or anything of the sort.

This is highly disturbing. A doctor ordered IV medication for you without doing any physical exam? I'd have a major problem with that.

Just because you have a history of migraines and are presenting with a headache doesn't prove you have a migraine. Lots of other things can cause headaches. How could the doctor possibly be sure it was a migraine without doing at least a basic exam to rule out other issues?

The reason my portion was so high was because I haven't met my annual deductible yet.

I figured that was the case.

It was really the visit fee that bothered me the most given the lack of time spent with anyone.

It isn't necessary to spend a certain amount of time with a patient to determine the appropriate billing code. There's a list of factors that enter into the coding determination. Time is one of them but it's not the only one.

The Dr. wasn't even able to answer my one question and told me to call my neurologist in the morning this wasn't his area of expertise.

I wouldn't fault them for this necessarily. Patients often ask me questions that aren't my place to answer. That doesn't mean I don't know the answer, but they aren't my patient. I'm only seeing them for the acute care. For any questions relating to their ongoing care, medications, etc., I always refer them back to their treating doctor.

I'm requesting the documentation of why my visit was classified as an L4, so far no one I've spoken with in their medical billing department has been able to answer this question. Which is what is so frustrating about medical billing - the lack of transparency. Even after two phone calls, no one has been able to tell me why my visit was classified as it was.

I would contact both the site manager and the medical director. One of them should be able to explain the rationale behind the bill and, if they can't, should be able to help you get the bill corrected if a 99213 code was more appropriate. I can't comment either way without knowing all of the details but that's the route I would suggest.

[disneysteve]

I think you would be farther ahead by talking to the medical records department.

The medical records department has nothing to do with billing. That's what the billing department is for. However, the billing department only processes the charges. Only the provider who saw you can really explain why they coded the visit the way they did. That's why I suggested contacting the site manager and/or medical director.

[disneysteve]

Minute Clinics are a likely an option

For some things though not in this particular case. They couldn't have given you IV therapy there. Your only choices for that are the ER or an urgent care that offers that service (not all urgent cares do that - mine doesn't).

[TexasHusker]

There is a big difference between what is billed and what is paid by the insurance company. They might have paid $150 of that bill. You'll pay your copay.

Medical facilities and physicians bill what they want to. That's worked OK until recently, when deductibles have sky-rocketed and Joe Patient is now paying the bill. It's pretty much the wild west out there right now for that situation, as medical providers are gleaning the fields while they can. Many can't give you a coherent answer of what their charge even is ahead of time. Pretty ridiculous, but the free market will take care of it in due time.

[jenn_jenn]

This is highly disturbing. A doctor ordered IV medication for you without doing any physical exam? I'd have a major problem with that.

Just because you have a history of migraines and are presenting with a headache doesn't prove you have a migraine. Lots of other things can cause headaches. How could the doctor possibly be sure it was a migraine without doing at least a basic exam to rule out other issues?

I feel like you're somehow questioning my urgent care experience.

I say this respectfully, but as someone who has suffered from migraines since childhood and experiences some form of headache on an almost daily basis, it's pretty easy for me to distinguish a migraine from a basic headache. I had all of my classic symptoms, which I told the nurse, and although no one checked with me on my triggers during this visit - I also know (some of) my triggers and looking back it makes sense that I'd be hit with a particularly bad one at that time.

I wasn't concerned that an IV was administered because I was fully confident that this was in fact a migraine. It didn't bother me that the Dr. trusted my medical history, diagnosis from a neurologist, and accepted my stated symptoms as a migraine. You may have a different view as a medical professional but from my perspective, on this particular medical issue, it didn't bother me because I knew it was a migraine (a three day debilitating migraine at that).

My only concern was on combining medications (ie. was it safe to take Imitrex tomorrow if the migraine came back?) and not wanting to cause a migraine later due to over medication. This was the question the attending Dr. wasn't able to answer and recommended I ask my neurologist.

Also, the reason I thought the Minute Clinic might have helped is because I hadn't taken any Imitrex that day because my prescription was out and they do one time prescription refills. I'd used the last of my meds on the first two days of this migraine. I didn't have any refills and was waiting until Monday to go to my neurologist for an IV, per her direction, if my migraine was still present. Technically, I shouldn't be taking that much Imitrex, and I wouldn't have loved doing it, but another pill would have likely gotten me through the night to see my neurologist on Monday and allowed me to avoid a $625 visit to urgent care.

Thank you for the helpful tip for calling the site itself. I will do that.

[jenn_jenn]

There is a big difference between what is billed and what is paid by the insurance company. They might have paid $150 of that bill. You'll pay your copay.

Medical facilities and physicians bill what they want to. That's worked OK until recently, when deductibles have sky-rocketed and Joe Patient is now paying the bill. It's pretty much the wild west out there right now for that situation, as medical providers are gleaning the fields while they can. Many can't give you a coherent answer of what their charge even is ahead of time. Pretty ridiculous, but the free market will take care of it in due time.

This is exactly how I feel. My concern is that due time is going to take too long.

[disneysteve]

I feel like you're somehow questioning my urgent care experience.

I wasn't concerned that an IV was administered because I was fully confident that this was in fact a migraine. It didn't bother me that the Dr. trusted my medical history, diagnosis from a neurologist, and accepted my stated symptoms as a migraine.

Also, the reason I thought the Minute Clinic might have helped is because I hadn't taken any Imitrex that day because my prescription was out and they do one time prescription refills. I'd used the last of my meds on the first two days of this migraine. I didn't have any refills and was waiting until Monday to go to my neurologist for an IV, per her direction, if my migraine was still present.

I wasn't questioning you at all. Sorry if it came across that way. I was just commenting on the doctor doing nothing to confirm your complaint before treating you. You certainly didn't do anything wrong.

Also, for billing purposes, the extent of the physical exam is part of what goes into determining the code for the visit. I'd have to check but I'm not sure if a visit that involved absolutely no physical exam can even qualify as a 99214, so that might help support your case.

And yes, if Minute Clinic does refills, they could have helped, though not at that time of night of course. The urgent care probably could have done a refill also though I totally understand why you went with the IV treatment since you had been there before and thought you knew what the cost would be. Unfortunately, every insurance company is different so what your previous plan covered is different that what the new plan covers, plus you have the deductible to deal with.

[disneysteve]

Many can't give you a coherent answer of what their charge even is ahead of time.

This is very true and is a huge problem. We have that problem at our center and I've complained about it numerous times. The vast majority of our patients have insurance but some don't. When they ask how much everything will be, I can't tell them. It drives me nuts. I've spoken to our director about it and he agrees that we should be able to have a simple price list for how much a strep test or flu test or tetanus shot or chest x-ray is going to cost a cash patient. I'm still waiting for that list.

[msomnipotent]

The medical records department has nothing to do with billing. That's what the billing department is for. However, the billing department only processes the charges. Only the provider who saw you can really explain why they coded the visit the way they did. That's why I suggested contacting the site manager and/or medical director.

I've worked in hospital billing for over 10 years. Any time a code needed to be changed, it had to be done by medical records. No one in the billing dept would know anything about what level of care she would have needed and wouldn't have been authorized to change it. Once a patient is discharged, the records would have to be pulled and notes and whatever would be read, and our medical records dept would have to change it.

I'm sure it depends on the size of the facility. Some places probably have one person to code and bill. We had at least 60 people just in the business office alone, and I have no idea how many in medical records. Our billing department had nothing to do with the bills until after it was cut. The doctors and nurses actually determined what went on the bill just by ordering things for the patient and data processing generated the bills. Registration determined where the bill would be sent when they entered the insurance information in the system. We wouldn't have even known a bill existed unless it needed to be sent to an insurance company or a patient called about a problem. There was very little we could do about problems unless it had to do with the wrong insurance info or something very obvious. I remember someone came in for something very minor and was charged for 41 lactated ringers. That was something I could change. Changing the level of care was not.