Legislation Seeks Remedy for Sticker Shock at Freestanding Emergency Rooms

Charles White was having dinner last year with friends at a sports bar in Saginaw, north of Fort Worth, when he started coughing so hard he fainted, fell over backwards and hit his head on a table.

Paramedics arrived, got an electrocardiogram on his heart and told him he was OK but that he should follow up with a doctor. He had his daughter drive him to the Medical City ER, a nearby freestanding emergency room, where doctors ordered another EKG, a chest X-Ray and blood and urine tests. They gave him a bag of ice to put on his head and, two hours later, told him he was free to go. He likely just cut off the oxygen to his brain when he was coughing and fainted, they said.

White, 63, said he got an $18,000 bill in the mail a month later for the visit. His insurance company agreed to cover the bulk of the cost but he was still on the hook for $2,000, which he is paying now in $50 monthly installments because he’s retired and living off Social Security.

“I am not able to go out and eat or anything because I have to pay these bills,” White told the American-Statesman by phone this week. “What they did for me, I could have gone anywhere else and paid less than $100.”

For anyone who has ever visited a freestanding ER and gotten slapped with a hefty surprise bill, a Houston lawmaker has filed legislation this session that would require such facilities in Texas to disclose costs and insurance coverage with patients before offering service.

The bill, HB 2041, filed by Rep. Tom Oliverson, R-Houston, however, has faced resounding opposition from emergency room doctors and other medical professionals, many of whom said it would lead to delays in care and force patients to make health decisions based on their finances, which could have deadly consequences.

The legislation would force freestanding ERs, before delivering care, to disclose to patients in writing all health plans that are in-network, as well as any facility fees that would be charged with service. Oliverson said this would prevent patients from being surprised by huge bills down the road.

“We think this bill is a critical step to keep patients informed during emergency situations,” Oliverson said. “There have been widespread problems in this environment with patients going, getting care, thinking that they were covered, thinking it was in-network and then, unfortunately with the situation we have with balance billing, the patient is the one who gets stuck with the big bill at the end the day, and they had no idea this was coming.”

Strip mall location, hospital prices

Freestanding ERs have been allowed under Texas law since 2009 and were created to help eliminate some of the burden on overcrowded emergency rooms. Texas has more than 200 such facilities, including 10 in Austin, and they offer many of the same services you find in a traditional hospital ER, including advanced imaging, X-rays, ultrasounds, laboratory analysis and intravenous medications. They are staffed 24 hours a day, seven days a week. But they aren’t attached to hospitals so they can’t perform emergency surgery or cardiac procedures.

Because freestanding ERs are located in strip malls and shopping centers, many people do confuse them with urgent care clinics, which are designed to provide acute care for things like sore throats, burns and insect bites at much lower prices. Freestanding ERs charge emergency room prices, something most clearly advertise up front. However, many patients remain confused about what facility to go to for what ailment, what services will cost and what is covered under their insurance.

Oliverson said freestanding ERs add to the confusion by saying that they “take” or “accept” certain insurance plans, when the facilities are actually out of the insurance network. This means the facilities can bill patients for whatever costs aren’t covered by their insurance — known as balance billing — and leave patients on the hook for big medical bills weeks and months down the road.

Providers who are in-network are prohibited from balance billing.

Several lawmakers at the committee hearing said they, themselves, had been surprised by huge bills from freestanding ERs.

The proposed legislation, which is backed by the Texas Medical Association and AARP, would prohibit freestanding ERs from advertising that they “take” or “accept” major health insurance plans that are out-of-network or posting the name or logo of an insurance company on its signs if the facility is out-of-network for that insurer. A facility that doesn’t comply could face a fine of up to $25,000 if the bill becomes law.

“Patients should not be expected to have previously researched and figured out if the facility is in network,” Oliverson said at a Texas House Public Health Committee hearing on March 20. “We think that this information should be provided up front in an unambiguous format.”

Financial vs. medical choices

But opponents of the bill say patients shouldn’t be forced to consider their finances when making serious decisions about their health.

“It is unsafe and irresponsible for patients to triage themselves in the midst of their perceived medical emergency, particularly due to the fear of financial harm,” said Rhonda Sandel, board president of the Texas Association of Freestanding Emergency Rooms, which opposes the bill.

Sandel said the bill unfairly targets independent freestanding ERs and makes patients walk through a series of disclosures that would delay treatment. She said the bill, if passed, would also violate existing state and federal laws that not only require ERs to treat all patients, regardless of their ability to pay, but also evaluate them for medical emergencies before any financial discussions.

“We are by law required to see, treat and stabilize every patient that walks through our door,” Sandel said. “I have to be responsible for that patient whether they walk out my door and kill someone because they decided not to get treatment.”

Brian Murph, 32, who testified against the legislation at the committee hearing, said he was driving to meet friends in Houston and got a sharp pain in his upper back. He went to a freestanding ER, and doctors did a CT scan and found a blood clot in his cervical spine. He was rushed to a nearby hospital for surgery. Doctors told him if he had waited any longer to come in, he could have been paralyzed or dead.

“It reminds me every day that timing is key in a medical emergency,” Murph told lawmakers. “If I had delayed treatment, I would not be here today.”

He said he’s glad no one told him ahead of time how much his treatment would cost.

“I don’t want to know that price up front because, as a patient, I will make the wrong decision,” he said.

But AARP associate state director Blake Hutson, who helped craft the legislation, said the aim of the bill is simply to increase transparency, not to burden patients by putting all their medical costs in front of them before they get care, especially if it is a true medical emergency.

“We have seen a pattern of independent freestanding ERs actively misleading patients when they enter their facilities as far as what they can expect in terms of insurance and payments. That’s why the bill is narrow,” Hutson said. “If a facility can’t operate in a clear and transparent way with what they are going to bill and how they are going to work with insurance, then I’m sorry, it doesn’t bring value to health care in Texas.”

White, who will be paying his medical bill from the Saginaw ER for the next three years, said he had no idea what he was getting himself into when he went to the facility the night he fainted, and no one explained to him what he would be charged.

“It says outside it was an emergency department. I am not positive of what it was. I think it might have urgent care,” he said. “Definitely I would have never gone there.”

Confusion about costs, service

A law that went into effect in 2017 already requires that freestanding ERs properly identify themselves and disclose network status, but Huston said many facilities have been able to skirt those regulations and deceive patients by hiding in small print on the bottom of paperwork or their websites that they are out of network for most providers.

survey of 213 Texas freestanding ERs conducted by AARP found that 30 percent of facilities appeared to not fully comply with the state’s disclosure laws. More than 60 percent said by phone that they were in-network with Blue Cross Blue Shield of Texas when they are not, the survey found.

Christion Rice, a managing partner for Physicians Premier ER on Burnet Road in Central Austin, one of the freestanding ERs that advertises outside that it accepts all major insurance, said he feels comfortable saying so because state and federal laws require insurance companies to pay all emergency claims at in-network rates, regardless of whether the facility is in-network. He wants patients to feel safe to come into the facility no matter what insurance they have.

“This is a protected part of medicine, emergency room care is,” Rice said. “Regardless of network status, if the patient presents in the emergency room with an emergency situation, their benefits default to in-network status. It’s not fair to the patients to make them second-guess.”

Opponents of the legislation blame insurance companies for surprise bills, not the facilities, because insurers often don’t cover services at the in-network rate. This forces many facilities and providers to balance-bill the remainder of the cost. Patients end up covering the deductible or co-insurance that isn’t paid at the time of service because those fees aren’t required up front in emergency care like in an urgent care center or a doctor’s office.

“We bill our charges and what happens is the insurance company comes back and says, ‘We will allow this much of the charges, but we are going to put it all to patient responsibility,’ ” Sandel said. “That’s what I call surprise billing. It is really surprise undercoverage by insurance carriers.”

Patients are also just as liable to get stuck with a big bill from a hospital ER as from a freestanding ER, and this legislation won’t stop that from happening. Hospitals often contract with doctors and other personnel who are out-of-network, and patients could get separate bills for pathology, radiology or any other services performed in the ER.

Many who testified at the March 20 committee hearing said lawmakers should consider expanding the scope of the bill to include all emergency facilities because of this.

Other legislation being considered this session would eliminate balance billing altogether and allow medical providers to bring payment disputes to an independent mediator.

2017 health policy study published in the Annals of Emergency Medicine analyzed insurance claims processed by Blue Cross Blue Shield of Texas, the state’s largest health insurer. It found that patients in 2015 paid an average $749 out of pocket for service at hospital ERs, which is close to the $763 they paid on average at freestanding ERs. This is significantly higher, however, than what patients paid on average at urgent care centers that year, which was $63.

Patients also appeared to be confused about what facility to visit, as the study found a 75 percent overlap in the 20 most common diagnoses at freestanding ERs and urgent care centers, meaning people are going to both with similar complaints.

Jamie Dudensing, CEO of the Texas Association of Health Plans, the state’s insurance trade group, said many people aren’t aware of the cost differences between the facilities and have little recourse when they receive bills they can’t pay, which could affect their credit rating or lead to bankruptcy.

″(Patients) are trying to figure out the difference between the CVS minute clinic, the urgent care, the freestanding ER,” Dudensing said. “They are asking the question, how much is this going to cost and are you in my network? And they are getting misleading information.”

As of Friday, the committee has yet to vote on HB 2041.