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Turned Away From Urgent Care — And Toward a Big ER Bill

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Frankie Cook only has flash memories of last year’s car accident.

She was driving a friend home from high school on a winding road outside of Rome, Georgia. She saw standing water from a recent rain. She tried to brake, but lost control of her car in a large corner. “The car rolled over about three times,” Frankie said. “We turned and walked down the side of that hill. My car was on its side and the rear end was crushed against a tree.”

Frankie said the airbags had deployed and both passengers were wearing seat belts, leaving her with a headache when her father, Russell Cook, came to pick her up from the crash site.

Frankie, then a high school junior, was concerned she might have a concussion that would affect her performance on an upcoming Advanced Placement exam, so she and her father decided to stop by an emergency center near her home to have her evaluated . They couldn’t get past the front desk.

Frankie Cook was driving a friend home from high school when her car went off a winding country road outside of Rome, Georgia, rolled over several times and crashed into a tree. She wasn’t seriously injured, but her family quickly ran into another problem after being turned away from an emergency center due to insurance issues.(Russell Koch)

“‘We don’t take out liability insurance,'” Russell said the receptionist at Atrium Health Floyd Urgent Care Rome told him, although he wasn’t sure what she meant. “She told me about three times.”

The problem didn’t seem to be that the clinic lacked the medical expertise to examine Frankie. Rather, the Cooks appeared to be faced with a reimbursement policy often employed by emergency care centers to avoid waiting on car insurance bill payments.

Russell was ordered to take Frankie to an emergency room, which by law is required to see all patients regardless of such issues. The closest, at Atrium Health Floyd Medical Center, was about a mile down the road and was owned by the same hospital system as the emergency center.

There, Russell said, a doctor examined Frankie “just for a few minutes,” performed precautionary CT scans of her head and body, and sent her home with the advice to “take some Tylenol” and rest. She did not have a concussion or serious head injury and was able to take her AP exam on time.

Then the bill came.

The patient: Frankie Cook, 18, now a freshman from Rome, Georgia.

Medical service: A medical exam and two CT scans.

Service provider: Atrium Health Floyd, a hospital system with emergency care centers in Northwest Georgia and Northeast Alabama.

Total bill: $17,005 for an emergency room visit; it was later adjusted to $11,805 after a duplicate charge was removed.

What gives: The Cooks have found a hazard in the healthcare system after Frankie’s car hit that tree: More and more hospital systems have emergency care centers that place restrictions on who they treat — for both financial and medical reasons.

Russell was quite upset after receiving such a high bill, especially when trying to get to the clinic quickly and cheaply. He said Frankie’s grandmother was seen at an emergency center after a car accident and left with a bill for just a few hundred dollars.

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“It’s kind of what I expected,” he said. “She just really needed to be examined.”

Why was Frankie turned away from an emergency center?

Lou Ellen Horwitz, CEO of the Urgent Care Association, said it’s a fairly standard policy for emergency centers not to treat injuries resulting from auto accidents, even minor ones. “In general, they don’t usually care about car accident victims, regardless of the extent of their injuries, because they go through the auto insurance claims process before the provider gets paid,” she said.

Horwitz said emergency care centers — even those owned by large health systems — often operate on tight margins and can’t wait months and months for an auto insurance company to pay out a claim. She said “unfortunately” people would tend to hear about such policies when they show up expecting care.

Add in the complicated relationship between health and auto insurance companies, and you have what Duke University Law School professor of health policy Barak Richman called “the exceedingly complex world in which we live.”

“Each product has its own specifications of where it is going and what it covers. Each one is incredibly difficult and complex to manage,” he said. “And everyone adds bugs to the system.”

Atrium Health did not respond to repeated requests for comment on Frankie’s case.

A photo shows Frankie Cook talking to her father in the kitchen.After Frankie Cook’s car accident on a wet street outside of Rome, Georgia, her father, Russell, received a letter from a lawyer stating that they owed $17,000 for an emergency room visit to determine if Frankie had suffered a concussion .(Audra Melton for KHN)

Horwitz dismissed the idea that a healthcare system could push people in wrecked cars from emergency centers into emergency rooms to make more money off them. However, car insurance usually pays more than health insurance for the same services.

Richman remained skeptical.

“At the risk of sounding a little too cynical, there’s always dollar signs whenever a healthcare provider sees a patient walking through the door,” Richman said.

dr Ateev Mehrotra, a professor of health policy at Harvard Medical School, said it was probably strategic that the emergency center is right next to the emergency room. Part of the strategy makes medical sense, he said, “because if something bad happens, you really want to move them to a more skillful place quickly.”

But he also said emergency centers are “one of the most effective ways” for a healthcare system to generate new revenue and create a pipeline of new patients who visit their hospitals and later see doctors for testing and follow-up.

Mehrotra also said emergency centers are not bound by the Emergency Medical Treatment and Labor Act, a federal law called EMTALA that requires hospitals to stabilize patients regardless of their ability to pay.

At the time of Frankie’s visit, both the emergency center and emergency room were owned by the Floyd Health Care System, which operated a handful of hospitals and clinics in northwest Georgia and northeast Alabama. Floyd has since merged with Atrium Health — a larger North Carolina-based company that operates dozens of hospitals in the Southeast.

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Frankie got a CT scan of her head and body in the ER, tests that KHN confirmed she couldn’t have gotten at the emergency center, regardless of whether the test was medically necessary or just part of a protocol for people in car wrecks who find themselves complaining of headaches.

One photo shows Frankie and Russell Cook sitting together on a sofa and looking at the camera.(Audra Melton for KHN)

Resolution: Sixteen months have passed since Frankie Cook’s hospital visit and Russell, on the advice of a family friend who is a lawyer, has delayed paying the bill. After insurance paid their cut, the cooks’ cut was $1,042.

It was a frustrating process to reach that number, Russell said. In a letter from an attorney representing the hospital, he heard about the original bill of $17,005 — another unnerving wrinkle of Frankie’s caring stemming from the car accident. The Cooks then had to start a lengthy appeals process to get a $5,200 double charge removed from the bill.

Anthem Blue Cross Blue Shield, the Cooks’ insurer, paid $4,006 of the claim. A statement said it was “committed to providing our members with access to quality medical care. This matter has been reviewed in accordance with our clinical guidelines and the billed claims have been processed accordingly.”

“It won’t put us on the road,” Russell said of the $1,042 balance, “but we have expenses like everyone else.”

He added, “I would have liked to have made a $200 emergency visit, but this ship has sailed.”

Take away: It’s important to remember that emergency department centers are not governed by the same laws as emergency departments and they can be more selective about who they treat. Sometimes their reasons are financial, not clinical.

It’s not uncommon for emergency centers — even those in large health care systems — to turn away people caught in car wrecks because of the complications posed by auto insurance bills.

Although urgent care visits are cheaper than visiting an emergency room, clinics often cannot provide the same level of care. And you may have to pay the cost of an urgent care visit, only to find out you need emergency room follow-up care. Then you could be stuck with two bills.

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

Sam Whitehead:
swhitehead@kff.org, @sclaudwhitehead

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