The $1000 Sprained Ankle
Why do we love sprained ankles in the ER? Why are we establishing Fast Tracks in our EMERGENCY departments in order to expedite these cases? Why don't we want them to leave without being seen and go somewhere else?
Because we can charge you over a thousand dollars for your sprained ankle, that's why. Here's how:
ERs make money by charging facility fees which are separate from the physician's (or PA's) billing. These fees are divided into 5 levels of care depending on how complicated the visit was. A basic triage with no prescriptions might be a level 1, whereas a cardiac arrest with multiple interventions is the highest level. Points are given for each intervention such as IV placement, medication administration, discharge teaching, etc., and the total number of points is used to determine the level of care (and therefore the ER charge).
At our facility, there is a big increase from a level 2 ($225) to a level 3 ($650) facility fee. After we've given you a pain pill, sent you off to X-ray, and applied a removable plastic splint to your sprained ankle, with one click on my electronic medical record I can increase your bill by over $400 - by ordering crutches and crutch training. For some reason, crutch training is worth several points, easily enough to catapult you into level 3 territory.
So after the cost of the X-ray, pain pill, plastic splint, and crutches are added to our facility fee, and once you receive your separate bills from the Radiologist for his interpretation of your X-ray and from me for evaluating and treating you, your charges are easily over $1000 for that sprained ankle. And you haven't even picked up your prescription yet.
That's why we love sprained ankles in the ER. You don't care, your copay is only $100. But maybe you should care.
Because we can charge you over a thousand dollars for your sprained ankle, that's why. Here's how:
ERs make money by charging facility fees which are separate from the physician's (or PA's) billing. These fees are divided into 5 levels of care depending on how complicated the visit was. A basic triage with no prescriptions might be a level 1, whereas a cardiac arrest with multiple interventions is the highest level. Points are given for each intervention such as IV placement, medication administration, discharge teaching, etc., and the total number of points is used to determine the level of care (and therefore the ER charge).
At our facility, there is a big increase from a level 2 ($225) to a level 3 ($650) facility fee. After we've given you a pain pill, sent you off to X-ray, and applied a removable plastic splint to your sprained ankle, with one click on my electronic medical record I can increase your bill by over $400 - by ordering crutches and crutch training. For some reason, crutch training is worth several points, easily enough to catapult you into level 3 territory.
So after the cost of the X-ray, pain pill, plastic splint, and crutches are added to our facility fee, and once you receive your separate bills from the Radiologist for his interpretation of your X-ray and from me for evaluating and treating you, your charges are easily over $1000 for that sprained ankle. And you haven't even picked up your prescription yet.
That's why we love sprained ankles in the ER. You don't care, your copay is only $100. But maybe you should care.
Labels: health care crisis
posted by scalpel at 9:22 AM
28 Comments:
I'd be interested in reading something about how to tell when you should go to the ER, urgent care, etc.
I usually err on the side of NOT going to the doctor, but how do you know?
My DH had surgery a couple of months ago. 4 hrs in the ER and an over night stay. $23,000 (yes all those 0's).
A year ago he had a comparable surgery at a facility across the street. $1800.
We had to go to the major-wallet-eating hospital because our insurance wouldn't approve the minor outpatient center across the street.
Maybe I missed something in the complexity of the second surgery and price increases of medicine, but it seems a little much.
I went to one ER over the summer for about 6 hours, IV antihistamine and a head CT - $1800
I went to another ER a few months ago for 8 hours, IV contrast and head/neck MRI and MRA - $15,000
Perhaps the difference in cost is merited by the more complex and longer imaging, but it was a real shock to me when I got the bill. I should have sucked it up and made an appointment with a PCP.
I left both times with no diagnosis and still have the problem. I was referred to a PCP and still have no diagnosis, other than the possibility of a "cyst" or "slightly enlarged lymph node" and no referral. We're going to watch it, make sure it doesn't get larger, even though it's causing intermittent pain levels ranging from 4-8.
But at least they were concerned about my high cholesterol.
-GOPer
Learn the Ottawa Ankle rules and send them on their way with an exam and ankle splint.
I wonder how much a sprained toe would cost??? I mean , I could just cut it off and save me some money ! LOL LOL J/K ,,.. Stacy.........
But what happens when the the insurance pays $329 of your $3000 bill and you have your $50 copay and the rest is written off by the hospital?
It doesn't matter what I have been seen for in the er and how complicated it is. My insurance company pays $329 for ER services, $50 copay from me, and everything else is wiped out. Except physician charges. I never see how much the physician originally charged, just what they paid.
Are you familiar with high-deductible consumer plans? They don't seem to be catching on.
My first 3 years with my employer, I scoffed and picked the PPO. "Bastards are trying to cheap out on my insurance and shove this consumer plan down my throat."
This year, for 2009, I reflected on my very low use of services for the past 7 or 8 years and thought, "Well, ASSUMING this year is no different than the rest, I stand to MAKE money with this plan next December IF I stay away from doctors." (My company makes a contribution toward the high deductible and if it's not used, you can keep it as an Health Savings Account).
The structure of the plan is such that I have a financial incentive (building my HSA $$ with boss contributions) to monitor costs and not use services if I don't need them.
I think that if everyone were encouraged to actively manage their health monies in this manner, we might have fewer $300 ER pregnancy tests, no?
Of course, the catch here is that I'm a low-user because I'm young, and if I had a serious medical condition, I'd probably do better with the PPO. But do you think they might be on to something in encouraging patients to pinch pennies?
(Dear god, please don't let me get sick in 2009 because Cigna will stick it to me. Amen.)
6:54
You touched on a major part of the problem. A hundred people with the same DX and treatment and the same $1,000 bill and the hospital will receive a hundred different payments from different insurers.
The uninsured will recieve the full bill. It is all stupid. It should be like shopping for peanut butter or a refridgerator. The price is marked and everyone pays the same.
10:43
This is true, however no hospital will receive the full $1,000 from any private insurance. Not even close, as all insurances have charts on how much a sprained ankle is worth and they will contest any charge that seems unnecessary.(crutch training comes to mind...)
And if you went to a hospital within your network, it can't charge you for the difference because that's illegal.
nurse k-
i hear they don't sue much in ottawa.
i don't think the rules of evidence-based medicine apply in this country- just look at that fm residency that was successfully sued for explaining the risks/benefits of psa screening and allowed the patient to decline the test.
Well, true. The sad thing is that the way insurance companies assign values to treatments and diagnoses is all out of whack. However, we live in a "free" market society so that is where we have set the value of such things. You have actually made an argument for nationalised health care and predetermined fee schedules.
Of course, the catch here is that I'm a low-user because I'm young, and if I had a serious medical condition, I'd probably do better with the PPO.
Yeah, I'm young AND would be totally uninsurable under a completely free-market system.
OK, I am sorry but unlike the fibro or sniffles or some of the other dumb reasons that I fully understand the med blogging community wishing not to show up at the ER. I don't quite get this. If after normal work hours say 10:00 p.m., I step off a curb and feel a sudden pain to my ankle, it swells to 2.5 - 3 times it normal size, it rates a 4-6 on the pain scale at rest, 5-7 to try to move the ankle, and 8-9 to try to bear weight. Do you suggest a couple of tylenol or motrin and ice packs and hope to get any sleep. I use the ER in a case like this because I don't have any real certainty if it is a bad sprain or a break and the ER will "probably" give something stronger than what is in my medicine cabinet at home. Obviously if it is during normal working hours an urgent care would fit the bill. Am I way off base because I don't factor in the cost to my insurance because that is why I purchase insurance?
We are pretty lucky because with our insurance if it is an emergency (ankle injury qualifies) they will pay 100% and no copay last I knew.
We are supposed to precert but they would approve.
Anonymous 10:35 -I think that if you are in extreme pain, concerned about it getting worse...you should go to the ED if there are no other PCPs or clinics available.
And know your plan. If it covers go! if it doesn't but you need it.. do what you need to do.
The nice thing about the ER Scalpel is it is a one stop deal because you guys take care of everything right there... and then refer to specialists when necessary.
But it is expensive.
Even though my ins covers the ED 100%, there is a 10% co pay for the radiologists and ED docs.
At the facility I have frequented... the anesthesiologists, radiologists and ED docs are nonparticipating with my plan and therefore my co-pay is 25%!
But...the hospital is in network and so I stated this fact to the ins company and that I can't help who works there...i still went where they said I could. They reimburse them at 90%.
I think the charge for crutch instruction is ridiculous...SERIOUSLY! Of course a pt would be shown how to use it but I know...everything is broken down with codes and for charges.
I wonder...Scalpel... do providers make more money with the way charges are broken down then they did 15-20 years ago when the claims were more generalized or less? the ED was ALWAYS expensive.
hey..I know how to to help the patient save money. Tell them if they figure out how to use the crutches on their own...they can save money! of course you need them to be able to leave too. ;)
Personally...I would go to my ortho doc because he can do x-rays right there.
Like Anonymous [1/1/2009 10:35], I can imagine several scenarios in which it would be very reasonable for me to visit the ER were I to injure an ankle.
Is there really a bean counter hidden somewhere in the facility (in the real time of my visit) who is tracking the level of care I receive? Do I need to worry that the doctor or PA treating me is padding the bill -- "with one click on my electronic medical record I can increase your bill by over $400 - by ordering crutches and crutch training."
I'm sure you are on a mission to alert healthcare consumers -- though your expertise in how to raise costs gives pause! I take medical charges and billing very seriously -- both what I have to pay and what my insurance has to pay. I pay $1100 a month in premiums and have a deductible/OOP due of $5000. I live on a disability income that consists of 60% of my teaching salary. So things like the artificial inflation of my level of care don't amuse me.
So thanks ever so much if this was an object lesson in how charges manage to accrue so mysteriously --I will be sure to pointedly inquire about the billing *while* being treated, and thereby secure my reputation as a pain in the ass.
But if this is a common modus operanci? Cease and desist. It sure sounds fraudulent!
Either way, my awareness is heightened. Thanks.
(I love the internet. Feeling very lazy, I plugged "medical fraud" into my search engine. The first line of the first site I chose? "There is no other drive so powerful than the desire to mutilate another's genitals." I think I'd better call it a day.)
It's not fraudulent, that's just how much it costs to be seen in the ER for a sprained ankle. Similarly, a half inch laceration that is closed with dermabond (superglue) will easily cost over $500.
I have never liked crutches -- feel unsafe and unbalanced -- and prefer to use a cane when needed. Glad to know I've saved $$$ as well.
>>It's not fraudulent, that's just how much it costs to be seen in the ER for a sprained ankle. Similarly, a half inch laceration that is closed with dermabond (superglue) will easily cost over $500.<<
Scalpel, it is fraudulent, but you've been doing it so long you think it's normal. For somebody who advocates market driven medicine you often come up with the most compelling reasons to junk the whole system and let the government run the hospitals. Anyway, it's only the uninsured who really get screwed with this system. Me - I'd go to an in-plan hospital where I know the bill will get resized appropriately.
The government already determines what we can charge for a given service and what sort of documentation we must produce in order to justify our charges. Everything we do is based upon satisfying CMS (Medicare) requirements, so we are already de facto government employees.
The strict Medicare rules (and the stiff penalties for their violation) have shaped the way we provide medical services in this country, and that has carried over to privately insured patients and uninsured alike.
Interestingly, from the link above, if I were to prescribe "multiple" (meaning two) medications to a patient, for example an antibiotic and some cough syrup, then the discharge instructions given by the nurse would automatically fall into the "complex" category, which would technically raise the facility fee to a level 4 no matter what else was done during the visit.
That's almost $1000 for an upper respiratory infection even before adding the physicians' bill. In practice, I doubt we would code such a visit like that, but it would appear to be justified if we did.
You think I'm making an argument FOR nationalized healthcare? You are quite mistaken. Over-regulation causes ridiculous things like this to happen.
Hey Scalpel, have you seen these ERs? I took my daughter to one last year. They do not accept Medicare or Medicaid.
I suspect we will be seeing a lot more of these around..or one can hope anyway. Our experience was a very pleasant one. We were in and out in under an hour. It was very clean. The staff was super nice.
http://www.24houremergencyroom.com/
Yes, I posted about them here: "the wave of the future." We're so used to being government employees that many freestanding ERs still follow government regulations even when they aren't required to do so: they still seek Joint Commission certification, I know of one that still follows EMTALA for the most part, and they still use government billing codes. That will all change, eventually.
Alot of you are missing the point. The ER is for emergiencies. I case you dont know how to figure out if you have an emergency, let me help you. Are you gonna die of your condition soon? If the answer is yes you need the ER if the answer is no then go somewhere more appropriate or dont bitch about your wait or your bill. Oh and I dont really give a damn what kind of insurance you have.
Here's the raw deal on this one, if I called my daughers or my PCP and said that I'd injured my ankle and I'd like someone to take a look at it, the receptionist at either office would tell me that they lacked the x-ray capability to diagnose it and that I should go to the emergency room. I know, because it's happened. Recently I called my PCP on a Thursday morning because it was apparent that I was coming down with cellulitis. I was told by the receptionist that the doctor didn't have any appointments until the following Tuesday. I'm a cancer survivor and I have lymphedema, and I have a serious heart condition that would put me in grave danger if the cellulitis went systemic. I went to the urgent care place, but the doctor there didn't know my history and didn't treat agressively enough. I ended up in the emergency room regardless of trying to stay out of it. Primary care physicians use the ER as back-up for expensive equipment they don't want to purchase or man and for overflow for their already packed schedules. As a patient, I have little choice in the matter. And as was pointed out above, if I question your financial motive for everything you do, I'm a pain in the rear. So, please don't think that patients can change the system for you. If you want the system changed to something that isn't broken you need to come up with a better plad. Patients have the least amount of power in this whole senario regardless of whether we have insurance or not.
I don't necessarily want the system changed. As I mentioned, we in the ER make a good living by capitalizing on the inefficiencies of the current system.
Bring me your sprained ankles and your cellulitises, and bring your credit card.
Perhaps we need a separate the ER room, one for life saving emergency and one for everything else.
Can someone answer my question. I am curious if an orthopedic surgeon is dictated what and how they must bill certain procedures by big brother (the government). My daughter chip fractured her ankle for which the doctor took her boot off, took an xray and told us everything was healing fine. That was the extent. Well we get the bill and it was coded as "surgery" and billed 1400 dollars!!!! after insurance it came to 550. After contacting the doctor he said that he is under control by the government on how he bills a "closed fracture" and that legally he has to bill it as surgery even the the only thing he did was take an xray and look at the ankle. The whole visit took 20 minutes. I am just wondering if he is telling the truth.
And I bitch about £100 a year for my prescription pre-payment certificate. Jesus feckin' H. Christ swivelling on a pencil.
The best thing about the NHS? You Yanks paid for it :D :D :D
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