Emergency Clinics

License to Bill

At a loss to explain your medical costs? So are doctors, insurance companies, and pretty much everyone else involved.

By Jeff Balke August 1, 2013 Published in the August 2013 issue of Houstonia Magazine

Image: Peter Ryan

Elizabeth Almond came to Houston in May 2012 to find a home for herself and her husband, who had been transferred here. Fresh off a wedding and honeymoon that took her to four states in as many weeks, she had begun suffering from what she suspected was a nasty sinus infection. Almond flew from New Hampshire to Houston one evening, waking up the next morning with neck glands so swollen that she could barely turn her head. She decided to see a doctor.

“I am the opposite of a hypochondriac,” she said. “For me to go to a doctor, it has to be pretty bad.”

Because she’d been prospecting for homes in the Rice Village area, the 31-year-old decided to visit the Elite Care 24 Hour Emergency Center on Rice Boulevard. According to Almond, the doctor, after consulting with her for a few minutes in an examining room and listening to her symptoms, dismissed her concerns about an infection. Relieved, she left, but not before asking if there was a copay. “Nope, you’re all set,” was the answer Almond says she got. A month later, she found out what that diagnosis really cost her.

“It turned out,” she said, “[I paid] $1,700 to have a doctor tell me I had allergies.”

As a quick internet search easily demonstrates, Almond isn’t the only Houston patient surprised by a bill from a walk-in provider of medical care. “They told me it would be $150 for the basic costs. It is more than $1250,” complained Bryan H. on Yelp after he visited the same Elite Care facility. Joshua T. went to Memorial Heights Emergency Center on Washington Avenue: “They charged us for both ‘Repair superficial wound’ ($650) AND ‘Surgical kit’ ($350).  That was what it cost to put superglue on my daughter’s face.” 

“I went in for a sore throat that wouldn’t go away,” said Vickie K., speaking of the Elite Care facility in League City. “5 1/2 months later, I’m getting a bill for more than $1,500.”

And then there was Lisa Grabowski’s Google review of River Oaks Emergency Center. I feel like a victim of fraud,” she wrote. “I was charged over $1000 for a brief exam, strep test, and one pill.”   

By the time I read those reviews, my fiancée and I had been to River Oaks Emergency Center ourselves and had a story of our own. 

We were at a party one Friday night last January when suddenly she began feeling so cold she actually crawled under a blanket on our host’s couch. In the space of an hour, she went from her normal self to a shaking, achy, anxious mess. She still had a 101-degree fever the next morning, so we got in the car.  

It wasn’t long before we came across a clinic called MedSpring Urgent Care on West Gray. The waiting room was crowded and chaotic. A nurse described the wait time as “at least two and a half hours,” at which point we saw a mother, her young daughter in tow, storm out of the facility while screaming about being stuck in an examining room for two hours. 

We left, soon finding another clinic that didn’t look busy in a strip mall on South Shepherd—River Oaks Emergency Center. Walking through the center’s double doors was like that moment in The Wizard of Oz when the screen goes from black-and-white to Technicolor. The receptionist was smiling. What was that smell? Fresh coffee? Contemporary art and a warm color palette greeted us. There were big, comfortable leather armchairs, generously spaced so that you’d never have to bump germ-laden elbows with a neighbor, if you had neighbors. Which we didn’t. 

The copay wasn’t cheap—$100—but we figured we’d splurge given the circumstances. How much would we ultimately owe, we wondered? A “few hundred dollars total,” said the receptionist, depending upon one’s insurance (Blue Cross Blue Shield, in our case). 

Our doctor was both polite and attentive. She personally took my fiancée’s temperature, all the while peppering her with pertinent questions: was she having a hard time breathing? Did she have any nausea? The doctor swabbed her nose to test for the flu, and handed her a couple of Tylenols with a cup of water. The flu test came back negative, she was given a steroid shot, and the doctor gave us both prophylactic prescriptions for Tamiflu. And that was it.

Four weeks later, a bill arrived. Having surrendered the $100 copay, I was surprised to get a bill at all, much less one for an additional $301. I was even more surprised when, two weeks after that, another bill arrived, this one for $139.  Total charges? $540. At least I hoped those were the total charges. 

I know what you’re thinking. You see a coffee bar in a waiting room, you should expect to pay for it. You don’t get a clean, chaos-free waiting room and 27 kinds of java for nothing. But once I knew what the experience had cost us, all I could do was kick myself for not staying home and riding out the illness with chicken soup and a Law and Order marathon. Ultimately, it was my fault. I chose River Oaks. I chose not to demand more answers about the costs of the visit before my fiancée was treated. I was angry and frustrated, but how was I supposed to feel after being charged 500 bucks for two Tylenol and a steroid shot? Lucky? 

Lucky is exactly what we were, according to a Blue Cross Blue Shield representative whom I called seeking guidance. It could have been much, much worse, she said. I could have been on the hook for the total cost of my River Oaks experience—$2,608. That was the amount of the bill River Oaks sent to the insurance company. When Blue Cross Blue Shield said they were going to pay only $149 of that—the cost of the two influenza tests performed on my fiancée—River Oaks decided to reduce the bill instead of charging me the remaining thousands.

“Why?” I asked the representative. “I don’t know,” she said. 

She told me that it wasn’t uncommon to see patients charged the full amount in these situations. And what if I’d been one of the more than 30 percent of Houstonians who lack health insurance, I wondered? Actually, that’s not what I wondered. 

“Do you think this is the last bill we’ll get?” I asked a different representative. “Probably,” she said. 

People living through minor emergencies—sudden fevers, earaches, migraines—are not the sort to make careful decisions, not the kind to notice that there are at least two varieties of neighborhood clinics—“urgent care” facilities such as MedSpring and “freestanding emergency centers,” or FECs, such as River Oaks Emergency Center. And even if they were, what’s the difference between an urgent situation and an emergency? Nothing when your kid is enduring a bout of strep throat or pink eye, but everything when it comes time to tally up the costs. According to a 2013 report from Debt.org, the cost of treating everyday illnesses like sore throat and pink eye is three to five times higher at FECs than at urgent care facilities. 

Why? Well, it turns out that FECs, unlike urgent care clinics, have a laundry list of regulatory requirements that distinguish them—in fact, if not in outward appearance—from urgent care. They must, for instance, be open 24 hours a day, 7 days a week; be staffed by doctors and registered nurses certified in emergency medical care; and possess elaborate and expensive diagnostic equipment necessary to produce CT scans and ultrasounds. All FECs must also have a pharmacy on site. 

Given that, you’d think the difference between an FEC and an urgent care facility would be obvious. Evidence suggests otherwise. Between the confusion over the nature of the clinic and the difficulty in understanding my bill, I realized I’d stumbled on yet another dysfunctional aspect of our health system.

Alan Ayers is a vice president of Concentra, a Dallas-based chain of urgent care centers, which is to say he works for the competition. “It’s something of a Texas phenomenon,” Ayers said of FECs. “With the epicenter in Houston.” 

He’s right. There are more FECs in Texas than any other state—43 in Houston alone, according to Ayers. Houston’s combination of affluent neighborhoods and less-than-restrictive billing regulations has made us an incubator for this rapidly growing industry. With the Texas Medical Center and an army of healthcare professionals, we also have the necessary labor pool.

There’s no question that many FECs provide excellent care, and that they are capable of handling some injuries—a broken leg, say—that urgent-care centers cannot. But should you visit one if you have a sore throat? Jason Armstrong would advise against it. That’s what brought him to Memorial Heights Emergency Center one evening. He told me he was given an injection, a prescription, and, weeks later, a bill for $1,100, of which his insurance didn’t cover a dime. In fact, all they gave him was a tip: in the future, avoid any place with emergency in the name, because it will always cost more. “People need to be aware of this,” Armstrong said. 

The observation that “emergency” and “expensive” are synonymous, even in the context of a strip mall clinic, was borne out by my conversation with a billing specialist at River Oaks Emergency Center. When asked why the initial charges for my fiancée’s visit had added up to over $2,600—of which we were stuck with $540—the biller explained that they were an “emergency facility,” not a regular clinic, and therefore their charges were comparable to a hospital emergency room’s. 

Elizabeth Almond got the same response when she contacted Elite Care. “When I called, they told me, ‘This is typical of any emergency room facility, because we’re open 24 hours a day.’ They just kept saying that over and over.”  

It’s true that FECs are more expensive to run than other clinics. Dr. Tim Seay is president of Greater Houston Emergency Physicians, a group that staffs emergency rooms—including FECs—and works directly with Elite Care. “We keep our volume low,” he said, explaining that each of Elite’s two Houston-area facilities sees between 10 and 40 patients per day. “We don’t want people to wait for four hours or five hours.” Their clientele, he says, consists of mostly “middle-class working guys with health insurance” who don’t want to be stuck in a waiting room. “We are specifically wanting to take care of people who want to be taken care of in an emergency environment,” he said. “And don’t have a problem paying for it.”

Some might take issue with Seay’s definition of “middle-class.” And while FECs know what kind of patients they’re looking for, the patients themselves—as evidenced by all those angry reviews—may have no idea what kind of facility they’re visiting, and therefore won’t know whether they “have a problem paying for it” until it’s too late. It’s like going out for fast food and ending up with a five-course meal from Tony’s. 

Oddly, Seay, when pressed on why fees aren’t discussed with patients before services are rendered, used the same analogy. 

“It’s like going into a restaurant,” he argued, “and saying ‘How much is my dinner going to be?’” 

Of course, restaurants have menus. Seay meant that just as no restaurant can tell you how much a meal will cost until you decide how much you want to eat, no medical facility can tell you how much the visit will cost until they know what’s wrong with you and what the treatment will be. “It would be nice to say, ‘Okay, here’s what it costs. It costs everybody this,’” Seay said. “It would be a wonderful thing, a great tool for us to have, but we don’t have that tool.” 

That’s another difference between FECs and restaurants: not everybody pays the same price for a meal. Each insurance company has a unique set of treatments it will cover and a standard amount it will pay for the treatments it does cover; furthermore, what an insurance company will pay is often determined through negotiations between the company and the provider. 

Nevertheless, emergency centers are required to provide prices when a patient requests them, thanks to a 2010 law. Rule 131.59 of the Texas Administrative Code specifically addresses freestanding emergency centers, and the wording seems unambiguous: “Information shall be available to patients and staff concerning fees for services provided,” though it leaves out the critical detail of when those prices must be given.

And what’s the penalty if an FEC fails to comply with rule 131.59? Well, there is none.  Christine Mann, who works for the Texas Department of State Health Services, the agency responsible for licensing and policing FECs, said facilities are asked to “self-investigate” by her agency after a patient complains to them. However, “they are under no obligation to respond to us.” According to Mann, the state has no real enforcement authority in this domain. And even if it did, “Our surveyors aren’t specifically trained as accountants to be able to get involved in all of those billing issues.”  

Elizabeth Almond fought Elite Care for months, filed a complaint with the Better Business Bureau, and took to the Internet to air her grievances. The company ultimately agreed to lower the bill, which did little to temper her anger. Ironically, she and her husband ended up leasing a house within walking distance of the Elite Care facility she’d visited. They even received a direct-mail flyer from the clinic. “I want to wrap this around a brick and throw it through their window,” said Almond’s husband when it arrived in the mail.

Jason Armstrong decided to only pay half of his bill.  “I will never go back to any place called an emergency clinic unless I’m literally dying at the doorstep,” he said. Memorial Heights never called him to ask for the rest. “I hope they don’t look me up based on this article and say, ‘Hey, he still owes half!’” he said.

He hopes, but he doesn’t know for sure. Like everyone else in this story—indeed everyone else in the country—Armstrong’s relationship to basic medical care is rife with uncertainties, a riddle wrapped in a mystery. All you can do is wait for the unexpected, and then wait for the bill.

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