Dhaval Bhatt had been warned about hospital emergency rooms.
鈥淧eople always told me to avoid the ER in America unless you are really dying,鈥 said Bhatt, an immigrant from India who got a Ph.D. in pharmacology in the U.S. and is now a research scientist at Washington University in St. Louis.
But when Bhatt鈥檚 2-year-old son burned his hand on the kitchen stove on a Wednesday morning in April, the family鈥檚 pediatrician directed them the next day to the local children鈥檚 hospital.
Bhatt was traveling. So, his wife, Mansi Bhatt, took their son to the hospital and was sent to the emergency room. A nurse practitioner took the toddler鈥檚 vitals and looked at the wound. She said a surgeon would inspect it more closely.
When the surgeon didn鈥檛 appear after more than an hour, Bhatt鈥檚 wife took her son home. The hospital told her to make a follow-up appointment with a doctor, which turned out to be unnecessary because the burn healed quickly.
Then the bill came.
The Patient: Martand Bhatt, a toddler covered by a UnitedHealthcare insurance plan provided by the employer of his father, Dhaval Bhatt.
Medical Service: An emergency room visit for a burn sustained when Martand touched an electric stove.
Total Bill: $1,012. UnitedHealthcare鈥檚 negotiated rate was $858.92, all of which the Bhatts were responsible for because their plan had a $3,000 deductible.
Service Provider: SSM Health Cardinal Glennon Children鈥檚 Hospital, one of 23 hospitals owned by SSM Health, a Catholic, nonprofit health system with .
What Gives: Many patients don鈥檛 understand that they can rack up huge bills almost as soon as they walk through the doors of an ER.
Unlike a restaurant or a mechanic who won鈥檛 charge if someone gets tired of waiting for a table or an inspection of a rattling engine, hospital emergency rooms almost invariably charge patients as soon as they check in.
And once they register, patients will be billed 鈥 often a lot 鈥 whether treatment was rendered or not.
Martand Bhatt received almost no medical service. A nurse practitioner looked over the toddler, listened to his heart and stomach, and looked in his nose, mouth and ears, according to provider notes prepared by the hospital and shared with KHN by Bhatt.
The nurse didn鈥檛 change the dressing on the wound or order any testing.
鈥淢y objection to this is that there was no care provided,鈥 Bhatt wrote to Bill of the Month.
鈥淢y wife did not drive for 45 minutes to get to an ER and wait for an additional 1陆 hours for someone to tell me that our child鈥檚 vitals 鈥 weight, height, temperature and blood pressure 鈥 were OK,鈥 Bhatt continued. 鈥淲e already knew that. 鈥 It is absolutely ridiculous and unethical.鈥
When the Bhatts left the emergency room, Martand was 鈥渁lert, active and well-appearing,鈥 according to the notes.
The nurse鈥檚 assessment of Martand cost $192, which was discounted by UnitedHealthcare to a negotiated rate of $38.92. The bulk of the Bhatts鈥 bill 鈥 $820 鈥 was something called a facility fee.
Hospital officials defend these fees as necessary to keep the emergency room open 24 hours a day as a community asset.
SSM Health spokesperson Stephanie Zoller Mueller declined to discuss the details of Martand鈥檚 medical condition even though the Bhatts gave their permission for the hospital to do so.
In an email, Zoller Mueller said the charges were 鈥渁ppropriate鈥 based on the 鈥渁cuity of condition, discharge instructions, vital sign monitoring, traumatic wound care (and) numerous assessments.鈥
She added: 鈥淎 patient does not have to receive additional treatment 鈥 procedure, labs, x-rays, etc. 鈥 to validate an ED [emergency department] level charge.鈥
But some patient advocates say these facility fees are applied much too widely and should be limited to patients who actually receive medical care.
鈥淚t鈥檚 just not appropriate for someone to be charged if they鈥檙e not provided treatment,鈥 said Adam Fox, deputy director of the Colorado Consumer Health Initiative. 鈥淧atients aren鈥檛 availing themselves of a facility if they don鈥檛 get care.鈥
At the very least, hospitals could communicate more clearly to patients about the fees they may be charged for coming to an emergency room, said Maureen Hensley-Quinn, senior program director at the National Academy for State Health Policy.
鈥淧eople should know that when they walk in to receive care, there is this fee that they will be assessed,鈥 Hensley-Quinn said.
Hospitals could also post at the entrance to the ER standard fees for different levels of emergency care.
Bhatt鈥檚 fee still could have been lower if the hospital had classified his son鈥檚 injury as minor. But, again, the hospital billing process worked against the family 鈥 and in favor of the hospital鈥檚 bottom line.
Emergency visits are usually classified for billing on a scale from 1 to 5. Level 1 is minor and routine; Level 5 requires complex care for life-threatening conditions. And hospitals are to classify emergency visits, research shows.
鈥淭here are financial incentives for billing at a higher severity,鈥 said Aditi Sen, who directs policy and research at the nonprofit Health Care Cost Institute, which has studied emergency room coding.
Despite the lack of severity of Martand鈥檚 wound and the absence of medical care, his visit was classified as Level 3, a moderate severity problem.
Resolution: Incensed that he鈥檇 been charged so much, Bhatt made numerous attempts to get the hospital to reduce the charges. He also appealed to UnitedHealthcare to review the charges.
His efforts failed. In August, Bhatt received a letter from an SSM Health 鈥減atient advocate鈥 informing him that the hospital would not adjust the bill and instructing him to contact patient billing to arrange for payment.
While Bhatt was trying to reach the patient advocate by phone, his bill was sent to Medicredit, a collection agency, which began sending him notices and calling him.
After KHN contacted SSM Health, Bhatt received a call from someone who worked on 鈥減atient financial experience鈥 issues at the hospital.
The hospital agreed to forgive the $820 facility fee. Bhatt agreed to pay the remaining $38.92, the professional fee for the ER nurse鈥檚 work. Bhatt also received a notice from Medicredit that it would take no further action against him.
The Takeaway: The Bhatts did what most parents would do when a pediatrician advises them to take their child to the hospital.
But emergency rooms are among the most expensive places to get care in the U.S. health system.
If you have a relatively low-level issue, think twice before even registering at the front desk, the act that initiates the billing process. If your doctor doesn鈥檛 have same-day appointments or after-hours service, think about urgent care, which is often much cheaper if the center isn鈥檛 attached to a hospital.
And remember that if you go to a hospital emergency room with a relatively minor issue, chances are that you鈥檒l have to wait, as the Bhatts did. Patients with more serious problems will be seen first.
Once you鈥檙e taken past the front desk, you will almost certainly be hit with a substantial facility fee even if you don鈥檛 receive care.
Appealing that fee to the hospital can occasionally be successful, but there are no guarantees. And, as Bhatt learned, don鈥檛 expect the health insurer to offer much help. Most insurers won鈥檛 challenge how a medical visit is coded except on extremely expensive medical claims that will cost them money.
In this case, Bhatt was on the hook for the whole fee because he had a high-deductible plan, so the insurer had little incentive to take up his cause.
For now, patients鈥 best hope, many advocates believe, is to publicize the high prices that hospitals charge for their services, inside and outside the emergency room.
Bill of the Month is a crowdsourced investigation by KHN and that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!